Aging Begins at 30

Diabetic Foot Ulcers

Creation Date: May 2000
Last Revision Date: May 2000
Peer Review Status: Internally Peer Reviewed

The Iowa Foundation for Medical Care, tries to improve medical practice in the state and pass on research findings to benefit patients. I was delighted to see in its annual report many improvements, particularly in diabetes, by doctors monitored for "quality of care indicators." An unusual entry caught my eye. Medical offices had been encouraged to use a sign that said "If you are a diabetic please remove your shoes and socks when consulting the doctor." There was a bar diagram showing improvement in regular foot examinations from 35% of patients in 1997 to 63% in 1998-1999. Home blood glucose monitoring had increased from 35% in 1997 to 63% in 1998-1999. Why are these tests necessary?

Almost 9,000 patients, 18 or older, with type 1 diabetes (insulin dependent) or type 2 diabetes were followed for 3 years at the Group Health Cooperative of Puget Sound, Washington. Approximately 17% of these diabetics are non-white. A leg ulcer developed in 514 (6%). Leg ulcer patients developed osteomyelitis (bone infection) in 13%, and 11% needed amputation. Amputation is thirteen times more frequent in diabetics as in the same age non-diabetics. Survival at 3 years for diabetic foot ulcer patients was 72% compared to matched diabetic patients with no foot ulcers. In a different study, survival of diabetic amputees was 75% at 1 year, 62% at 2 years and 56% at 5 years. One third of amputees lose the opposite foot in 5 years. Bilateral amputation means permanent wheelchair life. The good news is that with better care the rate of amputations is falling. A new foot ulcer in a 40- to 60-year-old male diabetic added $28,000 to the cost of care for the next 2 years in the Puget Sound study. Foot ulcers added 22 more outpatient visits and 5 more hospital days. Foot salvage is very important. Any prevention technique that prevents leg ulcers is very cost effective.

Among 16 million U.S. diabetics, 15% will develop foot ulcers yearly and will get 60,000 amputations. Debridement (junk removal in French) is excision of dead tissue with a sharp knife, removal by high pressure water jet or wet gauze placement. Other ways of cleansing the wound are protein dissolving enzymes, live maggots, or moisture retaining hydrocolloid dressings. Surgical debridement can include unroofing or saucerizing the wound.

Bacteria in large numbers, such as 100,000 per gram of tissue or more, delay healing by interfering with nature's healing cascade. Antibiotics are necessary and the choice may be difficult.

Diabetes damages nerves and prevents the patient from feeling the day-to-day trauma our feet receive. I remember a patient unaware of a thumb tack in his heel. The problem may be compounded because diabetics develop arteriosclerosis at a younger age and they may need major artery surgery. Corns develop and self surgery may do further damage and introduce infection. Careful education so that the patient knows almost as much about his or her disease as their doctor is a good target. A diabetic can live as well and as long as a non-diabetic but it takes hard work by both the patient and the doctor.

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See related Patient Topics Bones, Joints and Muscles, Diabetic Foot or Endocrine System (Hormones).

See related Provider Topics Bones, Joints and Muscles or Endocrine System (Hormones).

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http://www.vh.org/adult/patient/internalmedicine/aba30/2000/diabeticfeet.html