Diabetic foot natural history, complications and prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2] Vishnu Vardhan Serla M.B.B.S. [3] Usama Talib, BSc, MD [4]
Overview
Diabetic foot is a known complication of diabetes. Diabetic patients who are at risk of foot ulceration, develop diabetic foot which may get infected later. The healing process of diabetic foot usually takes a long time (2-5 months) with proper treatment. The final state of diabetic foot is a necrotic foot. The wound healing process can get prolonged in patients with high elevated body mass index or osteomyelitis. Diabetic foot ulcers can cause numerous complications, such as sepsis, osteomyelitis, gangrene, lower limb amputation, and death. The chance of amputation is increased with factors such as old age, peripheral vascular disease (PAD), transcutaneous oxygen reduction, poor glycemic control, being on dialysis, and osteomyelitis. If left untreated, prognosis could be very bad and it can eventually lead to death. Male gender, old age, peripheral vascular disease, and concurrent chronic renal failure are related to higher rate of death. The presence of a single ulcer is associated with a particularly good prognosis among patients with diabetic foot, compared to multiple ulcers. Glycemic control improvement, treatment of neuropathy, and immediate treatment of ulcers improve the prognosis.
Natural History, Complications, and Prognosis
Natural History
- Diabetic foot is a known complication of diabetes and is more related to diabetes mellitus type 2, compared to type 1 diabetes.[1][2]
- Diabetic foot ulcers heal slowly and it usually takes between 2-5 months to completely heal with proper treatment.[3]
- Diabetic patients who are at risk of foot ulceration, develop diabetic foot which may get infected later. The final state of diabetic foot is a necrotic foot.[4]
- Based on a study, factors such as elevated body mass index and osteomyelitis prolong the wound healing process.[5]
- If left untreated, diabetic ulcers may progress to infection, sepsis, or osteomyelitis. According to an estimate, 20% of significant diabetic foot ulcers end up requiring an amputation.
Complications
- Diabetic foot ulcers can cause numerous complications including:[6][7][8][9][5][10][11][12]
- Infection:
- Diabetic foot infection is the most common cause of hospitalization in diabetic patients.
- Sepsis
- Osteomyelitis:
- The following features of a diabetic foot ulcer increase the chance of osteomyelitis development:
- Gangrene
- Lower limb amputation
- It is estimated that roughly half of non traumatic lower limb amputation is due to diabetic foot in North America and Europe.
- The following factors increase the risk of amputation in diabetic foot patients:
- Old age
- Peripheral vascular disease (PAD)
- Neuropathy
- Transcutaneous oxygen reduction
- Poor glycemic control
- Osteomyelitis
- Smoking
- Dialysis
- Death
- Patients with diabetic foot have an increased risk of all-cause mortality, especially cardiovascular disorders, compared with diabetic patients without a history of diabetic foot ulcer.
- The following risk factors have been associated with higher rate of mortality:
- Infection:
- Complications of diabetic foot have been more common in male patients and patients older than 60 years old.[9]
Prognosis
- If left untreated, prognosis could be very bad and it can eventually lead to death.[6]
- The 5 year risk of mortality in diabetic patients with a foot ulcer is 2.5 times higher than diabetic individuals without a foot ulcer.[6][13]
- The 5-year survival rate in diabetic patients with lower limb ulcers is 43%, compared to non-diabetic patients with foot ulcer (56%).[13]
- The following factors can determine the prognosis of diabetic foot:[14]
- Peripheral arterial disease
- Edema
- Infection
- Presence of other comorbidities
- The presence of a single ulcer is associated with a particularly good prognosis among patients with diabetic foot, compared to multiple ulcers.[15]
- Modification of specific risk factors (such as improving glycemic control, treatment of neuropathy, and immediate treatment of ulcers) improves the prognosis in a significant manner.[16]
- Three year mortality has been estimated 35-50% after amputation of the diabetic foot.[17]
- Based on different studies, toe pressure more than 55 mmHg is indicative for a better wound healing, and therefore, a better prognosis. In the contrary, toe pressure less than 30 mmHg in a diabetic patient with diabetic foot is indicative of a severely defective wound healing.[18][19]
References
- ↑ Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y (2017). "Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis †". Ann Med. 49 (2): 106–116. doi:10.1080/07853890.2016.1231932. PMID 27585063.
- ↑ Moura Neto A, Zantut-Wittmann DE, Fernandes TD, Nery M, Parisi MC (2013). "Risk factors for ulceration and amputation in diabetic foot: study in a cohort of 496 patients". Endocrine. 44 (1): 119–24. doi:10.1007/s12020-012-9829-2. PMID 23124278.
- ↑ Nabuurs-Franssen, M. H.; Huijberts, M. S. P.; Nieuwenhuijzen Kruseman, A. C.; Willems, J.; Schaper, N. C. (2005). "Health-related quality of life of diabetic foot ulcer patients and their caregivers". Diabetologia. 48 (9): 1906–1910. doi:10.1007/s00125-005-1856-6. ISSN 0012-186X.
- ↑ Edmonds M (2006). "Diabetic foot ulcers: practical treatment recommendations". Drugs. 66 (7): 913–29. doi:10.2165/00003495-200666070-00003. PMID 16740006.
- ↑ 5.0 5.1 Dutra LMA, Melo MC, Moura MC, Leme LAP, De Carvalho MR, Mascarenhas AN; et al. (2019). "Prognosis of the outcome of severe diabetic foot ulcers with multidisciplinary care". J Multidiscip Healthc. 12: 349–359. doi:10.2147/JMDH.S194969. PMC 6506632 Check
|pmc=value (help). PMID 31118658. - ↑ 6.0 6.1 6.2 Armstrong DG, Boulton AJM, Bus SA (2017). "Diabetic Foot Ulcers and Their Recurrence". N Engl J Med. 376 (24): 2367–2375. doi:10.1056/NEJMra1615439. PMID 28614678.
- ↑ Gardner SE, Frantz RA (2008). "Wound bioburden and infection-related complications in diabetic foot ulcers". Biol Res Nurs. 10 (1): 44–53. doi:10.1177/1099800408319056. PMC 3777233. PMID 18647759.
- ↑ Brownrigg JR, Davey J, Holt PJ, Davis WA, Thompson MM, Ray KK; et al. (2012). "The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: a meta-analysis". Diabetologia. 55 (11): 2906–12. doi:10.1007/s00125-012-2673-3. PMID 22890823.
- ↑ 9.0 9.1 Rathur HM, Boulton AJ (2007). "The diabetic foot". Clin Dermatol. 25 (1): 109–20. doi:10.1016/j.clindermatol.2006.09.015. PMID 17276208.
- ↑ Chammas NK, Hill RL, Edmonds ME (2016). "Increased Mortality in Diabetic Foot Ulcer Patients: The Significance of Ulcer Type". J Diabetes Res. 2016: 2879809. doi:10.1155/2016/2879809. PMC 4860228. PMID 27213157.
- ↑ Morbach S, Furchert H, Gröblinghoff U, Hoffmeier H, Kersten K, Klauke GT; et al. (2012). "Long-term prognosis of diabetic foot patients and their limbs: amputation and death over the course of a decade". Diabetes Care. 35 (10): 2021–7. doi:10.2337/dc12-0200. PMC 3447849. PMID 22815299.
- ↑ Giurato L, Meloni M, Izzo V, Uccioli L (2017). "Osteomyelitis in diabetic foot: A comprehensive overview". World J Diabetes. 8 (4): 135–142. doi:10.4239/wjd.v8.i4.135. PMC 5394733. PMID 28465790.
- ↑ 13.0 13.1 Chammas, N. K.; Hill, R. L. R.; Edmonds, M. E. (2016). "Increased Mortality in Diabetic Foot Ulcer Patients: The Significance of Ulcer Type". Journal of Diabetes Research. 2016: 1–7. doi:10.1155/2016/2879809. ISSN 2314-6745.
- ↑ Schaper, N. C.; Andros, G.; Apelqvist, J.; Bakker, K.; Lammer, J.; Lepantalo, M.; Mills, J. L.; Reekers, J.; Shearman, C. P.; Zierler, R. E.; Hinchliffe, R. J. (2012). "Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot". Diabetes/Metabolism Research and Reviews. 28: 218–224. doi:10.1002/dmrr.2255. ISSN 1520-7552.
- ↑ Ndosi M, Wright-Hughes A, Brown S, Backhouse M, Lipsky BA, Bhogal M; et al. (2018). "Prognosis of the infected diabetic foot ulcer: a 12-month prospective observational study". Diabet Med. 35 (1): 78–88. doi:10.1111/dme.13537. PMC 5765512. PMID 29083500.
- ↑ ""Group therapy for schizophrenia: A meta-analysis": Correction to Burlingame et al. (2020)". Psychotherapy (Chic). 57 (4): 597. 2020. doi:10.1037/pst0000354. PMID 33301344 Check
|pmid=value (help). - ↑ Ugwu E, Adeleye O, Gezawa I, Okpe I, Enamino M, Ezeani I (2019). "Predictors of lower extremity amputation in patients with diabetic foot ulcer: findings from MEDFUN, a multi-center observational study". J Foot Ankle Res. 12: 34. doi:10.1186/s13047-019-0345-y. PMC 6570910 Check
|pmc=value (help). PMID 31223342. - ↑ Lepäntalo, M.; Apelqvist, J.; Setacci, C.; Ricco, J.-B.; de Donato, G.; Becker, F.; Robert-Ebadi, H.; Cao, P.; Eckstein, H.H.; De Rango, P.; Diehm, N.; Schmidli, J.; Teraa, M.; Moll, F.L.; Dick, F.; Davies, A.H. (2011). "Chapter V: Diabetic Foot". European Journal of Vascular and Endovascular Surgery. 42: S60–S74. doi:10.1016/S1078-5884(11)60012-9. ISSN 1078-5884.
- ↑ Raines JK, Darling RC, Buth J, Brewster DC, Austen WG (1976). "Vascular laboratory criteria for the management of peripheral vascular disease of the lower extremities". Surgery. 79 (1): 21–9. PMID 1246689.