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Diagnosis and Management of Diabetic Foot Complica
Diagnosis and Management of Diabetic Foot Complica
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Diabetic Foot
ANDREW J.M. BOULTON, MD, DSC (HON),
FACP, FRCP
Professor of Medicine, University of
Complications
Manchester, Manchester, U.K., and
Visiting Professor of Medicine, University
of Miami Miller School of Medicine,
Miami, FL
CHRISTOPHER E. ATTINGER, MD
Professor of Plastic Surgery, Georgetown
University School of Medicine and
MedStar Health, Washington, DC
Management of
Robert S. Kirsner, MD, PhD2
Christopher E. Attinger, MD5,6
Diabetic Foot
Lawrence A. Lavery, DPM, MPH7
Benjamin A. Lipsky, MD, FACP,
FIDSA, FRCP (London), FFPM,
Complications
RCPS (Glasg)8,9
Joseph L. Mills, Sr., MD, FACS10
John S. Steinberg, DPM, FACFAS5,6
F oot problems in diabetes are common and costly, and people Medicine, Washington, DC
6
MedStar Health, Washington, DC
with diabetes make up about half of all hospital admissions for 7
University of Texas Southwestern Medical
amputations. In the United Kingdom, people with diabetes account Center, Dallas, TX
for more than 40% of hospitalizations for major amputations and 8
Green Templeton College, University of
Oxford, Oxford, U.K.
73% of emergency room admissions for minor amputations. Because 9
University of Washington College of
most amputations in diabetes are preceded by foot ulceration, a Medicine, Seattle, WA
thorough understanding of the causes and management of ulceration 10
Baylor College of Medicine, Houston, TX
is essential.
Address correspondence to
The annual incidence of foot ulcers in diabetes is approximately 2%
Andrew J.M. Boulton,
in most Western countries, although higher rates have been reported ABoulton@med.miami.edu,
in certain populations with diabetes, including Medicare beneficia- and David G. Armstrong,
ries (6%) and U.S. veterans (5%) (1). Although the lifetime risk of foot armstrong@usa.net.
ulcers until recently was generally believed to be 15–25%, recent data
suggest that the figure may be as high as 34% (1). It was the famous di- ©2018 by the American Diabetes
abetes physician Elliott P. Joslin who, having observed many clinical Association, Inc.
cases of diabetic foot disease, re- The Scottish poet Thomas bination of infection, foot ul-
marked that “diabetic gangrene Campbell wrote, “Coming events ceration, and peripheral artery
is not heaven-sent, but earth- cast their shadows before.” Al- disease (PAD) often results in
born.” Thus, foot ulceration is though he was not referring to amputation, additional sections
not an inevitable consequence foot ulcers at the time, these cover these pivotal areas of man-
of having diabetes; rather, ul- words can usefully be applied to agement.
cers develop as a consequence of the breakdown of the diabetic The number of available topi-
an interaction between specific foot. Ulcers do not occur spon- cal treatments for foot ulcers has
lower-limb pathologies and envi- taneously, but rather as a con- rapidly increased in recent years.
ronmental hazards. sequence of a combination of We explore these options in de-
This treatise will therefore fo- factors. These contributory fac- tail, including growth factors,
cus on the pathways that result in tors are summarized in the next skin substitutes, stem cells, and
foot ulcer development, the im- section. This is followed by a dis- other biologics.
portance of regular screening to cussion of foot screening to iden- No treatise on the diabetic foot
identify members of the at-risk tify individuals who are at risk would be complete without men-
population, and multiple aspects of ulceration. We then describe tion of Charcot neuroarthropa-
of novel treatment approaches. the importance of wound classi- thy, so our next section is devot-
Care of the foot in diabetes often fication systems and answer the ed to the differential diagnosis of
falls between specialties, and a questions of when and where to the hot, swollen foot in diabetes.
team approach is required. Thus, refer diabetic foot problems. It is increasingly recognized
we have assembled a team of It is often stated that what you that foot ulcer recurrence is com-
experts in the care of diabetes- take off a foot ulcer is as important mon, occurring in up to 50% of
related foot conditions from a as what is placed on the wound. cases, and using the term “in re-
variety of specialties, including Therefore, we also include dis- mission” has been deemed more
endocrinology; dermatology and cussions of various methods for appropriate than describing an
wound healing; infectious dis- off-loading foot lesions and the ulcer as “healed.” Thus, in our
eases; and podiatric, plastic, and importance of aggressive wound penultimate section, we describe
vascular surgery. debridement. Because the com- methods to maintain a foot in
DIABETES
Peripheral artery
disease
FOOT AT RISK
Repetitive trauma
(e.g., ill-fitting shoes, barefoot
gait, or foreign body in shoe)
FOOT ULCERS
Suggested
Priority Indications Timeline Follow-up
URGENT ⊲⊲ Open wound or ulcerative area, with or without signs Immediate referral/ As determined by
(active pathology) of infection consultation specialist
⊲⊲ New neuropathic pain or pain at rest
⊲⊲ Signs of active Charcot deformity (red, hot, swollen
midfoot or ankle)
⊲⊲ Vascular compromise (sudden absent DP/PT pulses or
gangrene)
HIGH ⊲⊲ Presence of diabetes with a previous history of ulcer Immediate or “next Every 1–2 months
(ADA risk category 3: or lower-extremity amputation available” outpatient
the diabetic foot in ⊲⊲ Chronic venous insufficiency (skin color change or referral
remission) temperature difference)
MODERATE ⊲⊲ PAD ± LOPS Referral within 1–3 Every 2–3 months
(ADA risk category 2) ⊲⊲ DP/PT pulses diminished weeks (if not already
⊲⊲ Presence of swelling or edema receiving regular care)
LOW ⊲⊲ LOPS ± longstanding, nonchanging deformity Referral within 1 month Every 4–6 months
(ADA risk category 1) ⊲⊲ Patient requires prescriptive or accommodative
footwear
VERY LOW No LOPS or PAD
⊲⊲ Referral within 1–3 At least annually
(ADA risk category 0) Patient seeks education on topics such as routine foot months
⊲⊲ for all people with
care, athletic training, appropriate footwear, or injury diabetes
prevention
DP, dorsalis pedis; LOPS, loss of protective sensation; PT, posterior tibial. Modified from Diabetes Care 2008;31:1679–1685 (ref. 6),
with permission from the American Diabetes Association, ©2008.
TABLE 3 SVS Threatened Limb Classification System, With Clinical Stages 1–4 Based on Severity of Wound, Ischemia, and foot Infection (WIfI)
rhPDGF PRP HSE DSS IDRT SIS HADWM hVWM dHACM NPWT HBOT
(41) (42) (43) (45) (46) (47) (48) (38) (49) (50) (52)
n = 382 n = 35 n = 208 n = 245 n = 307 n = 82 n = 86 n = 97 n = 40 n = 162 n = 94
50 vs. 81 vs. 56 vs. 30 vs. 51 vs. 54 vs. 70 vs. 62 vs. 95 vs. 56 vs. 52 vs.
HEALED, % 35 at 20 42 at 12 38 at 12 18 at 12 32 at 16 32 at 12 46 at 12 21 at 12 35 at 6 39 at 16 29 at 1
weeks weeks weeks weeks weeks weeks weeks weeks weeks weeks year
TIME TO 86 vs. 43 vs. 65 vs. Not 63 vs. 40 vs. 42 vs. 24 vs.
CLOSURE, 43 vs. 78 N/A N/A
127 47 90 stated 77 48 70 57
DAYS
FDA- + + + +
APPROVED
STUDY +++ + +++ +++ +++ ++ ++ ++ + ++ ++
QUALITY
ADDITIONAL + + + + + +
RCTs
EFFECTIVE- + + + +
NESS DATA
Because of differences in study design and quality, caution is warranted regarding direct comparisons. Numbers in parentheses
after therapy abbreviations are reference citations. N/A, not applicable.
Combining the evidence-based ment: Surgical or Otherwise.” R.S.K. MedTech, and Medline Industries.
and common-sense therapies de- wrote “Evidence-Based Adjunctive B.A.L. is a consultant for Medimmune,
scribed here with emerging tech- Therapies for Diabetic Foot Ulcers.” Microbion, and Debiopharm. J.S.S. is
nologies has the potential to help L.A.L. wrote “When and Where to a consultant for Integra and Syntactx.
us maximize ulcer-free, hospi- Refer Diabetic Foot Problems” and
REFERENCES
tal-free, and activity-rich days for “Off-Loading the Diabetic Foot
our patients. Wound” and co-wrote “The Acute 1. Armstrong DG, Boulton AJM,
Hot, Swollen Foot: Charcot or Infec- Bus SA. Diabetic foot ulcers and
ACKNOWLEDGMENTS
tion?” B.A.L. wrote “Management of their recurrence. N Engl J Med
The authors acknowledge Jayson N. Infection.” J.L.M. wrote “Recogniz- 2017;376:2367–2375
Atves, DPM, CO, for contributions to ing and Treating Peripheral Artery 2. Jeffcoate WJ, Vileikyte L, Boyko
the section on debridement. Disease.” J.S.S. co-wrote “Wound EJ, Armstrong DG, Boulton AJM.
Editorial and project management ser- Debridement: Surgical or Otherwise.” Current challenges and opportunities
vices were provided by Debbie Kendall A.J.M.B. and D.G.A. are the guaran- in the prevention and management
of Kendall Editorial in Richmond, VA. tors of this work. of diabetic foot ulcers. Diabetes Care
2018;41:645–652
AUTHOR CONTRIBUTIONS DUALITIES OF INTEREST
A.J.M.B. and D.G.A. served as A.J.M.B., D.G.A., and J.L.M. have 3. Abbott CA, Carrington AL, Ashe H,
co-editors and, as such, co-wrote the no relevant dualities of interest to et al; North-West Diabetes Foot Care
introduction and conclusion and disclose. C.E.A. is a consultant for Study. The North-West Diabetes Foot
reviewed and edited the entire Acelity and Integra. R.S.K. has re- Care Study: incidence of, and risk fac-
manuscript. A.J.M.B. also wrote ceived honoraria for participation in tors for, new diabetic foot ulceration
“Pathways to Diabetic Foot Compli- educational programs for Healogics. in a community-based patient cohort.
cations,” and D.G.A. wrote “Screen- L.A.L. has received research grants Diabet Med 2002;19:377–384
ing for Foot Complications Risk” and from Cardinal Health; serves on 4. Boulton AJM. The pathway to ul-
“How to Maintain the Foot in Remis- speakers bureaus for Integra, Osiris, ceration. In The Foot in Diabetes, 5th
sion” and co-wrote “The Acute Hot, and Smith & Nephew; and is a con- ed. Boulton AJM, Rayman G, Wukich
Swollen Foot: Charcot or Infection?” sultant or advisor to Apilon Medical DK, Eds. Chichester, U.K., John Wiley
C.E.A. co-wrote “Wound Debride- Users, Boehringer Ingelheim, Harbor & Sons, 2019. In press