Diabetic foot ulcers and infections: Current concepts

Advances in Skin & Wound Care, Jan/Feb 2002 by Calhoun, Jason H, Overgaard, Kristi A, Stevens, C Melinda, Dowling, James P E, Mader, Jon T

Diabetes is the leading cause of amputation in the United States. In 1996, 86,000 lower-extremity amputations were performed on diabetic patients.80 Diabetic patients are 40 times more likely to have an amputation than nondiabetic patients. The most common indications for amputation are gangrene or infection in a nonhealing ulcer.81 Because ischemia is usually present in this situation, consultation with a vascular surgeon is prudent when determining the necessity and the level of amputation. It may be possible to improve the circulation with vascular intervention. Although this may not eliminate the need for amputation, it may reduce the level of the amputation. However, amputations at a more distal level are associated with higher reamputation rates and, consequently, longer healing times.82,83 Amputations at higher levels, on the other hand, are associated with lower reamputation rates and shorter healing times.82

The decision to amputate is difficult for patients and emotional factors often impede their ability to make a decision that will provide the best long-term functional outcome. A sensitive approach is required during the decision-making process. Counseling and time to consider the procedure may help the patient. Also, the patient can be encouraged to seek a second opinion. In addition, physical factors such as the patients general health, nutrition, and immunocompetence should be evaluated. The patient's ability to follow through with rehabilitation should be taken into consideration as well.

Morbidity and mortality rates are high following amputation and an accurate decision making process is essential. Those who undergo a lower-extremity amputation have up to a 30% chance of undergoing a similar amputation on the contralateral limb within 3 years or up to a 50% chance in 5 years.41,42 Additionally, in an evaluation of selected studies, the National Institutes of Health reported that the mortality rate 1 year after amputation is between 11% and 41%, the 3year postamputation mortality rate is 20% to 50%, and the 5-year rate is 39% to 68%.84 Serious comorbid conditions are common in the diabetic population and mortality in diabetic amputees has been attributed to cardiac or renal complications.85

Conclusion Robson has said, "Infection in a wound, like infection elsewhere in the body, is a manifestation of a disturbed hostbacteria equilibrium in favor of the bacteria... to be able to prevent and manage wound infections requires an understanding of how each prophylactic or therapeutic maneuver works to maintain or reestablish the bacteria-host balance. Only when this equilibrium is in balance can the normal processes of wound healing proceed to give a satisfactory healing trajectory."86

The treatment of diabetic foot ulcers and infections is complicated by the systemic nature of diabetes. Treatment is best rendered by a medical team consisting of endocrinologists, internists, diabetic educators, wound care specialists, orthotics specialists, podiatrists, vascular and orthopaedic surgeons, and infectious disease specialists. The application of optimal wound care techniques and the use of new technologies provide the best outcome for patients with diabetic foot ulcers and infections. Prevention of diabetic foot ulcers is possible and offers the best first-line approach to the care of the diabetic foot. #