https://www.archives-pmr.org/article/S0003-9993(07)01748-0/pdf

Estimating the prevalence of limb loss in the United States: 2005 to 2050.

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Foot infections are a common and serious problem in persons with diabetes Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations) This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy) Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation) Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures Employing multidisciplinary foot teams improves outcomes Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs

2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections

In 2005, it was estimated that more than 20 million people in the United States had diabetes. Approximately 30% of these people had undiagnosed cases. Increased risk for diabetes is primarily associated with age, ethnicity, family history of diabetes, smoking, obesity, and physical inactivity. Diabetes-related complications—including cardiovascular disease, kidney disease, neuropathy, blindness, and lower-extremity amputation—are a significant cause of increased morbidity and mortality among people with diabetes, and result in a heavy economic burden on the US health care system. With advances in treatment for diabetes and its associated complications, people with diabetes are living longer with their condition. This longer life span will contribute to further increases in the morbidity associated with diabetes, primarily in elderly people and in minority racial or ethnic groups. In 2050, the number of people in the United States with diagnosed diabetes is estimated to grow to 48.3 million. Results from randomized controlled trials provide evidence that intensive lifestyle interventions can prevent or delay the onset of diabetes in high-risk individuals. In addition, adequate and sustained control of blood sugar levels, blood pressure, and blood lipid levels can prevent or delay the onset of diabetes-related complications in people with diabetes. Effective interventions, at both the individual and population levels, are desperately needed to slow the diabetes epidemic and reduce diabetes-related complications in the United States. This report describes the current diabetes epidemic and the health and economic impact of diabetes complications on individuals and on the health care system. The report also provides suggestions by which the epidemic can be curbed.

/pdf/epidemiology-of-diabetes-and-diabetes-related-complications-1iyy5ab5ih.pdf

Epidemiology of Diabetes and Diabetes-Related Complications

OBJECTIVE: To determine the incidence of foot ulcers in a large cohort of patients with diabetes, the risk of developing serious complications after diagnosis, and the attributable cost of care compared with that in patients without foot ulcers. RESEARCH DESIGN AND METHODS: Retrospective cohort study of patients with diabetes in a large staff-model health maintenance organization from 1993 to 1995. Patients with diabetes were identified by algorithm using administrative, laboratory, and pharmacy records. The data were used to calculate incidence of foot ulcers, risk of osteomyelitis, amputation, and death after diagnosis of foot ulcer, and attributable costs in foot ulcer patients compared with patients without foot ulcers. RESULTS: Among 8,905 patients identified with type 1 or type 2 diabetes, 514 developed a foot ulcer over 3 years of observation (cumulative incidence 5.8%). On or after the time of diagnosis, 77 (15%) patients developed osteomyelitis and 80 (15.6%) required amputation. Survival at 3 years was 72% for the foot ulcer patients versus 87% for a group of age- and sex-matched diabetic patients without foot ulcers (P

Incidence, outcomes, and cost of foot ulcers in patients with diabetes.

The purpose of this retrospective study was to evaluate the changes in diabetes-related lower extremity amputations following the implementation of a multidisciplinary programme for prevention and treatment of diabetic foot ulcers in a 0.2 million population with a 2.4% prevalence of diabetes. All diabetes-related primary amputations from toe to hip from 1 January 1982 to 31 December 1993 were included. In 294 diabetic patients, 387 primary major (above the ankle) or minor (through or below the ankle) amputations were performed, constituting 48% of all lower extremity amputations. The annual number of amputations at all levels decreased from 38 to 21, equalling a decrease of incidence from 19.1 to 9.4/100,000 inhabitants (p = 0.001). The incidence of major amputations decreased by 78% from 16/1 to 3.6/100,000 inhabitants (p < 0.001). The absolute number of amputations with a final level below the ankle showed no increase, but their proportion increased from 28 to 53% (p < 0.001) and the reamputation rate decreased from 36 to 22% (p < 0.05) between the first and last 3-year period. Thus, a substantial long-term decrease in the incidence of major amputations was seen as well as a decrease in the total incidence of amputations in diabetic patients. Seventy-one per cent of the amputations were precipitated by a foot ulcer. These findings indicate that a multidisciplinary approach plays an important role to reduce and maintain a low incidence of major amputations in diabetic patients.

Decreasing Incidence of Major Amputation in Diabetic Patients: a Consequence of a Multidisciplinary Foot Care Team Approach?

In this prospective study, mortality, rehabilitation, and new amputations on the same or on the contralateral leg were studied in 189 patients with diabetes who had achieved healing of an index amputation. Ninety-three patients had achieved healing after an index minor (below the ankle) and 96 after an index major (above the ankle) amputation, precipitated by a foot ulcer. The healing time was 29 weeks (range, 3-191 weeks) with a minor amputation and 8 weeks (range, 3-104 weeks) with a primary major amputation. The mortality 1, 3, and 5 years after the index amputation was 15%, 38%, and 68%, respectively, and was higher in patients who had achieved healing after major amputation than in patients achieving healing after minor amputation. The rate of new amputations after 1, 3, and 5 years of observation was 14%, 30%, and 49%, respectively. There was no difference among patients with an index minor and those with an index major amputation. The rate of new major amputations was 9%, 13%, and 23%, respectively, and was higher in patients with an index major amputation. Eighty-five percent of new amputations were precipitated by a foot ulcer. Patients living independently before the index amputation returned to living independently more often after a minor than a major amputation (93% versus 61%). One year after the index amputation, 70% of patients who had achieved healing after having a minor amputation and who could walk 1 km or more before amputation had regained this walking capacity, compared with 19% of patients having a major amputation. Seventy percent of patients with an index transtibial amputation who could walk before amputation were fitted with a prosthesis, and 52% were using it regularly. Patients with diabetes who had an index major amputation had a higher mortality, an equal rate of new amputation, and a lower rehabilitation potential than did patients who had an index minor amputation.

Long-term prognosis after healed amputation in patients with diabetes.

Clinical characteristics and outcome in 223 consecutive diabetic patients with deep foot infections are reported. Patients were treated by a multidisciplinary diabetic foot-care team at the University Hospital, Lund, Sweden, and were prospectively followed until healing or death. About 50% of patients lacked clinical signs of infection, such as a body temperature > 37.8 degrees C, a sedimentation rate > 70 mm/hour, and white blood cell count (WBC) > 10 x 10(9)/liter. Eighty-six percent had surgery before healing or death. Thirty-nine percent healed without amputation; 34% healed after a minor and 8% after a major amputation. Sixteen percent were unhealed at death, and 3% were unhealed at the end of the observation period. Of those unhealed at death or follow-up, 4 patients had had a major and 11 a minor amputation. After correction for age and sex, duration of diabetes 45 mmHg, and an ankle pressure > 80 mm Hg, absence of exposed bone and a white blood cell count < 12 x 10(9)/liter were all related to healing without amputation in a logistic regression analysis. We conclude that although only 1 in 10 had a major amputation, nearly all diabetic patients with a deep foot infection needed surgery and more than one third had a minor amputation before healing or death in spite of a well-functioning diabetic foot-care team responsible for all included patients.

Clinical characteristics and outcome in 223 diabetic patients with deep foot infections

The prognostic value of distal blood pressure measurements has been studied in 314 consecutive diabetic patients with foot ulcers. Systolic toe blood pressure was measured with a strain-gauge technique, and ankle pressure was measured with strain-gauge or Doppler techniques. Wound healing was defined as intact skin for at least 6 mo. One hundred ninety-seven patients healed primarily, 77 had amputations, and 40 died before healing had occurred. In 294 of 300 patients, it was possible to measure either ankle or toe pressure. Fourteen patients were not available for pressure measurements. Of these, 10 patients healed primarily, and 4 died before healing occurred. Both ankle and toe pressures were higher (P less than .001) among patients who healed without amputation compared with those who underwent amputation or died before healing. No differences were seen in ankle or toe pressure levels among those who had amputations or died. No patient healed primarily with an ankle pressure less than 40 mmHg. An upper limit above which amputation was not required could not be defined. Primary healing was achieved in 139 of 164 patients (85%) with a toe pressure level greater than 45 mmHg, whereas 43 of 117 patients (36%; P less than .001) healed without amputation when toe pressure was less than or equal to 45 mmHg. In conclusion, a combination of ankle and toe pressure measurements is a useful tool to predict primary healing in diabetic foot ulcers.

Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer

The rate of normal growth in length from the proximal growth plate of the tibia in the Sprague-Dawley rat was measured between 20 and 100 days of age using the tetracycline method. The growth rate varied only slightly within different age groups. The rate was highest in young animals and decreased considerably with increasing age. Male rats grew faster than female. This study is intended to provide a base for an evaluation of experimental influence on the growth in length of the rat.

Anders Stenström

Papers

Decreasing Incidence of Major Amputation in Diabetic Patients: a Consequence of a Multidisciplinary Foot Care Team Approach?

Long-term prognosis after healed amputation in patients with diabetes.

Clinical characteristics and outcome in 223 diabetic patients with deep foot infections

Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer

Rate of normal longitudinal bone growth in the rat.