Decreasing incidence of foot ulcer among patients with type 1 and type 2 diabetes in the period 2001-2014.

AIM: Diabetic foot ulcer (DFU) is a serious complication to diabetes. The aim was to study the incidence of first DFU among patients with type 1 (T1DM) and type 2 diabetes (T2DM), stratified according to etiology: neuropathic, neuro-ischemic or ischemic, over a period of 14years (2001-2014). METHODS: DFU incidence rates were calculated from electronic patient record data from patients with T1DM and complicated T2DM from a large specialized diabetes hospital with a multidisciplinary foot clinic in Denmark. Poisson regression was used to model incidence of first DFU according to calendar year, diabetes type and etiology. RESULTS: Among 5640 patients with T1DM 255 developed a DFU, corresponding to an incidence of 5.8 (95% confidence interval (95%CI) 5.1-6.5) per 1000 patient years; this incidence dropped from 8.1 (95%CI 5.4-11.9) per 1000 patient years in 2002 to 2.6 (95%CI 1.3-5.3) in 2014 (p=0.0059). Among 6953 patients with T2DM 310 developed a DFU, corresponding to an incidence of 11.3 (95%CI 10.1-12.6) per 1000 patient years; this incidence dropped from 17.0 (95%CI 12.2-23.8) per 1000 patient years in 2002 to 8.7 (95%CI 5.3-14.1) per 1000 patient year (p=0.0260) in 2014. CONCLUSION: The incidence of DFU has decreased substantially in T1DM as well as in T2DM. This change was driven by a decrease in incidence of neuropathic ulcers.

Increased healing in diabetic toe ulcers in a multidisciplinary foot clinic-An observational cohort study.

AIM: To study toe ulcer healing in patients with diabetic foot ulcers attending a multidisciplinary foot clinic over a 10 years period. METHODS: The study was retrospective, consecutive and observational during 2001 through 2011. The patients were treated according to the International Consensus on the Diabetic Foot. During the period the chiropodist staffing in the foot clinic was doubled; new offloading material and orthopedic foot corrections for recalcitrant ulcers were introduced. Healing was investigated in toe ulcers in Cox regression models. RESULTS: 2634 patients developed foot ulcers, of which 1461 developed toe ulcers; in 790 patients these were neuropathic, in 551 they were neuro-ischemic and in 120 they were critically ischemic. One-year healing rates increased in the period 2001-2011 from 75% to 91% for neuropathic toe ulcers and from 72% to 80% for neuro-ischemic toe ulcers, while no changes was observed for ischemic toe ulcers. Adjusted for changes in the patient population, the overall rate of healing for neuropathic and neuro-ischemic toe ulcers almost doubled (HR=1.95 [95% CI: 1.36-2.80]). CONCLUSION: The results show that the healing of toe ulcers improved. This outcome could not be explained by changes in the patient characteristics, but coincided with a number of improvements in organization and therapy.

Motivation, effort and life circumstances as predictors of foot ulcers and amputations in people with Type 2 diabetes mellitus.

AIM: To investigate the predictive value of both patients' motivation and effort in their management of Type 2 diabetes and their life circumstances for the development of foot ulcers and amputations. METHODS: This study was based on the Diabetes Care in General Practice study and Danish population and health registers. The associations between patient motivation, effort and life circumstances and foot ulcer prevalence 6 years after diabetes diagnosis and the incidence of amputation in the following 13 years were analysed using odds ratios from logistic regression and hazard ratios from Cox regression models, respectively. RESULTS: Foot ulcer prevalence 6 years after diabetes diagnosis was 2.93% (95% CI 1.86-4.00) among 956 patients. General practitioners' indication of 'poor' vs 'very good' patient motivation for diabetes management was associated with higher foot ulcer prevalence (odds ratio 6.11, 95% CI 1.22-30.61). The same trend was seen for 'poor' vs 'good' influence of the patient's own effort in diabetes treatment (odds ratio 7.06, 95% CI 2.65-18.84). Of 1058 patients examined at 6-year follow-up, 45 experienced amputation during the following 13 years. 'Poor' vs 'good' influence of the patients' own effort was associated with amputation (hazard ratio 7.12, 95% CI 3.40-14.92). When general practitioners assessed the influence of patients' life circumstances as 'poor' vs 'good', the amputation incidence increased (hazard ratio 2.97, 95% CI 1.22-7.24). 'Poor' vs 'very good' patient motivation was also associated with a higher amputation incidence (hazard ratio 7.57, 95% CI 2.43-23.57), although not in fully adjusted models. CONCLUSIONS: General practitioners' existing knowledge of patients' life circumstances, motivation and effort in diabetes management should be included in treatment strategies to prevent foot complications.

Importance of factors determining the low health-related quality of life in people presenting with a diabetic foot ulcer: the Eurodiale study.

AIM: To identify the factors responsible for the low health-related quality of life associated with foot ulcers and the relative importance of these factors. METHODS: A total of 1232 patients with a new foot ulcer, who presented at one of the 14 centres in 10 European countries participating in the Eurodiale study, were included in this cross-sectional study. Patient and ulcer characteristics were obtained as well as results from the Euro-Qol-5D questionnaire, a health-related quality of life instrument with five domains (mobility, self-care, usual activities, pain/discomfort and anxiety/depression). To analyse the relative importance of comorbidities and ulcer- and patient-related factors for health-related quality of life, linear regression models were used to calculate the relative contributions of each factor to the fit (R(2) ) of the model. RESULTS: Patients reported poor overall health-related quality of life, with problems primarily in the mobility and pain/discomfort domains. Among the comorbidities, the inability to stand or walk without help was the most important determinant of decreased health-related quality of life in all five domains. Among ulcer-related factors, ulcer size, limb-threatening ischaemia and elevated C-reactive protein concentration also had high importance in all domains. The clinical diagnosis of infection, peripheral arterial disease and polyneuropathy were only important in the pain/discomfort domain. CONCLUSIONS: The factors that determine health-related quality of life are diverse and to an extent not disease-specific. To improve health-related quality of life, treatment should not only be focused on ulcer healing but a multifactorial approach by a specialized multidisciplinary team is also important.

Exostectomy for chronic midfoot plantar ulcer in Charcot deformity.

Charcot midfoot ulcers are rare and very difficult to heal, with surgery being an option. This retrospective study assessed healing rates, complications, and the incidence of re-ulceration and other foot ulcer problems following exostectomies

Incidence and management of ulcers in diabetic Charcot feet.

This study followed 115 patients with diabetes--who between them had 140 feet with Charcot's arthropathy--over six to 114 months (median: 48). A total of 43 patients (37%) developed ulcers in 53 feet. Their treatment was multifactorial. An offloading regimen was adopted, with the use of crutches and therapeutic sandals with soft, individually moulded insoles, followed by adjusted or bespoke shoes. Recalcitrant ulcers were treated with surgery in 16 patients (37%). Antibiotics were needed by 21 patients (49%). The incidence of ulceration was 17% per year. The median time interval between the acute component of Charcot's arthropathy and ulcer development was 36 months (range: 0-120 months). In seven patients, the ulcer developed during the acute phase. In 12 patients the ulcers were localised to the rockerbottom deformity in the mid-foot region, but in 31 patients other regions were affected. Dynamic footprint analysis was used to help adjust the offloading shoe/insole on the rockerbottom deformity. Such ulcers took twice as long to heal as other ulcers. Surgical treatment comprised: major amputation (two patients), arthrodesis for unstable ankle (three patients), toe amputations (seven patients), resection of the rockerbottom deformity (one patient) and other revisions (three patients). One patient died with an unhealed ulcer. There is a four-fold risk of ulcers in diabetic Charcot deformity compared with the overall risk of foot ulcers in diabetic feet. Healing was achieved in 40 patients (93%). The surgical intervention rate of 37% in ulcer cases in Charcot feet was low compared with the literature.

Long-term follow-up in diabetic Charcot feet with spontaneous onset.

OBJECTIVE: To assess the long-term results after Charcot breakdown with spontaneous onset in diabetic feet. RESEARCH DESIGN AND METHODS: This study was retrospective. A total of 115 patients (140 feet), 107 with acute deformity and 8 with chronic Charcot deformity, were followed for a median of 48 months (range 6-114). The routine treatment for acute cases was a weight-off regimen with crutches and foot protection with therapeutic shoes until skin temperature had normalized followed by increased weightbearing and the use of bespoke shoes or modification of conventional shoes. RESULTS: The incidence of Charcot deformity was 0.3%/year in the diabetic population investigated. About half of the patients were active in their jobs. Major complications were encountered in 5 (4%) of the patients that required surgical intervention: arthrodesis for unstable malaligned ankles in 3 subjects (1 bilaterally) and major amputation in 2 subjects for unstable ankle and pressure sores. Minor complications were recorded in 43% of subjects: new attacks of Charcot breakdown in 41 patients (36%) and/or foot ulceration in 43 patients (37%) that required minor surgical procedures for 11 patients. All healed except in 2 patients: 1 patient died before the Charcot fractures had healed, and 1 patient died with an unhealed ulcer. No patient lost the ability to walk independently. CONCLUSIONS: Major surgical procedures in only 4% were particularly related to patients with Charcot deformities in the ankle. Minor complications were recorded in about half of the patients. Lifelong foot care is required for diabetic patients with Charcot feet.

Limb salvage experience in a multidisciplinary diabetic foot unit.

OBJECTIVE: To assess the results of the strategy used in avoiding major amputations in patients admitted to a vascular surgical department with a new multidisciplinary diabetic foot unit. RESEARCH DESIGN AND METHODS: The study was retrospective. A total of 162 patients (172 limbs) were classified into three groups. Group A1 had limb-threatening ischemia and were undergoing revascularization (85 patients, 91 legs). Group A2 had limb-threatening ischemia, but revascularization was not feasible for them (23 patients). Group B had foot ulcers due to peripheral neuropathy and did not require arterial reconstruction (54 patients, 58 legs). RESULTS: In group A1 there were 115 revascularizations; 42 conduits had outflow to crural arteries and 14 to pedal arteries. Resection of gangrene was required in 43% of the limbs. The chances of preserved limb at 1 and at 24 months were 95 and 85%, respectively, and the chances of patient survival were 89 and 64%. In group A2, the chances of preserved limb at 1 and at 24 months were only 35 and 17%, respectively, and the chances of patient survival were only 64 and 16%. In group B, 51 of 58 limbs suffered invasive infection; debridement of the ulcers required resection of toes or part of the foot in 64% of cases. The chances of preserved limb at 1 and at 24 months was 98 and 86%; the chances of patient survival were 98 and 68%. Ankle and toe systolic pressures were less suitable than repeated clinical examinations in deciding the need for revascularization. CONCLUSIONS: Major amputation can be avoided in about 80% of patients with limb-threatening ischemia and in about 95% with foot ulceration complicated with infection. Multifactorial treatment of the complex foot lesions by a multidisciplinary foot care team is considered mandatory to obtain satisfactory limb salvage.

Minor amputations on the feet after revascularization for gangrene. A consecutive series of 95 limbs.

A consecutive series of 89 patients (95 limbs) with gangrene were operated on with amputation of toes or some distal part of the foot after arterial reconstruction. 43 patients had diabetes. Healing was achieved in 81/82 feet when the reconstruction was open. Amputation below or above the knee was required in 4/5 limbs when the reconstruction failed. 8 patients died before healing. The median time to healing was 30 (17-452) days, after a single amputation, and 115 (36-466) days, when more than one procedure had been necessary. We concluded that amputations on the feet for gangrene usually heal after arterial reconstruction, in patients with diabetes as well as in those with arteriosclerosis. No weight bearing and control of infection are important during the early postoperative period.

Epidemiology of leg amputation: the influence of vascular surgery.

The number of amputations performed for vascular disease in Denmark has decreased from 1777 (34.5 per 100,000 population) in 1983 to 1288 (25.0 per 100,000) in 1990, a reduction of 28 per cent. This decline coincided with an increase in vascular surgical activity of up to 100 per cent, including a marked rise in the rate of femorodistal reconstruction. Moreover, regional variation in vascular surgical activity correlated with percentage reduction in amputation rate (rS = 0.65, P < 0.01). The relative number of above-knee amputations also decreased in favour of more distal levels during the period studied. These findings suggest that vascular surgery may be responsible for the lower amputation rate.

The incidence of ureteral obstruction secondary to aorto-femoral bypass surgery. A prospective study.

Hydronephrosis is reported to be an infrequent complication of aorto-femoral bypass operations. To define the true incidence of this complication, renography (131I-Hippuran) and renal scintigraphy (99 Technetium) were performed both pre- and postoperatively on 56 asymptomatic patients following successful aortic reconstruction. No patient developed signs of ureteral obstruction. It is concluded that hydronephrosis is a rare complication to aorto-femoral bypass surgery and postoperative control is only indicated in patients with symptoms from the urinary tract.

Percutaneous transluminal angioplasty of iliac and femoral arteries in severe lower-limb ischaemia.

Percutaneous transluminal angioplasty was performed 92 times in 86 patients with severe lower-limb ischaemia (40% occlusion), giving rise to rest pain and/or gangrene. The patients were thereafter observed for periods up to 5 years. Criteria for success were appearance of normal groin pulse (iliac angioplasty) or persistent greater than or equal to 0.15 rise in arm/ankle blood pressure index (femoropopliteal angioplasty). The respective technical success rates were 82% and 64%. The complication rate was 10.9%, including 5.4% distal embolization. Patency rates were higher in iliac than in femoropopliteal lesions, in stenotic than occluded vessels, and also when the lesion was shorter than 5 cm and if there was good run-off. Limb salvage exceeded patency by 10% in the iliac procedures and by 15% in the femoropopliteal. Percutaneous transluminal angioplasty is recommended for selected cases of severe lower-limb ischaemia, and should always be considered for limb salvage. Reocclusion does not necessarily imply clinical failure. Technical failures should be included in calculated patency rates in order to document the method's limitations.

Percutaneous transluminal angioplasty of infrarenal arteries in intermittent claudication.

Percutaneous transluminal angioplasty was performed on 55 iliac and 31 femoropopliteal arteries in 71 patients with intermittent claudication (23 women, 48 men). The two-year patency rate was 80% after iliac and 41% after femoropopliteal angioplasty. In 17 femoropopliteal cases with lesions greater than or equal to 5 cm the 2-year patency rate was only 32%, but the corresponding figure for shorter lesions was 53%. Complicating haematoma appeared in 10% of the cases and the arterial state deteriorated in one patient. There was no distal embolization. Percutaneous transluminal angioplasty in intermittent claudication is indicated for all cases of occlusion or stenosis of the iliac artery and for occlusion or stenosis shorter than 5 cm of the superficial femoral or the popliteal artery.

Incidence of ureteral obstruction after aortic grafting: a prospective analysis.

In this prospective analysis of the incidence of ureteral obstruction after aortic bifurcation grafting, 120 patients were entered into the study: 19 were subsequently excluded for cause, and 101 patients were studied by isotope renography. The renographic findings were indicative for subsequent intravenous pyelography, which was performed in 26 patients. In two cases supplementary retrograde pyelograms were done. Two patients (2%) had ureteral obstruction related to the vascular prosthesis, and in one of these patients the process was bilateral. The lesions were asymptomatic in both patients.