Boulton AJ, Armstrong DG: Diabetic foot and ulceration: epidemiology and pathophysiology. In: Falabella AF, Kirsner RS, editors. London: Taylor & Francis; 2005.
Boulton AJ. The diabetic foot. Medicine 2010;38:644-8.
Robert J Snyder, Robert S Kirsner, Robert A Warriner, Lawrence A Lavery, Jason R Hanft, Peter Sheehan
Consensus recommendations on advancing the standard of care for treating neuropathic foot ulcers in patients with diabetes.
Ostomy Wound Manage. 2010 Apr;56(4 Suppl):S1-24.
Abstract/Text
Diabetic foot ulcers (DFUs) are a common and serious complication of diabetes mellitus. The presence of an unhealed DFU increases the risk of infection, amputation and death. Low rates of DFU healing remain a challenge. Recognizing these issues, a consensus panel was recently convened to review the evidence and practicalities for the evaluation and treatment of patients with DFUs. This consensus panel seeks to provide clinicians with the clinical markers, evidence and recommendations that, used in conjunction with orderly decision-making and good clinical judgment, will advance the standard of care for the treatment of neuropathic DFUs.
Sarah Wild, Gojka Roglic, Anders Green, Richard Sicree, Hilary King
Global prevalence of diabetes: estimates for the year 2000 and projections for 2030.
Diabetes Care. 2004 May;27(5):1047-53.
Abstract/Text
OBJECTIVE: The goal of this study was to estimate the prevalence of diabetes and the number of people of all ages with diabetes for years 2000 and 2030.
RESEARCH DESIGN AND METHODS: Data on diabetes prevalence by age and sex from a limited number of countries were extrapolated to all 191 World Health Organization member states and applied to United Nations' population estimates for 2000 and 2030. Urban and rural populations were considered separately for developing countries.
RESULTS: The prevalence of diabetes for all age-groups worldwide was estimated to be 2.8% in 2000 and 4.4% in 2030. The total number of people with diabetes is projected to rise from 171 million in 2000 to 366 million in 2030. The prevalence of diabetes is higher in men than women, but there are more women with diabetes than men. The urban population in developing countries is projected to double between 2000 and 2030. The most important demographic change to diabetes prevalence across the world appears to be the increase in the proportion of people >65 years of age.
CONCLUSIONS: These findings indicate that the "diabetes epidemic" will continue even if levels of obesity remain constant. Given the increasing prevalence of obesity, it is likely that these figures provide an underestimate of future diabetes prevalence.
David G Armstrong, Mark A Swerdlow, Alexandria A Armstrong, Michael S Conte, William V Padula, Sicco A Bus
Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer.
J Foot Ankle Res. 2020 Mar 24;13(1):16. doi: 10.1186/s13047-020-00383-2. Epub 2020 Mar 24.
Abstract/Text
BACKGROUND: In 2007, we reported a summary of data comparing diabetic foot complications to cancer. The purpose of this brief report was to refresh this with the best available data as they currently exist. Since that time, more reports have emerged both on cancer mortality and mortality associated with diabetic foot ulcer (DFU), Charcot arthropathy, and diabetes-associated lower extremity amputation.
METHODS: We collected data reporting 5-year mortality from studies published following 2007 and calculated a pooled mean. We evaluated data from DFU, Charcot arthropathy and lower extremity amputation. We dichotomized high and low amputation as proximal and distal to the ankle, respectively. This was compared with cancer mortality as reported by the American Cancer Society and the National Cancer Institute.
RESULTS: Five year mortality for Charcot, DFU, minor and major amputations were 29.0, 30.5, 46.2 and 56.6%, respectively. This is compared to 9.0% for breast cancer and 80.0% for lung cancer. 5 year pooled mortality for all reported cancer was 31.0%. Direct costs of care for diabetes in general was $237 billion in 2017. This is compared to $80 billion for cancer in 2015. As up to one-third of the direct costs of care for diabetes may be attributed to the lower extremity, these are also readily comparable.
CONCLUSION: Diabetic lower extremity complications remain enormously burdensome. Most notably, DFU and LEA appear to be more than just a marker of poor health. They are independent risk factors associated with premature death. While advances continue to improve outcomes of care for people with DFU and amputation, efforts should be directed at primary prevention as well as those for patients in diabetic foot ulcer remission to maximize ulcer-free, hospital-free and activity-rich days.
American Diabetes Association
Diagnosis and classification of diabetes mellitus.
Diabetes Care. 2012 Jan;35 Suppl 1:S64-71. doi: 10.2337/dc12-s064.
Abstract/Text
河野茂夫：糖尿病足壊疽. Diabetes Frontier 2009; 20(4):447-451.
Apelqvist J, Bakker K, van Houtum WH et al. ：International Consensus on the Diabetic Foot. In the International Working Group on the Diabetic Foot. Amsterdam, John Wiley & Sons、1999: 67.
Robert G Frykberg, Thomas Zgonis, David G Armstrong, Vickie R Driver, John M Giurini, Steven R Kravitz, Adam S Landsman, Lawrence A Lavery, J Christopher Moore, John M Schuberth, Dane K Wukich, Charles Andersen, John V Vanore, American College of Foot and Ankle Surgeons
Diabetic foot disorders. A clinical practice guideline (2006 revision).
J Foot Ankle Surg. 2006 Sep-Oct;45(5 Suppl):S1-66. doi: 10.1016/S1067-2516(07)60001-5.
Abstract/Text
The prevalence of diabetes mellitus is growing at epidemic proportions in the United States and worldwide. Most alarming is the steady increase in type 2 diabetes, especially among young and obese people. An estimated 7% of the US population has diabetes, and because of the increased longevity of this population, diabetes-associated complications are expected to rise in prevalence. Foot ulcerations, infections, Charcot neuroarthropathy, and peripheral arterial disease frequently result in gangrene and lower limb amputation. Consequently, foot disorders are leading causes of hospitalization for persons with diabetes and account for billion-dollar expenditures annually in the US. Although not all foot complications can be prevented, dramatic reductions in frequency have been achieved by taking a multidisciplinary approach to patient management. Using this concept, the authors present a clinical practice guideline for diabetic foot disorders based on currently available evidence, committee consensus, and current clinical practice. The pathophysiology and treatment of diabetic foot ulcers, infections, and the diabetic Charcot foot are reviewed. While these guidelines cannot and should not dictate the care of all affected patients, they provide evidence-based guidance for general patterns of practice. If these concepts are embraced and incorporated into patient management protocols, a major reduction in diabetic limb amputations is certainly an attainable goal.
爲政大幾，安部正敏，池上隆太ほか：創傷・褥瘡・熱傷ガイドライン―3：糖尿病性潰瘍・壊疽ガイドライン．日皮会誌2017;127(9)：1989-2031.
日本糖尿病学会編・著：糖尿病診療ガイドライン2019．南江堂、2019．p.183-199.
日本形成外科学会、日本創傷外科学会、日本頭蓋顔面外科学会編：形成外科診療ガイドライン 3慢性創傷 糖尿病性潰瘍．金原出版、2021、p.238-268．.
F W Wagner
The dysvascular foot: a system for diagnosis and treatment.
Foot Ankle. 1981 Sep;2(2):64-122.
Abstract/Text
D G Armstrong, L A Lavery, L B Harkless
Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation.
Diabetes Care. 1998 May;21(5):855-9.
Abstract/Text
OBJECTIVE: To validate a wound classification instrument that includes assessment of depth, infection, and ischemia based on the eventual outcome of the wound.
RESEARCH DESIGN AND METHODS: We evaluated the medical records of 360 diabetic patients presenting for care of foot wounds at a multidisciplinary tertiary care foot clinic. As per protocol, all patients had a standardized evaluation to assess wound depth, sensory neuropathy, vascular insufficiency, and infection. Patients were assessed at 6 months after their initial evaluation to see whether an amputation had been performed.
RESULTS: There was a significant overall trend toward increased prevalence of amputations as wounds increased in both depth (chi 2trend = 143.1, P < 0.001) and stage (chi 2trend = 91.0, P < 0.001). This was true for every subcategory as well with the exception of noninfected, nonischemic ulcers. There were no amputations performed within this stage during the follow-up period. Patients were more than 11 times more likely to receive a midfoot or higher level amputation if their wound probed to bone (18.3 vs. 2.0%, P < 0.001, chi 2 = 31.5, odds ratio (OR) = 11.1, CI = 4.0-30.3). Patients with infection and ischemia were nearly 90 times more likely to receive a midfoot or higher amputation compared with patients in less advanced wound stages (76.5 vs. 3.5%, P < 0.001, chi 2 = 133.5, OR = 89.6, CI = 25-316).
CONCLUSIONS: Outcomes deteriorated with increasing grade and stage of wounds when measured using the University of Texas Wound Classification System.
N C Schaper
Diabetic foot ulcer classification system for research purposes: a progress report on criteria for including patients in research studies.
Diabetes Metab Res Rev. 2004 May-Jun;20 Suppl 1:S90-5. doi: 10.1002/dmrr.464.
Abstract/Text
Various different systems have been proposed to classify diabetic foot ulcers, but none has gained widespread acceptance. The International Working Group of the Diabetic Foot (IWGDF) developed a classification system for research purposes, which is described in this report. In this PEDIS system, all foot ulcers should be classified according to five categories: perfusion, extent/size, depth/tissue loss, infection and sensation. The methods to determine the presence and severity of these factors are described; each (sub)category is defined according to strict criteria, which are applicable worldwide. All experts involved and all members of the IWGDF reached consensus on this system, which will be validated first, before it can be formally introduced.
Copyright 2004 John Wiley & Sons, Ltd.
Nicolaas C Schaper, Jaap J van Netten, Jan Apelqvist, Sicco A Bus, Robert J Hinchliffe, Benjamin A Lipsky, IWGDF Editorial Board
Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update).
Diabetes Metab Res Rev. 2020 Mar;36 Suppl 1:e3266. doi: 10.1002/dmrr.3266.
Abstract/Text
Diabetic foot disease results in a major global burden for patients and the health care system. The International Working Group on the Diabetic Foot (IWGDF) has been producing evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. In 2019, all IWGDF Guidelines have been updated based on systematic reviews of the literature and formulation of recommendations by multidisciplinary experts from all over the world. In this document, the IWGDF Practical Guidelines, we describe the basic principles of prevention, classification, and treatment of diabetic foot disease, based on the six IWGDF Guideline chapters. We also describe the organizational levels to successfully prevent and treat diabetic foot disease according to these principles and provide addenda to assist with foot screening. The information in these practical guidelines is aimed at the global community of health care professionals who are involved in the care of persons with diabetes. Many studies around the world support our belief that implementing these prevention and management principles is associated with a decrease in the frequency of diabetes-related lower extremity amputations. We hope that these updated practical guidelines continue to serve as reference document to aid health care providers in reducing the global burden of diabetic foot disease.
© 2020 John Wiley & Sons Ltd.
Joseph L Mills, Michael S Conte, David G Armstrong, Frank B Pomposelli, Andres Schanzer, Anton N Sidawy, George Andros, Society for Vascular Surgery Lower Extremity Guidelines Committee
The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI).
J Vasc Surg. 2014 Jan;59(1):220-34.e1-2. doi: 10.1016/j.jvs.2013.08.003. Epub 2013 Oct 12.
Abstract/Text
Critical limb ischemia, first defined in 1982, was intended to delineate a subgroup of patients with a threatened lower extremity primarily because of chronic ischemia. It was the intent of the original authors that patients with diabetes be excluded or analyzed separately. The Fontaine and Rutherford Systems have been used to classify risk of amputation and likelihood of benefit from revascularization by subcategorizing patients into two groups: ischemic rest pain and tissue loss. Due to demographic shifts over the last 40 years, especially a dramatic rise in the incidence of diabetes mellitus and rapidly expanding techniques of revascularization, it has become increasingly difficult to perform meaningful outcomes analysis for patients with threatened limbs using these existing classification systems. Particularly in patients with diabetes, limb threat is part of a broad disease spectrum. Perfusion is only one determinant of outcome; wound extent and the presence and severity of infection also greatly impact the threat to a limb. Therefore, the Society for Vascular Surgery Lower Extremity Guidelines Committee undertook the task of creating a new classification of the threatened lower extremity that reflects these important considerations. We term this new framework, the Society for Vascular Surgery Lower Extremity Threatened Limb Classification System. Risk stratification is based on three major factors that impact amputation risk and clinical management: Wound, Ischemia, and foot Infection (WIfI). The implementation of this classification system is intended to permit more meaningful analysis of outcomes for various forms of therapy in this challenging, but heterogeneous population.
Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.
Bernadette Aulivola, Chantel N Hile, Allen D Hamdan, Malachi G Sheahan, Jennifer R Veraldi, John J Skillman, David R Campbell, Sherry D Scovell, Frank W LoGerfo, Frank B Pomposelli
Major lower extremity amputation: outcome of a modern series.
Arch Surg. 2004 Apr;139(4):395-9; discussion 399. doi: 10.1001/archsurg.139.4.395.
Abstract/Text
HYPOTHESIS: Major lower extremity amputation results in significant morbidity and mortality.
DESIGN: Retrospective database query and medical record review for January 1, 1990, to December 31, 2001. Mean follow-up was 33.6 months.
SETTING: Academic tertiary care center.
PATIENTS: Nine hundred fifty-nine consecutive major lower extremity amputations in 788 patients, including 704 below-knee amputations (BKAs) (73.4%) and 255 above-knee amputations (AKAs) (26.6%).
MAIN OUTCOME MEASURES: Patient survival, cardiac morbidity, infectious complications, and subsequent operation.
RESULTS: Overall 30-day mortality was 8.6%, worse for AKA (16.5%) than BKA (5.7%) patients (P<.001). Thirty-day mortality for guillotine amputation for sepsis control was 14.3% compared with 7.8% for closed amputation (P =.03). Complications included cardiac (10.2%), wound infection (5.5%), and pneumonia (4.5%). Twelve AKA (4.7%) and 129 BKA (18.4%) limbs required subsequent operation. Only 66 BKAs (9.4%) required conversion to AKA (average, 77.1 days postoperatively). Overall survival was 69.7% and 34.7% at 1 and 5 years, respectively. Survival was significantly worse for AKAs (50.6% and 22.5%) than BKAs (74.5% and 37.8%) (P<.001). Survival in patients with diabetes mellitus (DM) was 69.4% and 30.9% vs 70.8% and 51.0% in patients without DM at 1 and 5 years, respectively (P =.002). Survival in end-stage renal disease patients was 51.9% and 14.4% vs 75.4% and 42.2% in patients without renal failure at 1 and 5 years, respectively (P<.001).
CONCLUSIONS: Major amputation continues to result in significant morbidity and mortality. Survivors with BKA require revision or conversion to AKA infrequently. Long-term survival is dismal for patients with DM and end-stage renal disease and those undergoing AKA.
L Norgren, W R Hiatt, J A Dormandy, M R Nehler, K A Harris, F G R Fowkes, TASC II Working Group
Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II).
J Vasc Surg. 2007 Jan;45 Suppl S:S5-67. doi: 10.1016/j.jvs.2006.12.037.
Abstract/Text
