For the vast majority of people with diabetes foot ulceration, ulcer healing can be achieved with debridement, offloading, infection control and re-vascularisation when required. In my view, the biggest challenges for the 21st century diabetes foot care team are reducing the substantial mortality of people with diabetes foot ulcers, a topic I return to time and again in these columns (Young, 2015), and preventing the recurrence of ulceration.
The most recent review on the subject of death after ulceration is by Jupiter et al (summarised alongside). The authors systematically reviewed the literature and reported high mortality rates after foot ulceration, over 40% at 5 years. Being male, having peripheral arterial disease and renal problems all increased mortality. Sadly, in 2015 things are only marginally better in most centres than they were in 1995.
Primary prevention of ulceration is a topic that is also frequently discussed in these columns. There is no clear evidence that it reduces ulceration, and this has threatened primary preventive podiatric care in many NHS trusts across the UK. The latest paper on this topic by Gibson et al (summarised opposite) confirms my own beliefs about the value of primary preventative podiatric care in individuals with risk factors for ulceration, but who have not yet ulcerated.
It may be true that we cannot stop individuals from developing ulcers. Many of the causes of ulceration in our patients are either bizarre (e.g. hammering a nail through their own foot by accident) or so mundane and ingrained in behavioural patterns (e.g. bad shoes) that it is not surprising they cannot be stopped even with comprehensive screening and attempts at foot care education. However, papers including Kennon et al (2012) have shown a reduction in amputation rates as screening programmes roll out. Gibson et al suggest that this is because people with risk factors for ulceration and in regular podiatric care are less likely to have amputations and be admitted to hospital. Presumably, they are identified earlier and managed quicker before the ulcers get substantially worse. Foot protection services may not prevent ulceration, but they are remarkable value for money if they can reduce amputations and are definitely worth the investment.
To view the summaries of each paper, please download the PDF of this article.