Part 6: Detection and Prevention of Foot Problems in Type 2 Diabetes

Background - Ulcer as a Risk Factor for AmputationObservational studies suggest that 6-43% of people with diabetes who have a footulcer eventually progress to amputation (Bild et al, 1989; Apelqvist et al, 1994;Larsson et al, 1995; Moss et al, 1996). Retrospective studies suggest that lowerextremity ulcers precede 71-85% of first (Reiber et al, 1992; Larsson et al, 1995;Moss et al, 1996) or second amputation (Larsson et al, 1998). While the presence of acurrent ulcer leads to an increased risk of amputation, it is important to know the levelof risk and whether a healed ulcer is also a risk factor in the assessment of the feet of aperson with diabetes for ongoing monitoring and preventative intervention. It hasbeen observed that the most likely site for plantar ulceration in neuropathic feet is atthe location of a previous ulcer (Sims et al, 1988).While sophisticated measurements are sometimes used to assess the high risk foot, thehistory of an ulcer or the detection of a current ulcer by physical examination are bothrisk factors capable of detection by all primary care health professionals. Preventativeaction can then be instituted in an easily identified high risk group (Apelqvist et al,1993).Evidence - Ulcer as a Risk Factor for AmputationA healed diabetic foot ulcer is an indicator of high risk for recurrent ulcerationand amputationA UK prospective study followed 63 neuropathic people (median age 62 years andmedian duration of diabetes 17 years) with plantar callus and high plantar footpressures. After 22 months follow-up previous ulceration proved to be the highest riskfactor for the development of a new foot ulcer with a RR of 56.8 (p=0.00001) (Murrayet al, 1996).A 14 year prospective study followed 984 diabetic individuals (mean age 64.4 yearsand a duration of diabetes 10.9 years) from a population based cohort fromWisconsin, US. A history of foot ulceration was associated with the highest OR of3.56 (CI 1.84-6.89, p≤0.0005) for amputation in a multivariate logistic regressionmodel. Male gender was also a risk factor (OR 2.66 [CI 1.49-4.76], p