Diabetic foot ulcers are a “silent, sinister syndrome” that contribute to far too many amputations and deaths, said David G. Armstrong, DPM, PhD, a podiatric surgeon at Keck Medicine of USC.
A new review published in JAMA highlights the prevalence of diabetic foot ulcers and identifies best practices to prevent and treat them, along with strategies to reduce recurrence rates.
“This is the first and most comprehensive guide on the subject,” said Armstrong, the review’s lead author, noting that the study is meant to serve as a roadmap for clinicians.
How prevalent are diabetic foot ulcers?
In an analysis of thousands of manuscripts from January 2013 and May 2023, Armstrong and his co-authors found that up to 34% of patients with diabetes develop a foot ulcer at some point in their lives. It affects 18.6 million patients globally — including 1.6 million people in the United States — each year.
This is because peripheral neuropathy is common among patients with diabetes. “They lose the ‘gift’ of pain,” Armstrong said. “They wear a hole in their foot as you would a hole in your shoe” because the affected individuals can’t feel the bottom of their feet.
The team found that up to 20% of diabetic foot ulcer cases result in a lower extremity amputation, mainly due to infections and gangrene. The data shows that Black, Hispanic, and Native American patients, as well as people with lower socioeconomic status, are at greater risk for developing diabetic foot ulcers that result in amputation.
Still, even patients who recover from a diabetic foot ulcer face continued risk.
“We use the term ‘remission’ to describe this patient population because they’re not fully healed and the risk doesn’t go away,” Armstrong said. The risk of recurrence is 42% after one year, and 65% at five years, the JAMA study found.
The five-year mortality rate for diabetic foot ulcer patients is about 30%, and it exceeds 70% for those who undergo a major amputation. “That’s worse than some forms of cancer,” Armstrong said. “This is a deadly condition and we need to treat it appropriately.”
Advancements in diabetic foot ulcer treatments
A multidisciplinary approach significantly improves outcomes for diabetic foot ulcer patients, Armstrong and his co-authors concluded. The study found that when a group of specialists — including podiatrists, infectious disease experts, vascular surgeons, and diabetologists — work in close collaboration, amputation rates drop.
“Referring a diabetes patient to a foot doctor can be a limb saver and a lifesaver,” Armstrong said. “The data shows that if a person sees a primary care doctor and a foot specialist, and then develops a wound over the next year, their risk of getting an amputation is dramatically reduced, along with their risk for death.”
Which is why Armstrong and his team include step-by-step instructions for assessing a foot ulcer and a flowchart with treatment recommendations in the study. Suggested treatments include weekly or bi-weekly debridement and offloading pressure from a patient’s body weight with a specialized cast or a surgical boot.
“We talk about current and next-generation wound-healing therapies analyzed in randomized controlled trials,” Armstrong said. “Everything from topical fibrin and leukocyte platelet patches, to placenta-derived products, to hyperbaric oxygen therapy.”
To help avoid recurrence, the study examines the value of patient education — including self-care, regular examinations and immediate treatment of calluses and pre-ulcer signs. The study also focuses on early and “aggressively conservative” surgical intervention to improve blood flow and reconstruct the foot to reduce risk for ulceration or amputation.
A highly focused effort at Keck Medicine
The highly specialized team at Keck Medicine is leading the way in improving care for diabetic foot ulcers. Armstrong is an internationally recognized leader in diabetic foot care and limb preservation, and he leads a team focused on eliminating preventable amputations over the next generation. He received the 2023 Karel Bakker Lifetime Achievement Award from the American Limb Preservation Society.
The study’s second author, Tze-Woei Tan, MD, a vascular surgeon at Keck Medicine, and co-director of the USC Limb Preservation Program, was also recently honored with the American Diabetes Association’s Roger E. Pecoraro Award.
"Top international awards like this demonstrate the strength of a really great team of women and men who really care about solving this problem,” Armstrong said. “Keck Medicine is at the center of a lot of the work that’s going on in limb preservation worldwide. It's really fun to be doing our best to help people move through the world a little better.”