Diagnosis and Management of Diabetic Foot Complications

| At least half of all amputations occur in people with diabetes, most commonly because of an infected diabetic foot ulcer. A thorough understanding of the causes and management of diabetic foot ulceration is essential to reducing lower-extremity amputation risk. This compendium elucidates the pathways leading to foot ulcers and enumerates multiple contributory risk factors. The authors emphasize the importance of appropriate screening and wound classification and explain when patients should be referred for specialist care, targeted education, or therapeutic shoes or insoles. They provide a comprehensive review of treatment approaches, including devices for foot lesion off-loading and aggressive wound debridement through mechanical, enzymatic, autolytic, biologic, and surgical means. Because infection and peripheral artery disease are key contributors to amputation risk, the authors discuss the diagnosis and management of these conditions in detail. They also review the expanding armamentarium of evidence-based adjunctive treatments for foot ulcers, including growth factors, skin substitutes, stem cells, and other biologics. Because Charcot neuroarthropathy is a serious but frequently missed condition in people with diabetic neuropathy, the authors explain the differential diagnosis of the hot, swollen foot that is a hallmark of this condition. The article ends with an overview of four strategies for maintaining a foot in remission, followed by a brief look at the future of diabetic foot care. F problems in diabetes are common and costly, and people with diabetes make up about half of all hospital admissions for amputations. In the United Kingdom, people with diabetes account for more than 40% of hospitalizations for major amputations and 73% of emergency room admissions for minor amputations. Because most amputations in diabetes are preceded by foot ulceration, a thorough understanding of the causes and management of ulceration is essential. The annual incidence of foot ulcers in diabetes is approximately 2% in most Western countries, although higher rates have been reported in certain populations with diabetes, including Medicare beneficiaries (6%) and U.S. veterans (5%) (1). Although the lifetime risk of foot ulcers until recently was generally believed to be 15–25%, recent data suggest that the figure may be as high as 34% (1). It was the famous diabetes physician Elliott P. Joslin who, having observed many clinical Diagnosis and Management of Diabetic Foot Complications Andrew J.M. Boulton, MD, DSc (Hon), FACP, FRCP David G. Armstrong, DPM, MD, PhD Robert S. Kirsner, MD, PhD Christopher E. Attinger, MD Lawrence A. Lavery, DPM, MPH Benjamin A. Lipsky, MD, FACP, FIDSA, FRCP (London), FFPM, RCPS (Glasg) Joseph L. Mills, Sr., MD, FACS John S. Steinberg, DPM, FACFAS University of Manchester, Manchester, U.K. University of Miami Miller School of Medicine, Miami, FL Keck School of Medicine of the University of Southern California, Los Angeles, CA Southwestern Academic Limb Salvage Alliance (SALSA), Los Angeles, CA Georgetown University School of Medicine, Washington, DC MedStar Health, Washington, DC University of Texas Southwestern Medical Center, Dallas, TX Green Templeton College, University of Oxford, Oxford, U.K. University of Washington College of Medicine, Seattle, WA Baylor College of Medicine, Houston, TX Address correspondence to Andrew J.M. Boulton, ABoulton@med.miami. edu, and David G. Armstrong,