Extent of the Problem

Foot ulcerations are one of the most common complications affecting patients with diabetes mellitus. One in four diabetic individuals will develop a lower extremity ulceration, most commonly in the mid to later stages of life. 

Roughly 85% of lower limb amputations in this patient population are preceded by an unhealed ulceration. It’s estimated that nearly 80,000 lower extremity amputations are performed each year in the United States on diabetic individuals, with an associated two–year treatment cost of more than $90,000 per person. Of much greater significance: the 5–year mortality after amputation for this group has been reported at nearly 45%. Recent literature suggests that if more attention is provided to foot care in this high risk patient population, serious complications and even death can be prevented. The Wound Center has a thorough approach to evaluating and managing these difficult diabetic foot wounds. Healing is achieved in cooperation with referring physicians, surgeons, podiatrists and patients. 

Infographic: Diabetes Risks, Reality and Resources

Causes of the problem

Peripheral neuropathy and minor trauma are critical factors which lead to foot and leg wounds in patients with diabetes. Once an injury occurs, the faulty healing in patients with diabetes can lead to a chronic wound. Ischemia (tissue hypoxia) and infection play major roles in healing failure. Low periwound tissue oxygen levels are uniformly associated with initial wound healing failure and increased infection risk. 

Treatment of the problem

Many authors have demonstrated the importance of providing an aggressive multidisciplinary approach to the management of patients with diabetic wounds. Frequently the total care required for optimal outcome exceeds the resources which any single physician can provide. The Wound Center provides a multidisciplinary approach to care and offers certain unique resources for patient evaluation and treatment:

• Since periwound tissue hypoxia has been shown to be an important determinant of wound healing in diabetic patients, the Wound Center can perform transcutaneous oxygen measurements when necessary. Patients with demonstrated tissue hypoxia and an abnormal pulse examination receive further peripheral vascular evaluation and possible surgical intervention. 
• Adjunctive hyperbaric oxygen treatment (HBOT) can be an important aspect of the treatment armamentarium as well. This therapy, recommended in the American Diabetes Association treatment guidelines, also improves the host response to local soft tissue and bone infection.
• Aggressive wound debridement is a mainstay in diabetic foot wound treatment. Initial surgical debridement, tissue cultures, and regular follow–up provide the best opportunity for healing.
• Pressure relief of plantar ulcers is provided utilizing orthotics and advanced casting techniques to support both initial wound healing and subsequently for long term re-injury prevention.
• Cellular and/or tissue based products, topically applied growth factors and negative pressure wound therapy may be used to support and promote more rapid wound healing in selected cases.
• Patient education is vital to improve compliance with initial treatment requirements. Lifestyle modifications to prevent future wounding are also stressed.

Team Effort

While treatment of established wounds in patients with diabetes is vital, reducing the overall risk of both complications and amputations is equally important. Discharge education focuses on patient follow–up with their primary physician, endocrinologist and podiatrist to maintain health, receive proper footwear, and undergo frequent foot examination.  

Patients are referred to the Wound Center for aggressive, outcome–based wound management. Our services are designed to complement the attending physician’s care by providing expert wound management consultation and intervention using evidence–based clinical practice guidelines. 

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After a leg injury threatened to keep him off of his motorcycle, Shane Lark began hyperbaric oxygen treatment with the goal of a quick recovery.