In a large prospective study out of Australia involving over 4,700 patients with diabetic foot ulcers (DFUs), researchers identified seven factors that were negatively associated with healing, including geographical remoteness and being younger than 50 years of age.1
The authors of the study, recently published online by Diabetes Care, assessed 4,709 patients, who presented at a first visit to 65 secondary or tertiary diabetic foot services in Queensland, Australia.1 The median age of the patients was 63 and reportedly 91 percent of the study participants had type 2 diabetes, according to the study. Looking at DFU treatment outcomes, Zhang and colleagues found that seven factors were negatively associated with healing at three and 12 months: peripheral arterial disease (PAD), smoking, large ulcer size, deep ulcer, infection, geographical remoteness and patients being younger than 50 years of age.
In the study, Zhang and coworkers suggest that the negative association with younger age may reflect a younger onset of type 2 diabetes “emerging as a more severe phenotype for (foot) complications.”1 David G. Armstrong, DPM, MD, PhD, the President of the American Limb Preservation Society (ALPS), is not surprised by this study finding.
“People who have end-stage complications of diabetes earlier in life will likely have worse outcomes,” notes Dr. Armstrong, a Professor of Surgery at the Keck School of Medicine at the University of Southern California.
Stephanie Wu, DPM, FACFAS, concurs and notes that one of her patients with a family history of diabetes recently passed away at 42 years of age due to complications from diabetes.
Zhang and colleagues speculate that geographical remoteness may have resulted in delayed access to medical care or more severe presentations of DFUs at the initial specialist visit.1 Acknowledging that rural versus urban is a consistently significant factor in the literature, Drs. Armstrong and Wu say food deserts and resulting nutritional deficits may contribute to this as well.
“Within certain geographies – Los Angeles County, for example, where we have over 10 million people – those who live in food deserts have much higher amputation rates than those who live in zip codes with fancier offerings,” notes Dr. Armstrong, the Director of the Southwestern Academic Limb Salvage Alliance (SALSA).
“It is also important to mention that eating healthy is expensive and time-consuming while fast food is cheap and convenient,” says Dr. Wu, the Dean and a Professor of Surgery at the Dr. William M. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine and Science in Chicago. “Unfortunately, many patients in the more rural areas tend to eat food from gas station convenience stores or fast-food chains because of the cheap/convenience factors and show up at our doorstep with blood sugars in the 500s.”
The study authors noted that 41.5 percent (1,956 patients) of the study cohort healed at three months and 64 percent (3,012 patients) healed at 12 months.1 Knee-high offloading was a consistently positive factor for healing in both groups, according to Zhang and colleagues.
“This again shows the importance of good quality offloading in helping drive positive healing outcomes,” maintains Dr. Armstrong. “This supports the work of Wu and colleagues from 2008 showing that most centers that purport to be limb preservation centers often do not employ good quality offloading as much as they should.2 This remains a great opportunity for improvement.”
Dr. Wu says practical limitations that may thwart the use of knee-high offloading include patients refusing to pay for these offloading devices, iatrogenic limb length discrepancy leading to antalgic gait, balance issues, knee, hip or lower back pain, and falls. She does agree that there needs to be more consistent use of effective offloading in the management of patients with DFUs.
“Studies have shown that shoe padding or modifications are one of the most common types of offloading employed for DFUs.2,3 There is definitely room for improvement there,” notes Dr. Wu, the Director of the Center for Lower Extremity Ambulatory Research (CLEAR) in Chicago and the founding Vice President of ALPS.
- Zhang Y, Crumb S, McPhail SM, et al. Factors associated with healing of diabetes-related foot ulcers: observations from a large prospective real-world cohort. Diabetes Care. 2021;44:e1-e3. https://doi.org/10.2337/dc20-3120. Online ahead of print.
- Wu SC, Jensen JL, Weber AK, Robinson DE, Armstrong DG. Use of pressure offloading devices in diabetic foot ulcers: do we practice what we preach? Diabetes Care. 2008;31(11):2118-9.
- Fleischli JG, Lavery LA, Vela SA, Ashry H, Lavery DC. 1997 William J Stickel Bronze Award. Comparison of strategies for reducing pressure at the site of neuropathic ulcers. J Am Podiatr Med Assoc. 1997;87(10):466-472.