New Study Reveals Elevated Mortality Risk In Patients With Hindfoot DFUs
26. April 2021
Jeff Hall, Senior Contributing Editor

In a recently published study looking at mortality rates in patients with diabetes, researchers found that patients with hindfoot diabetic foot ulcerations (DFUs) had an over sixfold higher risk of mortality.1

The study, published online by Diabetic Medicine, involved 98 patients (81 with type 2 diabetes and 17 with type 1 diabetes).1 Schofield and colleagues followed patients up to four years after they presented to podiatry with a DFU. Sixty-nine percent of the DFUs were forefoot ulcerations and 23 percent were hindfoot ulcers, according to the study. For the patients with hindfoot DFUs, Schofield and coworkers noted a 6.3-fold increased risk of death independent of other risk factors such as BMI, HbA1c, age and total cholesterol.

In her clinical experience, Stephanie C. Wu, DPM, MSc, FACFAS says patients with hindfoot DFUs tend to have poorer overall health, which significantly contributes to worsening outcomes.

“Should the wound become infected, these patients (with hindfoot DFUs) tend to deteriorate quickly. (Due to) the anatomical location of wound/infection, most patients end up with more adverse outcomes in terms of amputations (either a Symes, transtibial or even more proximal amputations) that have been shown to be associated with higher mortality rates,” notes Dr. Wu, the founding Vice President of the American Limb Preservation Society (ALPS).

Hindfoot DFUs are particularly challenging to treat and heal, according to Dr. Wu. She says the frequently chronic nature of these wounds leads to an increased susceptibility to infection, which is compounded even further by a variety of concomitant conditions in this patient population.

“The majority of patients with hindfoot ulcers, at least in our practice, have underlying conditions such as Charcot neuroarthropathy that resulted in some form of musculoskeletal dysfunction/deformity,” explains Dr. Wu. “They also have concomitant conditions such as severe heart disease, renal failure, cardiovascular impairment, and are often not good surgical candidates.”

In the aforementioned Diabetic Medicine study, Schofield and colleagues pointed out that 35 percent of the study patients died from renal failure and 62 percent of the study patients had vascular insufficiency.1

Noting the likelihood of poor tissue perfusion in this patient population, Dr. Wu emphasizes timely vascular assessment for patients who present with hindfoot ulcerations.

“In addition to the standard vascular exams, I make sure to obtain TCPo2 or skin perfusion pressure (SPP) to help assess perfusion to the surrounding wound area,” maintains Dr. Wu. “I also look to ensure the patient is being managed closely by his or her PCP and cardiologist. Increased mortality rates in this patient population are not necessarily from the wound itself but from cardiovascular issues that result from autonomic neuropathy.”

Dr. Wu says the lack of mobility in this patient population compounds the health issues even further.

“A good portion of patients with heel ulcers require wheelchairs and are unable to transfer without assistance. They tend to have poorer physical functioning when compared to those with forefoot ulcers, and their reduced mobility, independence and possible associated depression further contribute to their poor health,” says Dr. Wu.


  1. Schofield H, Haycocks S, Robinson A, et al. Mortality in 98 type 1 diabetes mellitus and type 2 diabetes mellitus: foot ulcer location is an independent risk determinant. Diabet Med. 2021 Mar 27; e14568. Doi: 10.1111/dme.14568. Online ahead of print.

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