Diabetic foot ulceration is a serious complication of diabetes mellitus; it is the cause of more than half of nontraumatic lower limb amputations. Diabetic foot ulcers are the major cause of hospital admission for diabetic patients. Treatment costs are high. There have been advances in managing diabetic foot ulceration with the development of new dressings, growth factors, skin substitutes, and other novel approaches to stimulating wound healing. The management of vascular disease in the patient with diabetes mellitus is an essential and important consideration. However, the need for a multidisciplinary team to provide good foot care to diabetic patients is still vital for the prevention and treatment of diabetic foot ulceration.
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References
1.
1. Reiber G. The epidemiology of diabetic foot problems . Diabet Med1996;13: S6-S11 .
2.
2. Pecoraro R. The nonhealing diabetic ulcer—a major cause for limb loss. In: Barbul A, Caldwell M, Eaglstein W, editors. Clinical and experimental approaches to dermal and epidermal repair: normal and chronic wounds. New York: Wiley-Liss ; 1991. p. 27-43.
3.
3. Songer T. The economics of diabetes care. In: Alberti KGMM, DeFronzo R, Keen H, Zimmet P, editors. International textbook of diabetes mellitus. Chichester, UK: Wiley ; 1987, p. 1643-1654.
4.
4. Reiber G. Diabetic foot care: financial implications and practical guidelines. Diabetes Care1992;15: 29-31 .
5.
5. Williams D, Airey M. The size of the problem: epidemiological and economic aspects of foot problems in diabetes. In: Boulton A, Connor H, Cavanagh P, editors. The foot in diabetes. 3rd ed. Chichester, UK: Wiley ; 2000. p. 3-17.
6.
6. Smith D, Wienberger M, Katz B. A controlled trial to increase office visits and reduce hospitalisations of diabetic patients . J Gen Intern Med1987;2: 232-238 .
7.
7. Laing P, Cogley D, Klenerman L. Economic aspects of diabetic foot . Foot1991;1: 111-112 .
8.
8. Pecoraro R, Reiber G, Burgess E. Pathways to diabetic limb amputation: basis for prevention . Diabetes Care1990;13: 513-521 .
9.
9. Apelqvist J, Larsson J, Agardh C. Long-term prognosis for diabetic patients with foot ulcers. J Intern Med1993;233: 485-491 .
10.
10. WHO/IDF Europe. Diabetes care and research in Europe: the St. Vincent declaration . Diabet Med1990;7: 360-360 .
11.
11. Oyibo S, Abouaesha F, Connor H, et al. The diabetic foot 2000 . Diabet Med2000;17: 875-876 .
12.
12. Thomson F, Veves A, Ashe H, et al. A team approach to diabetic foot care: the Manchester experience . Foot1991;1: 75-82 .
13.
13. Young MJ, Breddy JL, Veves A, et al. The prediction of neuropathic foot ulceration using vibration perception thresholds . Diabetes Care1994;18: 34-38 .
14.
14. Shaw J, Zimmett P. The epidemiology of diabetic neuropathy . Diabetes Rev1999;7: 245-252 .
15.
15. Dyck P, Kratz K, Karnes J, et al. The prevalence by staged severity of various types of diabetic neuropathy, nephropathy and retinopathy in a population-based cohort: the Rochester Diabetic Neuropathy Study . Neurology1993;43: 817-824 .
16.
16. Abbott C, Carrington A, Ashe H, et al. The North-West Diabetes Foot Care Study: incidence of and risk factors for new diabetic foot ulceration in a community-based patient cohort . Diabetic Med2002;19: 377-384 .
17.
17. Young M, Boulton A, McLeod A, et al. A multi-centre study of the prevalence of diabetic neuropathy in the UK hospital clinic population . Diabetologia1993;36: 150-154 .
18.
18. Cabezas-Cerrato J. The prevalence of clinical diabetic polyneuropathy in Spain: a study in primary care and hospital clinic groups . Diabetologia1998;41: 1263-1269 .
19.
19. Tesfaye S, Stevens L, Stephenson J, et al. Prevalence of diabetic peripheral neuropathy and its relation to glycaemic control and potential risk factors: the Eurodiab IDDM Complications Study . Diabetologia1996;29: 1377-1384 .
20.
20. DCCT Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus . N Engl J Med1993;329: 977-986 .
21.
21. Ziegler D, Wiefels K, Dannehl K, et al. Effects of one year of near-normoglycaemia on peripheral nerve function in type 1 (insulin dependent) diabetic patients . Klin Wochenschr1988;66: 388-396 .
22.
22. Wang P, Lau J, Chalmers T. Meta-analysis of effects of intensive blood glucose control on the late diabetic complications of type 1 diabetes . Lancet1993;341: 1306-1309 .
23.
23. Cotter M, Cameron N. The aetiopathogenesis of diabetic neuropathy: metabolic theories. In: Boulton A, editor. Diabetic neuropathy. Lancashire, UK: Marius ; 1997. p.97-119.
24.
24. Cotter M, Cameron N. The aetiopathogenesis of diabetic neuropathy: vascular theories. In: Boulton AJM, editor. Diabetic neuropathy. Lancashire, UK: Marius ; 1997. p. 121-146.
25.
25. Young M, Boulton A, Williams D, et al. A multi-centre study of the prevalence of diabetic neuropathy in patients attending UK diabetic clinics . Diabetologia1993;36: 150-154 .
26.
26. Abbott C, Carrington A, Faragher B, et al. Prospective risk factors for diabetic foot ulceration in a large population sample . Diabetes1999;48: A78-A78 .
27.
27. Vileikyte L, Hutchings G, Hollis S, et al. The tactile circumferential discriminator: a new, simple screening device to identify diabetic patients at risk of foot ulceration . Diabetes Care1997;20: 623-626 .
28.
28. Young M, Breddy J, Veves A, et al. The prediction of diabetic foot ulceration using vibration perception thresholds . Diabetes Care1994;17: 557-561 .
29.
29. DCCT Research Group. The effect of intensive diabetes therapy on the development and progression of neuropathy . Ann Intern Med1995;122: 561-568 .
30.
30. Navarro X, Sutherland D, Kennedy W. Long-term effects of pancreatic transplantation on diabetic neuropathy . Ann Neurol1997;42: 727-736 .
31.
31. Boulton A. Current and emerging treatments of diabetic neuropathies . Diabetes Rev1999;7: 379-386 .
32.
32. Abuaisha B, Costanzi J, Boulton A. Acupuncture for the treatment of chronic painful peripheral diabetic neuropathy: a long-term study . Diabetes Res Clin Pract1998;39: 115-121 .
33.
33. Hamza M, White P, Craig W, et al. Percutaneous electrical nerve stimulation: a novel analgesic therapy for diabetic neuropathic pain . Diabetes Care2000;23: 365-370 .
34.
34. Steele J, Faulds F, Goa K. Epalrestat: a review of its pharmacology and therapeutic potential in late-onset complications of diabetes mellitus . Drugs Aging1993;3: 532-555 .
35.
35. Boulton A, Levin S, Comstock J. A multicentre trial of the aldose reductase inhibitor, tolrestat, in patients with symptomatic diabetic neuropathy . Diabetologia1990;33: 431-431 .
36.
36. Ziegler D, Hanefeld M, Ruhnau K, et al. Treatment of symptomatic diabetic peripheral neuropathy with anti-oxidant alpha-lipoic acid: a 3-week multicentre randomised controlled trial (ALADIN Study) . Diabetologia1995;38: 1425-1433 .
37.
37. Ziegler D, Reljanovic M, Mehnert H, et al. Alpha-lipoic acid in the treatment of diabetic polyneuropathy in Germany: current evidence from clinical trials . Exp Clin Endocrinol Diabetes1999;107: 421-430 .
38.
38. Horrobin D. Essential fatty acids in the management of impaired nerve function in diabetes . Diabetes1997;46: S90-S93 .
39.
39. Jamal G, Carmichael H. The effect of gamma-linolenic acid on human diabetic peripheral neuropathy: a double-blind placebocontrolled trial . Diabet Med1990;7: 319-323 .
40.
40. Reja A, Tesfaye S, Harris N, et al. Improvement in nerve conduction and quantitative sensory tests after treatment with lisinopril . Diabet Med1995;12: 307-309 .
41.
41. Malik R, Williams S, Abbott C, et al. Effect of angiotensin-converting-enzyme (ACE) inhibitor trandolapril on human diabetic neuropathy: randomised double-blind controlled trial . Lancet1998;352: 1978-1981 .
42.
42. Apfel S, Schwartz S, Adornato B, et al. Efficacy and safety of recombinant human nerve growth factor in patients with diabetic polyneuropathy: a randomised controlled trial . rhNGF Clinical Investigator Group. JAMA2000;284: 2215-2221 .
43.
43. Young M, Adams J, Anderson G, et al. Medial arterial calcification in the feet of diabetic patients and matched non-diabetic control subjects . Diabetologia1993;36: 615-621 .
44.
44. Jude E, Oyibo S, Chalmers N, et al. Peripheral arterial disease in diabetic and non-diabetic patients: a comparison of severity and outcome . Diabetes Care2001;24: 1433-1437 .
45.
45. Fowkes F, Housley E, Riemersma R, et al. Smoking, lipids, glucose intolerance, and blood pressure as risk factors for peripheral atherosclerosis compared with ischemic heart disease in the Edingburgh Artery Study . Am J Epidemiol1991;135: 331-340 .
46.
46. Reiber G, Pecoraro R, Koepsell T. Risk factors for amputation in patients with diabetes: a case control study . Ann Int Med1992;117: 97-105 .
47.
47. Boulton A. Why bother educating the multi-disciplinary team and the patient—the example of prevention of lower extremity amputation in diabetes . Patient Education and Counseling1995;26: 183-188 .
48.
48. Malone J, Snyder M, Anderson G, et al. Prevention of amputation by diabetic education . Am J Surg1989;158: 520-524 .
49.
49. Young M, Cavanagh P, Thomas G, et al. The effect of callus removal on dynamic plantar foot pressures in diabetic patients . Diabetic Med1992;9: 55-57 .
50.
50. Ronnemma T, Hamalainen H, Toikka T, et al. Evaluation of the impact of podiatrist care in the primary prevention of foot problems in diabetic subjects . Diabetes Care1997;20: 1833-1837 .
51.
51. Ward A. Footwear and orthoses for diabetic patients . Diabetic Med1993;10: 497-498 .
52.
52. Mason J. O'Keeffe C, McIntosh A, et al. A systematic review of foot ulcers in patients with type 2 diabetes: prevention . Diabetic Med1999;16: 801-862 .
53.
53. Uccioli L, Aldeghi A, Faglia E, et al. Manufactured shoes in the prevention of diabetic footwear . Diabetes Care1995;18: 1376-1378 .
54.
54. Reiber G, Smith D, Wallace C, et al. Effect of therapeutic footwear on foot reulceration in patients with diabetes a randomized controlled trial . JAMA2002;287: 2552-2558 .
55.
55. Cavanagh P, Boulton A, Sheehan P, et al. Therapeutic footwear in patients with diabetes . JAMA2002;288: 1231-1232 .
56.
56. Dahmen R, Haspels R, Koomen B, et al. Therapeutic footwear for the neuropathic foot: an algorithm . Diabetes Care2001;24: 705-709 .
57.
57. McCabe C, Stevenson R, Dolan A. Evaluation of a diabetic foot screening and protection programme . Diabetic Med1998;15: 80-84 .
58.
58. Jeffcoate W, Macfarlane R, Fletcher E. The description and classification of diabetic foot lesions . Diabet Med1993;10: 676-679 .
59.
59. Lavery L, Armstrong D, Harkless L. Classification of diabetic foot wounds . J Foot Ankle Surg1996;35: 528-531 .
60.
60. Oyibo S, Jude E, Tarawneh I, et al. Comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas Systems . Diabetes Care2001;24: 84-88 .
61.
61. Oyibo S, Jude E, Tarawneh I, et al. The effects of ulcer size and site, patient's age, gender and type and duration of diabetes on the outcome of diabetic foot ulcers . Diabet Med2001;18: 133-138 .
62.
62. Grayson M, Gibbons G, Balogh K, et al. Probing to bone in infected pedal ulcers: a clinical sign of underlying osteomyelitis in diabetic patients . JAMA1995;273: 721-723 .
63.
63. Edmonds M, Foster A. Stage 3: The ulcerated foot. In: Managing the diabetic foot. London: Blackwell Science ; 2000. p. 45-76.
64.
64. Lipsky B, Pecoraro R, Larson S, et al. Outpatient management of uncomplicated lower-extremity infections in diabetic patients . Arch Intern Med1990;150: 790-797 .
65.
65. Venkatesan P, Lawn S, Macfarlane R, et al. Conservative management of osteomyelitis in the feet of diabetic patients . Diabetic Med1997;14: 487-490 .
66.
66. Murray H, Young M, Hollis S, et al. The association between callus formation, high pressures and neuropathy in diabetic foot ulceration . Diabetic Med1996;13: 979-982 .
67.
67. Balkin S, Kaplan L. Injectable silicone and the diabetic foot: a 25-year report . Foot1991;2: 83-88 .
68.
68. Van Schie C, Whalley A, Vileikyte L, et al. Efficacy of injected liquid silicone in the diabetic foot to reduce risk factors for foot ulceration . Diabetes Care2000;23: 634-638 .
69.
69. Smiell J, Wieman T, Steed D, et al. Efficacy and safety of Becaplermin (recombinant human platelet-derived growth factor-BB) in patients with non-healing lower extremity diabetic ulcers: a combined analysis of four randomised controlled studies . Wound Rep Regen1999;7: 335-346 .
70.
70. Steed D, Donohoe D, Webster N, et al. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers . J Am Coll Surg1996;183: 61-64 .
71.
71. Gough A, Clapperton M, Rolando N, et al. Randomised placebocontrolled trial of granulocyte-colony stimulating factor in diabetic foot infection . Lancet1997;350: 855-859 .
72.
72. Sabolinski M, Toole T, Giovino K, et al. Graft skin bi-layered living skin construct in the treatment of diabetic foot ulcers . Diabetologia2000;43: A16-A16 .
73.
73. Gentzkow G, Iwasaki S, Hershon K, et al. Use of Dermagraft, a cultured human dermis to treat diabetic foot ulcers . Diabetes Care1996;19: 350-354 .
74.
74. Mansbridge J, Liu K, Patch R, et al. Three-dimensional fibroblast culture implant for the treatment of diabetic foot ulcers: metabolic activity and therapeutic range . Tissue Eng1998;4: 403-414 .
75.
75. Mansbrige J, Liu K, Pinney R, et al. Growth factors secreted by fibroblasts: role in healing diabetic foot ulcers . Diabetes Obes Metab1999;1: 265-279 .
76.
76. Veves A, Sheehan P, Pham H. A randomized, controlled trial of. Promogran (a collagen/oxidized regenerated cellulose dressing) vs standard treatment in the management of diabetic foot ulcers . Arch Surg2002;137: 822-827 .
77.
77. Petrova A. Gipsfulung von Knochenhohlen bei Osteomyelitis . Zentral Ges Chir1928;43: 885-885 .
78.
78. Armstrong D, Findlow A, Oyibo S, et al. The use of absorbable antibiotic-impregnated calcium sulphate pellets in the management of diabetic foot ulcers . Diabet Med2001;18: 941-942 .
79.
79. Mackey D, Varlet A, Debeaumont D. Antibiotic loaded plaster of Paris pellets: an in vitro study of a possible method of local antibiotic therapy in bone infection . Clin Orthop1982;167: 263-268 .
80.
80. Thomas S, Jones M, Shutler S, et al. Using larvae in modern wound management . Journal of Wound Care1996;5: 60-69 .
81.
81. Thomas S. New drugs for diabetic foot ulcers: larval therapy. In: Boulton AJM, Connor H, Cavanagh PR, editors. The foot in diabetes. 3rd ed. Chichester, UK: Wiley ; 2000. p. 185-191.
82.
82. Casu R, Eisemann C, Vuoclo T, et al. The major excretory/secretory protease from Lucilia cuprina larvae is also gut digestive protease . Int J Parasitol1996;26: 623-628 .
83.
83. Patel V, Wieman T. Effect of metatarsal head resection for diabetic foot ulcers on the dynamic plantar pressure distribution . Am J Surg1994;167; 297-301 .
84.
84. Wieman T, Mercke Y, Cerrito P, et al. Resection of the metatarsal head for diabetic foot ulcers . Am J Surg1998;176: 436-441 .
85.
85. Lin S, Lee T, Wapner K. Plantar forefoot ulceration with equines deformity of the ankle in diabetic patients: the effect of tendo-Achilles lengthening and total contact cast . Orthopedics1996;19: 465-475 .
86.
86. Armstrong D, Stacpoole-Shea, Nguyen H, et al. Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot . J Bone Joint Surg Am2000;82-A: 1196-1196 .
87.
87. Olejniczak S, Zielinski A. Low hyperbaric oxygen therapy in the management of leg ulcers . Mich Med1975;74: 707-707 .
88.
88. Kalani M, Jorneskog G, Naderi N, et al. Hyperbaric oxygen (HBO) therapy in the treatment of diabetic foot ulcers: long-term follow-up . J Diabetes Complication2002;16: 153-158 .
89.
89. Leslie C, Sapio F, Ginunas V, et al. Randomised controlled trial of topical hyperbaric oxygen for treatment of diabetic foot ulcers . Diabetes Care1988;11: 111-115 .
90.
90. Faglia E, Favales F, Aldeghi A, et al. Adjunctive systemic hyperbaric oxygen therapy in the treatment of severe prevalently ischemic diabetic foot ulcers . Diabetes Care1996;19: 1338-1343 .
91.
91. Landau Z, Schattner A. Topical hyperbaric oxygen and low energy laser therapy for chronic diabetic foot ulcers resistant to conventional treatment . Yale J Biol Med2001;74: 95-100 .
92.
92. Clare M, Fitzgibbons T, McMullen S, et al. Experience with the vacuum assisted closure negative pressure technique in the treatment of non-diabetic and dysvascular wounds . Foot Ankle Int2002;23: 896-901 .
93.
93. Litzelman D, Slemenda C, Langfeld C, et al. Reduction of lower extremity clinical abnormalities in patients with non-insulin dependent diabetes mellitus: a randomised controlled trial . Ann Intern Med1993;119: 36-41 .
94.
94. Dargis V, Pantelejeva O, Jonushaite A, et al. Benefits of a multidisciplinary approach in the management of recurrent diabetic foot ulceration in Lithuania: a prospective study . Diabetes Care1999;22: 1428-1431 .
