Evaluation and treatment of diabetic foot ulcers

Diabetic foot problems, such asulcerations, infections, and gan-grene, are the most common cause of hospitalization among diabetic patients. Routine ulcer care, treatment of infections, amputations, and hospitaliza-tions cost billions of dollars every year and place a tremendous burden on the health care system. The average cost of healing a single ulcer is $8,000, that of an infected ulcer is $17,000, and that of a major amputa-tion is $45,000. More than 80,000 ampu-tations are performed each year on dia-betic patients in the United States, and ~ 50 % of the people with amputations will develop ulcerations and infections in the contralateral limb within 18 months. An alarming 58 % will have a contralat-eral amputation 3–5 years after the first amputation. In addition, the 3-year mor-tality after a first amputation has been estimated as high as 20–50%, and these numbers have not changed much in the past 30 years, despite huge advances in the medical and surgical treatment of patients with diabetes. Etiology “The majority of foot ulcers appear to result from minor trauma in the presence of sensory neuropathy. ” This famous but simple quote from McNeely et al.1 best describes the critical triad most com-monly seen in patients with diabetic foot ulcers: peripheral sensory neuropathy, deformity, and trauma. All three of these risk factors are present in 65 % of diabet-ic foot ulcers. Calluses, edema, and peripheral vascular disease have also been identified as etiological factors in the development of diabetic foot ulcers. 91CLINICAL DIABETES • Volume 24, Number 2, 2006 Although the pathogenesis of periph-eral sensory neuropathy is still poorly understood, there seem to be multiple mechanisms involved, including the for-mation of advanced glycosylated end products and diacylglycerol, oxidative stress, and activation of protein kinas