Risk Factors for Plantar Foot Ulcer Recurrence in Neuropathic Diabetic Patients

Abstract

OBJECTIVERecurrence of plantar foot ulcers is a common and major problem in diabetes but not well understood. Foot biomechanics and patient behavior may be important. The aim was to identify risk factors for ulcer recurrence and to establish targets for ulcer prevention. RESEARCH DESIGN AND METHODSAs part of a footwear trial, 171 neuropathic diabetic patients with a recently healed plantar foot ulcer and custom-made footwear were followed for 18 months or until ulceration. Demographic data, disease-related parameters, presence of minor lesions, barefoot and in-shoe plantar peak pressures, footwear adherence, and daily stride count were entered in a multivariate multilevel logistic regression model of plantar foot ulcer recurrence. RESULTSA total of 71 patients had a recurrent ulcer. Significant independent predictors were presence of minor lesions (odds ratio 9.06 [95% CI 2.98-27.57]), day-to-day variation in stride count (0.93 [0.89-0.99 CONCLUSIONSThe presence of a minor lesion was clearly the strongest predictor, while recommended use of adequately offloading footwear was a strong protector against ulcer recurrence from unrecognized repetitive trauma. These outcomes define clear targets for diabetic foot screening and ulcer prevention.In patients with diabetes, foot ulcers are a serious risk for infection and amputation (1). The prevention of foot ulcers is important to avoid these devastating outcomes. Several studies have identified risk factors for diabetic foot ulceration, which include, among others, peripheral neuropathy, peripheral arterial disease, and foot deformity (2-7). The strongest predictors of ulceration are presence of peripheral neuropathy and a history of ulceration, which shows that ulcers often recurdup to 40% annually (8). Ulcer recurrence significantly increases long-term costs for diabetic foot care (9) and further increases risk for amputation and deterioration of

Diabetic foot ulcers: a review of current management

“…9,10 These risk factors are as follows: gender (male), duration of diabetes longer than 10 years, advanced age of patients, high Body Mass Index, and other comorbidities such as retinopathy, diabetic peripheral neuropathy, peripheral vascular disease, glycosylated hemoglobin level (HbA1c), foot deformity, high plantar pressure, infections, and inappropriate foot self-care habits (Table 1). [9][10][11] Most Diabetic foot ulcers till date has been caused by ischemic, neuropathic or combined neuro-ischemic abnormalities Only 10% of Diabetic foot ulcers are pure ischemic ulcers and 90% are caused by neuropathy, alone or with ischemia. [12][13][14] Peripheral sensorimotor and autonomic neuropathy is the most common pathway for development of foot problems in diabetic patients that leads to high foot pressure, foot deformities, and gait instability, which increases the risks of developing ulcers.…”

Role and Determinants of Adherence to Off-loading in Diabetic Foot Ulcer Healing: A Prospective Investigation

“…Although clinical opinion speaks to the importance of adherence to off-loading in DFU healing, research conducted to date either examined the role of off-loading adherence in DFU prevention (13) or, when assessing off-loading in DFU healing, focused on total adherence, as assumed with TCC rather than varying levels of adherence, as determined by patients using removable devices (11,12). The only study that examined adherence to RCW in patients with active DFU found it to be low (14); however, no attempt was made to link off-loading adherence to DFU healing in this report.…”

Beyond dichotomous thinking: a process perspective on diabetic foot disease

“…This reinforces David´s belief that therapeutic shoes cannot prevent ulcers (incorrect mental model of the DF) and consequently further reduces his adherence to wearing them, which becomes a self-fulfilling prophecy confirming his incorrect mental model. Every turn in this vicious cycle (Figure 2(b)) fosters a fatalistic view that ulcers cannot be prevented, a common view among patients [24], despite evidence for the preventive effect of wearing therapeutic shoes [41].

Figure 1.Visualization of the process perspective on the diabetic foot (DF).

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