My Most Problematic Ulcer: Diabetic Foot Ulcer (DFU)
|March 8, 2017 by Arti Masturszo, MD, Executive Vice President of Clinical Innovation
I love treating all types of wounds, but I especially enjoy treating the complex cases that are not easy to heal. In my experience of treating patients in all sites of service, the DFU patient is one of the hardest to heal and keep healed. Peripheral neuropathy, combined with mechanical changes in the foot, raises the risk of trauma that results in high recidivism rates in this group. Once the injury occurs, microvascular dysfunction, peripheral vascular disease, poor glycemic control, impaired immunity, and malnutrition are just a few of the factors that make treating DFUs so challenging.
That is also what makes healing these patients so rewarding!
With about 50 percent of the Healogics patient population living with diabetes, and a quarter of the wounds treated at our Wound Care Centers being DFUs, it is imperative that we understand the impact DFUs can have on our patient’s quality of life. Here are some facts you may not know about Diabetic Foot Ulcers:
- Foot ulcerations are one of the most common complications affecting patients with diabetes mellitus.
- One in four diabetic individuals will develop a lower extremity ulceration, most commonly in the mid to later stages of life.
- Roughly 85 percent of lower limb amputations in this patient population are preceded by an unhealed ulceration.
- It’s estimated that nearly 80,000 lower extremity amputations are performed each year in the United States on diabetic individuals, with an associated two–year treatment cost of more than $90,000 per person.
- The five–year mortality after amputation for this group has been reported at nearly 45 percent.
One especially memorable case was a 70 year-old patient seeking a third opinion after being told that he needed a below-knee amputation (BKA) for a Wagner grade IV DFU. As the primary caregiver for his wife with Alzheimer’s, he was concerned that a BKA at his age was going impact not only his mobility but also his ability to care for her.
Unfortunately, he did not have enough tissue to primarily close with a transmetatarsal amputation (TMA). To avoid leg amputation, we performed an open TMA on a Friday and discharged him on Monday. He underwent 20 HBOT sessions and was seen weekly in the wound center for serial debridement including excision of any residual exposed bone. A dermal scaffold along with vacuum assisted closure was used to achieve homogeneous tissue coverage. At this time, he underwent a split-thickness skin graft followed by 10 HBOT. He made a full wound recovery and was discharged with a walkable leg rather than a BKA. Even years later, he still drops off Holiday treats for the wound center staff to express his appreciation.
Because the DFU patient typically has more than two chronic medical conditions, successful treatment to closure and avoidance of recidivism requires an aggressive, multidisciplinary approach. Understanding and bringing forward information on advanced wound care modalities, especially to patients living with diabetes and their treating physicians, helps us to continue to heal as many people as we can, everywhere we can, by the best means available.
- Sen, Chandan K., Gayle M. Gordillo, Sashwati Roy, Robert Kirsner, and Lynn Lambert. "Human Skin Wounds: A Major and Snowballing Threat to Public Health and the Economy." Wound Repair Regen. 17, no. 6 (2009): 763-71
- Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care. 1990;13:513–21
- Robbins JM, Strauss G, Aron D, Long J, Kuba J, Kaplan Y. Mortality Rates and Diabetic Foot Ulcers. Journal of the American Podiatric Medical Association2008 November 1, 2008;98(6):489‐93.
- Prim Care Companion J ClinPsychiatry. 2007; 9(4): 303–308 “Reactions to Amputation: Recognition and Treatment”
- J Bone Joint Surg Am. 2007 Aug;89(8):1685-92. “Health-care costs associated with amputation or reconstruction of a limb-threatening injury.”