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The challenge of diabetic foot ulcers

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Diabetes
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commentary
DFU
diabetes complications
diabetes management
diabetic foot management
diabetic foot ulcer
King's College Hospital
lower limb amputation
peripheral neuropathy
 
Diabetic foot ulcers (DFU) are responsible for more hospitalizations than any other complication of diabetes, and the biggest cause of amputation. Of the 26 million people in the US, and some 3.8 million in the UK diagnosed with diabetes, as many as 25% may experience a DFU in their lifetime. 
 
People living with diabetes are at risk of nerve damage (neuropathy), and problems with the blood supply to their feet (ischaemia). Nerve damage results in a reduced ability to feel pain, and therefore injuries often go un-noticed. Ischaemia can slow down wound healing. Both ischaemia and neuropathy can lead to DFUs. Infections in DFUs can lead to amputation.
 
The burden of DFUs
DFUs impose a substantial burden on public and private payers, doubling care costs per patient compared with diabetic patients without foot ulcers. In the US, ulcer care adds around US$9 to US$13 billion to the direct yearly costs associated with diabetes, and in the UK, around £650 million is spent on DFUs and amputations each year.
 
The five-year recurrence rates of DFUs are as high as 70%. People with diabetes with one lower limb amputation have a 50% risk of developing a serious ulcer in the second limb within two years. People with diabetes have a 50% mortality rate in the five years following an initial amputation. These numbers have not changed much in the past 30 years, despite significant advances in the medical and surgical therapies for people with diabetes.
  
Poorly understood pathology
The exact mechanism by which diabetes impairs wound healing is not fully understood, and as a result, the management of DFUs is challenging, and has been a neglected area of healthcare research and planning. Current clinical practice is based more on opinion than scientific fact.
 
According to Hisham Rashid, a consultant vascular surgeon at Kings College Hospital, London who specializes in the surgical therapy for DFUs,  "Because the pathological processes of DFUs are complex, they tend to be poorly understood, and communication between the many specialties involved can be disjointed and insensitive to the needs of patients. One of the biggest recent improvements in foot care has been the close liaison of different specialties in multidisciplinary foot clinics."
Advances in therapeutics
Surgeons have tended to use free tissue transfer, as the treatment of choice for complex DFUs, but the length and intricacies of these procedures is contraindicated, and can lead to complications. This has led surgeons to turn to bioengineered alternative tissue in the reconstruction of these complex wounds.

One new bioengineered tissue for DFUs is an advanced bilayer skin replacement system designed to provide immediate wound closure, and permanent regeneration of the dermis. The product, Integra Dermal Regeneration Template, recently completed a clinical study, and an initial review suggests that the study has achieved its primary goal, which is complete wound closure at 16 weeks.

Takeaways
It's possible to reduce DFUs and consequent amputation rates by as much as 49 to 85%. This can be achieved through a care strategy, which combines prevention, close monitoring and education. According to Rashid, "Health professionals have an important role to play in enhancing the education for people living with diabetes in order to propel them towards self-management, and slow the onset of complications such as DFUs."
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