Health science specialist Tova Bergsten watches as Army Reserve Vietnam-Era veteran Stephen Fisher uses a special thermometer to help detect early-stage ulcers in his feet. (VA Photo by Claudie Benjamin)

TAMPA, FL — Some of the risks of diabetic foot ulcers (DFUs) are well-known, including infection and, in the most severe cases, amputation.

VA researchers now have identified additional risks—primarily falls—heightening the urgency to implement new tools to manage and treat DFUs.

Yet, that has always not been easy. “The treatment of diabetic foot ulcers is complex, and the literature indicates a wide variety of evidence-based methods to improve wound healing and prevent adverse events,” explained Latricia Allen, DPM, of the James A. Haley VAMC in Tampa.

As part of a quality improvement project, researchers at the Haley VAMC gathered demographic information from the VHA’s Corporate Data Warehouse (CDW) database, including ICD-9 codes, adverse effects and comorbidities for all patients with a diagnosis of diabetes mellitus (DM) and/or DFU treated between 2009 and 2014.1

With adjustments for age, race, gender, marital status and comorbidities, data on 3,238 patients with a DFU, average age 66, and 41,324 patients with diabetes but without DFU, average age 64.4, were extracted. About 80% of patients in both cohorts were Caucasian and more than 95% were male.

Results published last summer in the journal Ostomy Wound Management indicated that the most common comorbidities in those cases were peripheral vascular disease (PVD), at 39.5%, and peripheral neuropathy (PN), at 23.2%, with PVD more common in veterans with a DFU than without one. Patients with both diabetes and a foot ulcer—as opposed to those with just diabetes—were significantly more likely to:

  • experience an infection (OR = 9.43; 95% CI 8.54-10.4),
  • undergo an amputation (OR = 7.40; 95% CI 6.16-8.89),
  • experience a fracture (OR = 3.65; 95% CI 2.59-5.15), or
  • have a fall (OR = 2.26; 95% CI 1.96-2.60).

“Although the increased risk of infection and amputation among persons with DFUs has been documented, less is known about the rate of falls and fractures,” study authors emphasized. “The current findings will serve as baseline data for future implementation trials to reduce DFU-associated AEs, and clinicians may want to consider expanding DFU patient education efforts to include fall risk.”

According to the American Diabetes Association, as many as 70% of diabetes patients have peripheral neuropathy, which can create an unsteady gait and/or impaired proprioception that puts them at risk for falls, fractures, contusions and other types of AEs. At the same time, according to background information in the article, PVD reduces blood flow to the extremities, often leading to delayed wound healing and infection.

The study cited previous research finding that 63% of patients with a history of foot ulcer reported falls over a two-year follow-up period. The fall rate for the same age group without a history of foot ulcer was reported as 28.7% in 2014.

The data is especially significant at the VA because of the high rate of diabetes among its veteran patients. Recently, the national Centers for Disease Control and Prevention noted, “Diabetes is more prevalent among U.S. veterans, who make up 9% of the civilian U.S. population, than among the general population and affects nearly 25% of U.S. Department of Veterans Affairs (VA) patients.”2

Avoiding Amputation

The American Diabetes Association estimates that between 80 and 100,000 non-traumatic amputations of lower extremities are done each year in the United States due to the complications of diabetes. The results for veterans can be devastating beyond the obvious mobility issues.

“It is not uncommon for patients to experience a decreased quality of life and survival rate after having a diabetes-related amputation,” Allen point out. “Approximately 85% of non-traumatic limb amputations in the United States are related to diabetes. Within roughly five years, about half of all patients with a diabetic-related amputation require a contralateral limb amputation and have an increased mortality rate. Further, patients with diabetes with advanced age along with comorbid disease (such as depression and/or peripheral vascular disease) may be at risk for decreased survival rates.”

The issue is how best to treat veterans’ diabetic foot ulcers to avoid unfavorable outcomes. Allen noted options might include holistic management of the patient, including blood glucose control, improved nutrition or management of comorbidities. Other options could be evidence-based wound management, offloading or prophylactic foot surgery, adding that advanced wound care technologies (e.g., negative wound pressure therapy, growth factors, acellular tissue matrices, bioengineered allogenic cellular therapies, hyperbaric oxygen therapies) would be appropriate for some patients.

Allen also cited the use of less direct care, including mental health screening and treatment and/or diabetes self-management education, which might include standard diabetes education, online education or telehealth education.

One area that has garnered a lot of interest and has benefitted from new technology is the use of off-loading in the management of DFUs.

A study published in the Journal of the American Podiatric Medical Association in 2014 discussed the development of a consensus statement on the therapy.3

“Evidence is clear that adequate off-loading increases the likelihood of DFU healing and that increased clinician use of effective off-loading is necessary,” the authors wrote. “Recommendations are included to guide clinicians on the optimal use of off-loading based on an initial comprehensive patient/wound assessment and the necessity to improve patient adherence with off-loading devices.”

Their guidelines suggest “the likelihood of DFU healing is increased with off-loading adherence, and, current evidence favors the use of nonremovable casts or fixed ankle walking braces as optimum off-loading modalities. There currently exists a gap between what the evidence supports regarding the efficacy of DFU off-loading and what is performed in clinical practice despite expert consensus on the standard of care.”

Allen said off-loading is frequently used at the VA, noting, “Considering the high prevalence of diabetic foot ulcers among veterans, VA continues to research use of offloading modalities.

VA gives healthcare providers significant leeway in deciding what is best for each patient, she explained. “The selection of a non-removable versus a removable cast is a decision each provider and patient make based on individual needs,” Allen emphasized. “While the total contact cast is considered the gold standard for treating plantar diabetic foot ulcers, it may not be practical in a patient that a non-removable cast is contraindicated. Some alternatives to a non-removable cast may be a removable cast, custom offloading shoe, or forefoot offloading shoe.”

1Allen L, Powell-Cope G, Mbah A, Bulat T, Njoh E. A Retrospective Review of Adverse Events Related to Diabetic Foot Ulcers. Ostomy Wound Manage. 2017 Jun;63(6):30-33. PubMed PMID: 28657897.

2Liu Y, Sayam S, Shao X, Wang K, Zheng S, Li Y, Wang L. Prevalence of and Trends in Diabetes Among Veterans, United States, 2005-2014. Prev Chronic Dis. 2017 Dec 14;14:E135. doi: 10.5888/pcd14.170230. PubMed PMID: 29240552; PubMed Central PMCID: PMC5737977.

3Snyder RJ, Frykberg RG, Rogers LC, Applewhite AJ, Bell D, Bohn G, Fife CE, Jensen J, Wilcox J. The management of diabetic foot ulcers through optimal off-loading: building consensus guidelines and practical recommendations to improve outcomes. J Am Podiatr Med Assoc. 2014 Nov;104(6):555-67. doi: 10.7547/8750-7315-104.6.555. PubMed PMID: 25514266.