Epidemiology

Two of the most significant diabetic foot complications are foot ulcers and lower extremity amputations. These two entities are responsible for the substantial utilization of medical efforts and healthcare resources, in addition to contributing to significant morbidity and mortality in the patient with diabetes. Foot ulcers result from a number of etiological factors, and are wounds that are associated with delayed healing. These etiological factors arise from pathophysiological changes in the diabetic state, anatomical deformities in the diabetic foot, and environmental influences. Annually, 2% of all patients with diabetes will develop a foot ulcer (3), whereas 15% will ulcerate during a lifetime (3,4). The prevalence of diabetic foot ulcers has been reported to range from 5.3% to 10.5% (3,5-7). This variation in range may be because of the lack of awareness and appropriate preventative care on the part of both patient and provider. Furthermore, this wide variation may be because of the fact that most studies select only patients with diabetes who are at risk for diabetic foot complications for inclusion in evaluation of ulcer formation. Nonetheless, the aforementioned figures illustrate the chronicity of the problem of ulcerations in patients with diabetes.

The cost of diabetic foot complications vary considerably, probably depending on the problem, its severity, its outcome, and extent of intervention required. The majority of the costs are attributed to inpatient expenditures (8). The cost of treating an ulceration without surgical intervention approaches several thousand dollars, whereas those ulcers that are ultimately treated with an amputation can cost many times higher (9).

Foot ulcerations precede 85% of amputations and so the relationship between ulcers and lower extremity amputations is obvious (10,11). Alarmingly, 15% of all foot ulcers will ultimately require amputation, indeed the major risk factor for amputation is ulceration representing the major risk factor for amputation. Ultimately 15% of all ulcerations may evolve an amputation at some level (3). Other risk factors for amputation include greater duration of diabetes, peripheral vascular disease, peripheral neuropathy, poor glycemic control, prior history of foot ulcers, previous foot surgery and amputation, retinopathy, and nephropathy (12-17).

In the United States, approximately 50% of all amputations are performed on patients with diabetes (18), which is about 60% of total amputation (19). Amputation rates have also been shown to vary with both gender and ethnicity. Being male, African American, or Hispanic has been associated with higher risk for amputation (20,21). Lack of access to education and routine preventative care may be the underlying reason for this increase. When programs designed to prevent and promote awareness of diabetic foot complications were instituted in high-risk populations, the rate of amputations was decreased by nearly 50% (22,23).

In the early 1990's, there were approximately 60,000 lower extremity amputations in the diabetic population performed per year with an estimated expense of USD 30,000-60,000 per case (24). The incidence of lower extremity amputations continues to escalate despite greater awareness levels and promotion of preventative care. Since 1990, the rate of lower extremity amputation in patients with diabetes has increased and 82,000 amputations were performed from 2000 to 2001 (25).

As the data illustrates, diabetic foot complications can place an overwhelming burden on patients, their families, and healthcare professionals. The total cost of diabetic foot complications in the United States has been estimated to approach 4 billion annually, as extrapolated from the costs of ulcer care and amputations (26). Continued efforts to identify high-risk patients, ensure adequate availability of preventative care, and prompt treatment remain the best means of reducing the destructive consequences of amputations and death.

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