Beyond Wound Resolution: Focusing On The Diabetic Foot In Remission And Preventing Recurrence
Rates of diabetic foot ulceration (DFU) recurrence reported at one, three and five years range from 25 to 40 percent, 50 to 60 percent and 65 to 80 percent respectively.1–6 Almost all patients with a history of a DFU will experience a recurrent DFU within 10 years.5 Between 71 to 85 percent of recurrent DFUs will end in amputation.7 This should serve as an impetus for providers to look at ways to reduce DFU recurrence rates.
The strongest predictor for DFU recurrence is a history of previous DFU due to the continued presence of peripheral neuropathy, foot deformity and peripheral vascular disease.1,3 Lack of patient adherence to the behavioral processes outlined in the U.S. Health Resources and Services Administration’s five-step Lower Extremity Amputation Prevention (LEAP) program (annual foot screening, patient education, daily self-inspection, footwear selection and management of simple foot problems) also contribute to DFU recurrence.8
Employment of surgical procedures to reduce foot deformities and alleviate sensory abnormalities may reduce DFU recurrence rates. For example, combining an Achilles tendon lengthening or gastrocnemius recession with total contact cast use yields significantly lower rates of DFU recurrence.9 However, one must take precautions not to overlengthen the Achilles tendon in order to avoid development of a plantar central DFU. Surgeons may also choose peroneus longus and posterior tibial tendon recessions to prevent recurrence of plantar first and fifth metatarsal head DFUs respectively.
In an eight-year retrospective review of 16 patients (19 DFUs) who had tendon lengthening procedures and an average follow-up of 45 months, Laborde reported a 15.8 percent DFU recurrence rate.10 All three recurrent DFUs resolved with repeat tendon recession. The use of selective plantar fascia release for plantar forefoot ulcerations has a reported zero percent incidence of DFU recurrence.9 Two systematic reviews on the utility of flexor tenotomies to reduce DFU recurrence reported an average recurrence rate of 9.8 percent (range: zero to 18 percent) at a median 22 month follow-up.11,12 All recurrences occurred in digits with exposed tendon or infection penetrating to bone.11,12
Rigid foot deformities resulting in DFU require osseous correction. Physicians most often see these deformities in midfoot ulcerations occurring secondary to Charcot deformity of the foot. Exostectomy and realignment arthrodesis reportedly have ulcer recurrence rates ranging from four to 33 percent at two to three years follow-up.13,14 Diabetic foot ulcer recurrence following exostectomy is most often due to use of a split-thickness skin graft for coverage, instability and inadequate bone resection.13–18
Nerve decompression involves release of the soft tissue structures that creates a fibro-osseous tunnel at the fibular neck, medial ankle and medial plantar foot to increase space for enlarged peripheral nerves secondary to diabetes. These procedures reportedly resolve neuropathic symptoms, lead to recovery of sensation and reduce DFU recurrence rates by 80 percent in over 80 percent of the patients who have the procedure.5,19 Objective measures of improvement include recovery of over half of a 30 percent deficit on nerve conduction velocity studies, improved vibratory and warm/cold perception, and improvement in two-point discrimination from greater than nine mm to less than seven mm.5
Reduction in DFU recurrence following nerve decompression could potentially result in an annual savings of over $1.3 billion in direct and indirect costs associated with recurrent DFU treatment at three years postoperative.19
What The Literature Reveals About Emerging And Traditional Offloading
A newer procedure for the prevention of recurrent DFU involves injection of an acellular adipose allograft matrix to augment tissue thickness in areas of high plantar pressure. A single case report demonstrated a 76.8 percent and 70.1 percent reduction in mean peak plantar pressure beneath the second metatarsal head and distal first ray respectively in a patient with a history of recurrent ulceration following a partial first ray amputation.4 The paucity of literature on the safety and efficacy of the procedure does not allow for a recommendation for or against its use at this time.
High-quality evidence supports that consistent use of pressure offloading custom insoles and appropriately fitting shoe gear reduce DFU recurrence rates by 46 to 63 percent.1,2,20,21 Unfortunately, only about one out of every four patients wears their prescription shoe gear for greater than 80 percent of the time they are on their feet.6,20,22 The majority of non-shoe gear use occurs when patients are at home due to failure of the patient to understand the risk in this environment without adequate protection of their feet.23 Understanding why a patient is not adherent to recommendations for shoe gear use may help improve adherence through tailored patient education engaging him or her to play an active role in controlling the potential for DFU recurrence.7
What About Patient Education?
In a systematic review and meta-analysis looking at the effectiveness of intensive patient education (single or multiple 45-minute to two-hour individual or group sessions on diabetes education), Adiewere and colleagues found a statistically significant reduction in DFU recurrence in the short-term in comparison to patient education provided via written instructions alone.7 This benefit was evident for patients at low, moderate and high risk for recurrent DFU.
Cognitive behavioral therapy involves helping patients to understand their risk for DFU recurrence, how to adapt their behaviors to prevent recurrence and recognition of early warning signs of recurrence that should prompt them to seek medical attention. Cognitive behavorial therapy reportedly has a high level of patient acceptance and yields an increase in patient self-knowledge, risk awareness and perceived patient control of his or her health.3
What appears to be imperative with patient education is that one should not conduct it in a didactic manner, but more as a way to increase the awareness of patients about their condition and how they can manage it to reduce their risk for DFU recurrence.3
Assessing The Potential Impact Of Remote Monitoring Technologies
Given the current practice environment, where many patient encounters have transitioned to virtual visits due to COVID-19, the use of smart technology and monitoring modalities is increasingly enticing. Novel monitoring technologies, whether it is the use of temperature monitoring, a pressure mat or wearable textiles, reportedly have high patient acceptance with use and an ability to reduce the incidence of DFU.22
These novel technologies allow for monitoring of total weightbearing activity, including walking, standing and sitting, and the frequency and intensity of these weightbearing activities. This can help identify patients at risk for DFU and allow for timely intervention in which providers can discuss the need to tailor weightbearing activities and increase shoe gear use.6
Concluding Thoughts
Once a DFU heals, treatment does not stop. Prevention of recurrent DFU is critical to mitigate the potential for lower extremity amputation. Efforts to reduce DFU recurrence should focus on surgical procedures for reduction of foot deformities and addressing sensory abnormalities. Providers must work in conjunction with their patients to develop a partnership in which the patient understands his or her risks, and the control he or she has in mitigating DFU recurrence through appropriate lifelong requirements for appropriate foot care.
Use of novel monitoring technologies may assist patients and providers alike in increasing adherence with appropriate weightbearing activities and shoe gear use, and facilitating early intervention for areas at risk for tissue loss.
Dr. Marmolejo is a member of the Podiatry Today Editorial Advisory Board and is the founder of Scriptum Medica Medical Writing. She is also a Clinical Wound Specialist for LifeNet Health.
1. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376(24):2367-2375.
2. López-Moral M, Lázaro-Martínez JL, García-Morales E, García-Álvarez Y, Álvaro-Afonso FJ, Molines-Barroso RJ. Clinical efficacy of therapeutic footwear with a rigid rocker sole in the prevention of recurrence in patients with diabetes mellitus and diabetic polineuropathy: A randomized clinical trial. PLoS One. 2019;14(7):e0219537.
3. Vedhara K, Beattie A, Metcalfe C, et al. Development and preliminary evaluation of a psychosocial intervention for modifying psychosocial risk factors associated with foot re-ulceration in diabetes. Behav Res Ther. 2012;50(5):323-332.
4. Shahin TB, Vaishnav KV, Watchman M, et al. Tissue augmentation with allograft adipose matrix for the diabetic foot in remission. Plast Reconstr Surg Glob Open. 2017;5(10):e1555.
5. Nickerson DS. Reconsidering nerve decompression: an overlooked opportunity to limit diabetic foot ulcer recurrence and amputation. J Diabetes Sci Technol. 2013;7(5):1195-1201.
6. Najafi B, Reeves ND, Armstrong DG. Leveraging smart technologies to improve the management of diabetic foot ulcers and extend ulcer-free days in remission. Diabetes Metab Res Rev. 2020;36(Suppl 1):e3239.
7. Adiewere P, Gillis RB, Imran Jiwani S, Meal A, Shaw I, Adams GG. A systematic review and meta-analysis of patient education in preventing and reducing the incidence or recurrence of adult diabetes foot ulcers (DFU). Heliyon. 2018;4(5):e00614.
8. U.S. Health Resources & Services Administration. Lower Extremity Amputation Prevention (LEAP). Available at: https://www.hrsa.gov/hansens-disease/leap. Accessed October 9, 2020.
9. Dallimore SM, Kaminski MR. Tendon lengthening and fascia release for healing and preventing diabetic foot ulcers: a systematic review and meta-analysis. J Foot Ankle Res. 2015;8:33.
10. Laborde JM. Neuropathic plantar forefoot ulcers treated with tendon lengthenings. Foot Ankle Int. 2008;29(4):378-384.
11. Scott JE, Hendry GJ, Locke J. Effectiveness of percutaneous flexor tenotomies for the management and prevention of recurrence of diabetic toe ulcers: a systematic review. J Foot Ankle Res. 2016;9:25.
12. Roukis TS, Schade VL. Percutaneous flexor tenotomy for treatment of neuropathic toe ulceration secondary to toe contracture in persons with diabetes: a systematic review. J Foot Ankle Surg. 2009;48(6):684-689.
13. Brodsky JW, Rouse AM. Exostectomy for symptomatic bony prominences in diabetic charcot feet. Clin Orthop Relat Res. 1993;296:21-26.
14. Laurinaviciene R, Kirketerp-Moeller K, Holstein PE. Exostectomy for chronic midfoot plantar ulcer in Charcot deformity. J Wound Care. 2008;17(2):53-58.
15. Wieman TJ, Griffiths GD, Polk HC Jr. Management of diabetic midfoot ulcers. Ann Surg. 1992;215(6):627-632.
16. Rosenblum BI, Giurini JM, Miller LB, Chrzan JS, Habershaw GM. Neuropathic ulcerations plantar to the lateral column in patients with Charcot foot deformity: a flexible approach to limb salvage. J Foot Ankle Surg. 1997;36(5):360-363.
17. Myerson MS, Henderson MR, Saxby T, Short KW. Management of midfoot diabetic neuroarthropathy. Foot Ankle Int. 1994;15(5):233-241.
18. Catanzariti AR, Mendicino R, Haverstock B. Ostectomy for diabetic neuroarthropathy involving the midfoot. J Foot Ankle Surg. 2000;39(5):291-300.
19. Rankin TM, Miller JD, Gruessner AC, Nickerson DS. Illustration of cost saving implications of lower extremity nerve decompression to prevent recurrence of diabetic foot ulceration. J Diabetes Sci Technol. 2015;9(4):873-880.
20. Bus SA, Waaijman R, Arts M, et al. Effect of custom-made footwear on foot ulcer recurrence in diabetes: a multicenter randomized controlled trial. Diabetes Care. 2013;36(12):4109-4116.
21. Ulbrecht JS, Hurley T, Mauger DT, Cavanagh PR. Prevention of recurrent foot ulcers with plantar pressure-based in-shoe orthoses: the CareFUL prevention multicenter randomized controlled trial. Diabetes Care. 2014;37(7):1982-1989.
22. Skafjeld A, Iversen MM, Holme I, Ribu L, Hvaal K, Kilhovd BK. A pilot study testing the feasibility of skin temperature monitoring to reduce recurrent foot ulcers in patients with diabetes--a randomized controlled trial. BMC Endocr Disord. 2015;15:55.
23. Beattie AM, Campbell R, Vedhara K. ‘What ever I do it’s a lost cause.’ The emotional and behavioural experiences of individuals who are ulcer free living with the threat of developing further diabetic foot ulcers: a qualitative interview study. Health Expect. 2014;17(3):429-439.
