Monday, October 14, 2013

The Diabetic Foot Ulcer: How a Wound Care Center Can Help

By: G. Blaine Bishop, Jr., MD
The Centers for Disease Control estimates there are 25.8 million diabetic American as of 2011, with 1.9 million new cases being diagnosed annually.  Medicare FFS data from 2008 showed diabetic foot ulcers in these patients.  20-25% of these patients went on to some form of amputation (toe, foot, or leg).  “Up to 83% of lower limb amputations in diabetic patients are preceded by foot ulcers that fail to heal.”
            Sadly, the 5 year death rate on a diabetic patient following a below-the-knee amputation is 47%! (In contrast, only 28% of Stage III breast cancer patients die within 5 years – American Cancer Society.)  Both the in-hospital and in-home healthcare costs skyrocket after a major amputation.  Surprisingly, virtually all insurers are willing to invest significant monies in order to heal diabetic foot ulcers (DFU’s).
            As most physicians are aware, chronically elevated glucose levels can lead to neuropathy, peripheral vascular disease, and impaired white blood cell function.  It is estimated that 30-50% of diabetics will develop neuropathy in their feet.  Unsurprisingly, 60% of DFU’s occur in patients with neuropathy only, 15-20% in diabetics with peripheral vascular disease, and 15-20% DFU patients with both neuropathy and peripheral capsular disease.
Rare is the physician who hasn’t see a foot ulcer in a diabetic patient whose poorly fitting shoe and lack of sensation have resulted in callus build up, followed by pressure necrosis, followed by infection.  Cellulitis, deep space infections, and even osteomyelitis result all too commonly from this scenario.  Frequently, a multidisciplinary team treating the many components of these lesions will be required.  Such resources often exceed the office capabilities of our hard working primary care physicians.
            The initial patient encounter in a dedicated wound care center (WCC) involves wound measurement, evaluation of blood sugar control, assessment of arterial blood inflow/wound tissue oxygenation, evaluation for infection, as well as determining the correction of the cause of the chronic foot trauma.  Typical initial treatments involve off-loading the ulcer (total contact cast, walking boot, temporary diabetic shoe, and –ultimately- a custom designed orthotic shoe insert to prevent further ulcers). Regular wound debridement that rids the ulcer of callus, dead tissue, and the bacteria-laden biofilm which so often covers the surface of the ulcers.  A specialized wound dressing helps provide enough moisture to promote healing but not so much as to cause wound maceration.
            When these primary therapies aren’t enough (i.e. the wound is less than 40% healed after 4 weeks of these initial treatments), more advanced therapies are indicated.
            Many physicians are familiar with the Wound VAC wound closure system.  Some may not be as familiar with topical vascular endothelial and human platelet derived growth factors. Also human “skin substitutes” from tissue cultured neo-natal foreskin contain a number of growth factors which stimulate ingrowth of the patients own skin calls in order to heal the wound.
            Revascularization via stenting or leg artery bypass can improve oxygen delivery to the wound when peripheral vascular disease is an issue.  Hyperbaric oxygen is another advanced therapy to improve DFU oxygen level.  100% oxygen under 2 atmospheres of pressure for 90 minutes at a time is demonstrated to 1) kill bacteria (even osteomyelitis), 2) stimulate the growth of new arterioles into the ulcer, and 3) stimulate the proliferation of wound healing cells.  Thus, according to the American Diabetic Association, examples of wound patients who should be referred to a Wound Care Center include:
1)      A wound that had failed to show significant progress after 4 weeks of standard care
2)      A wound that involves deep tissue structures or is limb-threatening
3)      A wound complicated by significant comorbidities including peripheral vascular disease, vascular disease, persistent edema, persistent infection, or prior radiation to the area
1)      Bowering; Canadian Family Physician
Vol 47, May 2001 : 1007-16
2)      ADA Consensus Development Conference On Diabetic Foot Wound Care
-          Diabetes Care 22(8) 1345-60, 1999
G. Blaine Bishop, Jr., MD
General Surgeon
Advanced Surgeons, PC
Member of the Medical Staff – Trinity Medical Center


  1. Mostly people who use insulin are at a higher risk of developing a foot ulcer.

  2. Excellent doctor. Your way of explaining about the The Diabetic Foot Ulcer and how wound care its a amazing.

  3. wow its great this blog is super i suggested my friends to see your blog keep attached more blog for usefull to people

  4. this blog is very nice i inform my friends to see this blog its very helpful to use please post more blogs...

  5. this blog is totally based on diabetes foot and ulcer its very useful to people and i get lot of information through this blog thank you.

  6. The diabetes is a hidden killer disease it very dangerous and your blog is awesome. you clear my doubts about diabetes and its used more people keep post more blog than you.

  7. The wound and sore ulcer is affected usually because of people carelessness but if the saw your blog means they have taken extra care of them health. Thank you for posting blog keep more posting blog because it very useful to people.

  8. So many diabetic people will be get help from this blog. Thanks to you for making many people happy.
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  9. Nice blog.........As foot ulcers is common of diabetic foot problem and get also infected to gangrene or deep infection, so suggest to Delhi foot & ankle clinic regarding any pain in foot.

  10. I was surprised to read that the chance of death within the five year period after an amputation is 47%. Those numbers are very high. My mom and sister have struggled with diabetes their entire lives. I hope they don' have to go through something like that.