best practice guidelines: wound management in diabetic foot ulcers

INTRODUCTIONIntroductionDFUs are complex, chronic wounds, whichhave a major long-term impact on themorbidity, mortality and quality of patients’lives 1,2 . Individuals who develop a DFU are atgreater risk of premature death, myocardialinfarction and fatal stroke than those withouta history of DFU 3 . Unlike other chronicwounds, the development and progression ofa DFU is often complicated by wide-rangingdiabetic changes, such as neuropathy andvascular disease. These, along with thealtered neutrophil function, diminished tissueperfusion and defective protein synthesisthat frequently accompany diabetes, presentpractitioners with specific and unique managementchallenges 1 .DFUs are relatively common — in the UK,5–7% of people with diabetes currently haveor have had a DFU 4,5 . Furthermore, around25% of people with diabetes will develop aDFU during their lifetime 6 . Globally, around370 million people have diabetes and thisnumber is increasing in every country 7 . DiabetesUK estimates that by 2030 some 552million people worldwide will have diabetes 8 .DFUs have a major economic impact. A USstudy in 1999 estimated the average outpatientcost of treating one DFU episode as$28,000 USD over a two–year period 9 . Averageinpatient costs for lower limb complicationsin 1997 were reported as $16,580 USDfor DFUs, $25,241 USD for toe or toe plusother distal amputations and $31,436 USDfor major amputations 10,11 .such as the effect on physical, psychologicaland social wellbeing and the fact that manypatients are unable to work long term as aresult of their wounds 6 .A DFU is a pivotal event in the life of aperson with diabetes and a marker of seriousdisease and comorbidities. Without earlyand optimal intervention, the wound canrapidly deteriorate, leading to amputation ofthe affected limb 5,13 .It has been estimated that every 20 secondsa lower limb is amputated due to complicationsof diabetes 14 .In Europe, the annual amputation rate forpeople with diabetes has been cited as 0.5-0.8% 1,15 , and in the US it has been reportedthat around 85% of lower-extremityamputations due to diabetes begin with footulceration 16,17 .Mortality following amputation increaseswith level of amputation 18 and ranges from50–68% at five years, which is comparableor worse than for most malignancies 13,19(Figure 1).The statistics need not make for such grimreading. With appropriate and carefulmanagement it is possible to delay or avoidmost serious complications of DFUs 1 .FIGURE 1: Relative five-year mortality (%) (adapted from 19 )The EURODIALE study examined total directand indirect costs for one year across severalEuropean countries. Average total costsbased on 821 patients were approximately10,000 euros, with hospitalisation representingthe highest direct cost. Based on prevalencedata for Europe, they estimated thatcosts associated with treatment of DFUsmay be as high as 10 billion euros per year 12 .In England, foot complications account for20% of the total National Health Servicespend on diabetes care, which equates toaround £650 million per year (or £1 in every£150) 5 . Of course, these figures do not takeaccount of the indirect costs to patients,Prostate cancerBreast cancerHodgkin's lymphomaNeuropathic DFUAmputationColon cancerIschaemic DFUPeripheral arterial diseaseLung cancerPancreatic cancerBEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS 1