title: Contemporary management of diabetic neuropathic foot ulceration: a study of 917 consecutively treated limbs.
abstract: BACKGROUND
  For patients with diabetic neuropathic foot ulceration, the current treatment paradigm is heavily weighted toward limb revascularization; aligning incentives to perform more surgery and less ulcer management/prevention. Our purpose was to perform an analysis of functional outcomes to assess this current treatment paradigm.
  
  
  METHODS
  Nine hundred and seventeen neuropathic ulcerated feet in 706 patients with diabetes were analyzed. Four hundred and sixty limbs (50.2%) had concomitant ischemia, 219 of which were revascularized (137 angioplasty and 82 open surgery). Outcomes measured included ulcer healing, survival, limb salvage, amputation-free survival, maintenance of ambulation, and independence. Independent predictors of outcomes were measured using an Extended Cox Model.
  
  
  RESULTS
  Overall outcomes (n = 917) were: ulcer healed, n = 250 (27%; mean time to healing 33 weeks); functionally healed, n = 488 (53%; mean time to functional healing 29 weeks); 5-year limb salvage, 68%; survival, 38%; amputation-free survival, 30%; maintenance of ambulation, 64%; and maintenance of independence, 74%. There was little difference in ulcer healing rates for patients with or without ischemia (28.5% versus 26%; p = 0.4). However, ischemia was a significant marker of poor outcomes (nonischemic ulcer, ischemic ulcer revascularized, and ischemic ulcer not revascularized: 5-year limb salvage of 80%, 61%, and 51%; p < 0.001); survival (47%, 37%, and 24%; p = 0.03); amputation-free survival (37%, 28%, and 17%; p < 0.001); maintenance of ambulation (74%, 55%, and 55%; p < 0.001); and maintenance of independence (82%, 72%, and 58%; p = 0.01). Wound healing was an independent predictor of survival and amputation-free survival (survival: hazard ratio = 0.58; 95% CI,0.46-0.73; amputation-free survival: hazard ratio = 0.42; 95% CI, 0.33-0.53).
  
  
  CONCLUSIONS
  The current treatment paradigm is associated with relatively poor healing rates and substantial late morbidity and mortality. Although revascularization is effective treatment for ischemia, it is probably overvalued when compared with the potential improvement afforded by better medical foot wound management.
authors.affiliation: Academic Department of Surgery, Greenville Hospital System University Medical, Center, Greenville, SC, USA. staylor@ghs.org
authors.forename: Spence M
authors.initials: SM
authors.lastname: Taylor
authors.forename: Brent L
authors.initials: BL
authors.lastname: Johnson
authors.forename: Nicole L
authors.initials: NL
authors.lastname: Samies
authors.forename: R Dustin
authors.initials: RD
authors.lastname: Rawlinson
authors.forename: Louis E
authors.initials: LE
authors.lastname: Williamson
authors.forename: Scott A
authors.initials: SA
authors.lastname: Davis
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Kotrady
authors.forename: John W
authors.initials: JW
authors.lastname: York
authors.forename: Eugene M
authors.initials: EM
authors.lastname: Langan
authors.forename: David L
authors.initials: DL
authors.lastname: Cull
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty; D002985:Clinical Protocols; D015331:Cohort Studies; D017719:Diabetic Foot / Q000175:diagnosis* / Q000209:etiology / Q000601:surgery*; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome; D014945:Wound Healing