title: Custom-made orthesis and shoes in a structured follow-up program reduces the incidence of neuropathic ulcers in high-risk diabetic foot patients.
abstract: OBJECTIVE
  The objective of this study was to assess the impact of a structured follow-up program on the incidence of diabetic foot ulceration (DFU) in high-risk diabetic patients.
  
  
  METHODS
  A total of 1874 diabetic patients referred to the Diabetic Foot Unit of the University of Pisa were ranked based on the ulcerative risk score proposed by the International Consensus on Diabetic Foot. Out of 334 patients (17.8%) with a score ≥2, 298 accepted to participate in this prospective trial and were randomized into 2 groups: group A, which received standard treatment, and group B, in which the patients received, as a part of a structured prevention program, custom-made orthesis and shoes. Incidence of new DFUs was observed for no less than 1 year and in a subset of patients after 3 and 5 years, respectively. Incidence of new DFUs and recurrences were considered as primary endpoints to establish the effectiveness of the program; costs were also compared.
  
  
  RESULTS
  Among the patients enrolled in this follow-up analysis, 46% had neuropathy and deformities, 20% had previous ulceration, 25% had previous minor amputation, and 9% had neuro-osteoarthropathy. During the first 12-month follow-up, 11.5% of patients in group B developed a DFU compared with 38.6% in group A (P < .0001). In the extended follow-up, the cumulative incidence of ulcer in group B compared with group A was 17.6% versus 61% (P < .0001) after 3 years and 23.5% versus 72% (P < .0001) after 5 years, respectively. The net balance at the end of the follow-up was highly in favor of the prevention program, with a saving of more than €100 000 per year.
  
  
  CONCLUSIONS
  The implementation of a structured follow-up with the use of orthesis and shoes can reduce the incidence of DFU in diabetic patients who are at high ulcerative risk and its related costs.
authors.affiliation: University of Pisa, Pisa, Italy.
authors.forename: Loredana
authors.initials: L
authors.lastname: Rizzo
authors.forename: Anna
authors.initials: A
authors.lastname: Tedeschi
authors.forename: Eliana
authors.initials: E
authors.lastname: Fallani
authors.forename: Alberto
authors.initials: A
authors.lastname: Coppelli
authors.forename: Valerio
authors.initials: V
authors.lastname: Vallini
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Iacopi
authors.forename: Alberto
authors.initials: A
authors.lastname: Piaggesi
mesh_terms: D000368:Aged; D000465:Algorithms; D016009:Chi-Square Distribution; D017719:Diabetic Foot / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control*; D005260:Female; D016523:Foot Ulcer / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control*; D017048:Health Care Costs; D006801:Humans; D015994:Incidence; D007558:Italy / Q000453:epidemiology; D008297:Male; D009989:Orthotic Devices; D016730:Program Development; D015397:Program Evaluation; D011446:Prospective Studies; D018570:Risk Assessment / Q000379:methods; D012775:Shoes