Is chronic diabetic foot ulcer an indicator of cardiac disease?

Unravelling the cardio-renal-metabolic-foot connection in people with diabetes-related foot ulceration: a narrative review

Diabetes-related foot ulceration (DFU), a serious but preventable complication of diabetes, is a leading cause of hospitalisation, lower extremity amputation and disability worldwide. People with DFU have a greater burden of cardiovascular risk factors, heart failure and chronic kidney disease, resulting in over two-fold higher risk of cardiovascular death compared with people with diabetes without DFU. Here, we propose a "cardio-renal-metabolic-foot" connection in people with diabetes based on shared pathophysiological mechanisms linking DFU with cardiovascular and renal disease. Whilst these mechanistic links remain to be fully elucidated, systemic inflammation and infection in the context of DFU are postulated as key mediators in the development, and progression of, cardiovascular and renal disease. However, cardiovascular and renal disease are also implicated in the pathogenesis of DFU, highlighting the multi-directional interplay between conditions. The impact of screening, prevention, and early management of cardiovascular complications associated with DFU requires further research. Multi-modality cardiac imaging could play a role in unravelling disease mechanisms leading to novel therapeutic strategies, as well as facilitating personalised risk assessment and management. Recent clinical trials have transformed the therapeutic landscape for people with type 2 diabetes, by demonstrating that sodium glucose co-transporter 2 inhibitors, glucagon-like peptide-1 agonists and non-steroidal mineralocorticoid receptor antagonists improve cardiovascular and renal outcomes. Although dedicated research in people with DFU is warranted, these therapies could target multiple facets of the "cardio-renal-metabolic-foot" connection. The holistic, person-centred approach to managing DFU should incorporate new multidisciplinary models of care focusing on the prevention and management of cardiovascular and kidney disease.

Development of a major amputation prediction model and nomogram in patients with diabetic foot

BACKGROUND

Diabetes mellitus, as one of the world's fastest-growing diseases, is a chronic metabolic disease that has now become a public health problem worldwide. The purpose of this research was to develop a predictive nomogram model to demonstrate the risk of major amputation in patients with diabetic foot.

METHODS

A total of 634 Type 2 Diabetes Mellitus (T2DM) patients with diabetic foot ulcer hospitalized at the Air Force Medical Center between January 2018 and December 2023 were included in our retrospective study. There were 468 males (73.82%) and 166 females (26.18%) with an average age of 61.64 ± 11.27 years and average body mass index of 24.45 ± 3.56 kg/m2. The predictive factors were evaluated by single factor logistic regression and multiple logistic regression and the predictive nomogram was established with these features. Receiver operating characteristic (subject working characteristic curve) and their area under the curve, calibration curve, and decision curve analysis of this major amputation nomogram were assessed. Model validation was performed by the internal validation set, and the receiver operating characteristic curve, calibration curve, and decision curve analysis were used to further evaluate the nomogram model performance and clinical usefulness.

RESULTS

Predictors contained in this predictive model included body mass index, ulcer sites, hemoglobin, neutrophil-to-lymphocyte ratio, blood uric acid (BUA), and ejection fraction. Good discrimination with a C-index of 0.957 (95% CI, 0.931-0.983) in the training group and a C-index of 0.987 (95% CI, 0.969-1.000) in the validation cohort were showed with this predictive model. Good calibration were displayed. The decision curve analysis showed that using the nomogram prediction model in the training cohort and validation cohort would respectively have clinical benefits.

CONCLUSION

This new nomogram incorporating body mass index, ulcer sites, hemoglobin, neutrophil-to-lymphocyte ratio, BUA, and ejection fraction has good accuracy and good predictive value for predicting the risk of major amputation in patients with diabetic foot.

The role of diabetic foot treatment in improving left ventricular function: Insights from global longitudinal strain echocardiography

We decided to evaluate the effect of treatment of diabetic foot ulcers in improving heart function by strain echocardiography than conventional transthoracic echocardiography. This prospective cross-sectional study included patients with diabetic foot ulcer (DFU). Conventional and two-dimensional strain echocardiography performed before and after three months diabetic foot treatment. Then, we compared the echocardiographic parameters including left ventricular ejection fraction (LV-EF), left ventricular global longitudinal strain (LV-GLS). Multivariate and univariate logistic regression analysis were performed to find which variable was mainly associated with LV-GLS changes. 62 patients with DFU were conducted. After echocardiography, all patients underwent surgical or non-surgical treatments. Three months after the treatment, LV-EF was not significantly different with its' primary values (P = 0.250), but LV-GLS became significantly different (P<0.05). In the multivariate logistic regression analysis, with the increase in the grade of ulcer, LV-GLS improved by 6.3 times. Not only the treatment of DFU helps to control adverse outcomes like infection, limb loss and morbidity but also it enhances cardiac function. Of note, strain echocardiography found to be a better indicator of myocardial dysfunction than LV-EF. These findings make a strong reason for the routine assessment of cardiac function in patients with DFU.

Old and Novel Predictors for Cardiovascular Risk in Diabetic Foot Syndrome—A Narrative Review

Diabetic foot syndrome (DFS) is a complication associated with diabetes that has a strong negative impact, both medically and socio-economically. Recent epidemiological data show that one in six patients with diabetes will develop an ulcer in their lifetime. Vascular complications associated with diabetic foot have multiple prognostic implications in addition to limiting functional status and leading to decreased quality of life for these patients. We searched the electronic databases of PubMed, MEDLINE and EMBASE for studies that evaluated the role of DFS as a cardiovascular risk factor through the pathophysiological mechanisms involved, in particular the inflammatory ones and the associated metabolic changes. In the era of evidence-based medicine, the management of these cases in multidisciplinary teams of “cardio-diabetologists” prevents the occurrence of long-term disabling complications and has prognostic value for cardiovascular morbidity and mortality among diabetic patients. Identifying artificial-intelligence-based cardiovascular risk prediction models or conducting extensive clinical trials on gene therapy or potential therapeutic targets promoted by in vitro studies represent future research directions with a modulating role on the risk of morbidity and mortality in patients with DFS.

Below-the-ankle arterial disease: a new marker of coronary artery disease in patients with diabetes and foot ulcers

AIM

The aim of the current study is to evaluate the association between below-the-ankle (BTA) arterial disease and coronary artery disease (CAD) in patients with diabetic foot ulcers (DFUs).

METHODS

The study group was composed of patients with an active neuro-ischaemic DFUs managed in a tertiary care diabetic foot clinic. All patients received a pre-set limb salvage protocol including lower limb revascularization. By a retrospective analysis of individual angiograms, patients were divided in two groups: below-the-ankle (BTA) and above-the-ankle (ATA) arterial disease groups. The rate of CAD at baseline assessment and the new events of acute myocardial ischaemia (AMI) during 1-year of follow-up were evaluated and compared between the two groups.

RESULTS

Two hundreds seventy-two (272) patients were included, 120 (44.1%) showed BTA arterial disease while 152 (55.9%) ATA arterial disease. The mean age was 68.9 ± 9.6 years, 198 (72.8%) were male, 246 (90.4%) had type 2 diabetes, the mean diabetes duration was 20.7 ± 11.6 years, the mean HbA1c was 7.8 ± 4.2% (62 ± 22 mmmol/mol). The whole population reported CAD in 172 cases (63.4%), and the rate in the BTA group was significantly higher than in ATA group, respectively, 90 (75.4%) vs 82 (54.1%), p < 0.0001. During the follow-up, BTA group had 5% of new cases of AMI in comparison to 1.3% in ATA group (p < 0.001). At the multivariate analysis BTA resulted an independent marker of CAD [OR 1.9 CI 9 5% (1.3-4.5) p = 0.0001].

CONCLUSION

The current study shows a significant association between BTA arterial disease and CAD. A close cardiovascular screen should be required in patients with DFUs.

Healing below the ankle is possible in patients with diabetes mellitus and a forefoot gangrene

Background

Forefoot gangrene in patients with diabetes is a severe form of foot ulcers with risk of progress and major amputation. No large cohort studies have examined clinical characteristics and outcome of forefoot gangrene in patients with diabetes. The aim was to examine clinical characteristics and outcome of forefoot gangrene in patients with diabetes admitted to a diabetic foot centre.

Methods

Patients with diabetes and foot ulcer consecutively presenting were included if they had forefoot gangrene (Wagner grade 4) at initial visit or developed forefoot gangrene during follow-up at diabetic foot centre. Patients were prospectively followed up until final outcome, either healing or death. The median follow-up period until healing was 41 (3-234) weeks.

Results

Four hundred and seventy-six patients were included. The median age was 73 (35-95) years and 63% were males. Of the patients, 82% had cardiovascular disease and 16% had diabetic nephropathy. Vascular intervention was performed in 64%. Fifty-one patients (17% of surviving patients) healed after auto-amputation, 150 after minor amputation (48% of surviving patients), 103 had major amputation (33% of surviving patients) and 162 patients deceased unhealed. Ten patients were lost at follow-up. The median time to healing for all surviving patients was 41 (3-234) weeks; for auto-amputated, 48 (10-228) weeks; for minor amputated, 48 (6-234) weeks; and for major amputation, 32 (3-116) weeks.

Conclusion

Healing without major amputation is possible in a large proportion of patients with diabetes and forefoot gangrene, despite these patients being elderly and with extensive co-morbidity.

Heart failure management; a perspective from diabetes care

People with type 2 diabetes (T2DM) are recognized as having a 2-4 times increased risk of heart failure (HF). Ambulatory diabetes care has long concentrated on the prevention of microvascular and arterial disease, and surveillance for manageable problems such as with the feet and retinae. Accordingly, management of heart failure has never been a specific focus, although the preventative management of cardiac and kidney disease through glucose-lowering, blood pressure (BP) control, and blood lipid control, have had a positive impact on its incidence. Indeed, the very complexity of routine diabetes care, and its enormous prevalence, has generally excluded the management of any of the advanced late complications, whether cardiac, arterial, retinal, renal, or neurodegenerative. Furthermore, advances in HF management itself, in diagnostics, medications, and technology, has carried it deeper into the remit of specialist cardiological care. More recently and in addition to medications already routinely used in diabetes care such as renin-angiotensin system (RAS) blockers, some glucose-lowering therapies such as sodium glucose transporter inhibitors 2 (SGLT-2 inhibitors), have been found to have very positive effects on hospitalization for HF, indeed even in people who do not have T2DM. Here, from the perspective of the diabetologist, we review the clinical scenario of ambulatory diabetes care, in regard of how HF prevention and management should fit in to clinical practice.

Prevalence, Clinical Aspects and Outcomes in a Large Cohort of Persons with Diabetic Foot Disease: Comparison between Neuropathic and Ischemic Ulcers

This study aims to evaluate clinical and ulcer characteristics as well the outcomes of patients with diabetic foot ulcers (DFUs). The study group was composed of DFUs patients managed by a limb salvage protocol according to guidance. Clinical and ulcers findings were described, and 1-year outcomes defined as limb salvage, healing, healing time, major amputation and death were compared between neuropathic and ischemic DFUs. One thousand, one hundred and ninety-eight subjects were included; 386 (32.2%) neuropathic and 812 (67.8%) ischemic DFUs. Neuropathic patients were younger (69.5 ± 11.5 vs. 74.5 ± 11.5, p < 0.0001) and reported less cases of nephropathy (22.8 vs. 39.6%, p < 0.0001), ischemic heart disease (22.8 vs. 36.9, p = 0.0004), cerebrovascular disease (8.3 vs. 17.2%, p = 0.002), heart failure (10.1 vs. 24.7%, p = 0.0002) and end-stage-renal-disease (ESRD) (5.4 vs. 27%, p = 0.0001) than ischemic patients; they also showed less cases of large (>5 cm2) (10.3 vs. 22.9%, p = 0.0007), infected (40.4 vs. 55.7%, p = 0.0005) and deep to the bone (22.3 vs. 39.2, p = 0.0002) ulcers, as well less multiple ulcerations (21.8 vs. 32.8%, p = 0.006) than patients with ischemic DFUs. The outcomes for neuropathic and ischemic DFUs were limb salvage (98.4 vs. 82.3%, p < 0.0001), healing (97.3 vs. 79.6%, p < 0.0001), healing time (34.9 vs. 35.6 weeks, p = 0.8), major amputation (0.5 vs. 6.6%, p = 0.0001), death (1.1 vs. 11%, p < 0.0001) respectively. Revascularization failure and ESRD were independent predictors of major amputation, while heart failure and number of co-morbidities (³5) were independent predictors of death. Ischemic DFUs patients showed more severe clinical and ulcers features as well worse outcomes than neuropathic DFUs patients.

In patients with diabetic foot, improved left ventricular functions are detected by strain echocardiography after the diabetic foot treatment: A cross-sectional study

Diabetic foot is a macrovascular complication of diabetes mellitus (DM). In the literature, the relationship between diabetic foot and another macrovascular complication of DM is not clear. The aim of this study was to determine the current left ventricular (LV) systolic function in patients with diabetic foot and to investigate the effect of diabetic foot treatment on LV systolic functions.In this study, 54 patients with diabetic foot and 22 patients without diabetic foot were included. Routine anamnesis, physical examination, echocardiography, and laboratory examinations were performed. In addition, LV global longitudinal strain (LV-GLS) was measured by strain echocardiography technique. LV ejection fraction (LV-EF) and LV-GLS measurements were repeated with echocardiography at the 3rd month of diabetic foot treatment.The incidence of cardiovascular risk factors such as smoking, hypertension, and coronary artery disease was found to be higher in patients with diabetic foot. (P < .05 for each one). Similarly, in patients with diabetic foot, glucose, Hemoglobin A1c, neutrophil, sedimentation, urea, creatinine, potassium, uric acid, alanine aminotransferase, aspartate aminotransferase, C-reactive protein, and brain natriuretic protein were higher; high-density lipoprotein cholesterol level was found to be significantly lower. LV wall thicknesses and diameters were higher and LV-EF was lower in patients with diabetic foot (P < .05 each one). LV-GLS values were significantly lower in patients with diabetic foot (P < .05). Although no significant change was found in the LV-EF value at the 3rd-month follow-up echocardiography (48.6% ± 7.0% vs 48.5% ± 5.9% and P = .747), it was detected that LV-GLS values (17.3 ± 2.1 vs 18.4 ± 2.3) were significantly increased (P < .001).LV systolic function was significantly affected in patients with diabetic foot. This may be related to the increased frequency of cardiovascular risk factors in these patients. However, the significant improvement in LV-GLS values after the diabetic foot treatment showed that diabetic foot itself was an important cause of LV systolic dysfunction.

Can we predict vascular status and culture result based through wound status in diabetic foot infection?

Diabetic foot infection (DFI) should be treated by a multidisciplinary team to prevent amputation and morbid status. As physicians encountering DFI in outpatient clinic, a proper selection of antibiotic treatment and diagnostic approach for a vascular status is essential. We retrospectively investigated the patients with DFI from 2016 to 2017. All patients were examined for vascular status, wound status, and pathologic culture preceding the treatment. No statistical significance was observed between PEDIS grade 1 and 2 and 3 and 4 in culture status and culture results. Association analysis between vascular status and other variables, such as wound score and culture results, has no significant difference. Through these results, the helpful epidemiologic result of microbiology and necessity of examination for peripheral arterial disease were verified.

Impact of heart failure and dialysis in the prognosis of diabetic patients with ischemic foot ulcers

Aim

To establish the role of heart failure (HF) and dialysis (D) in the prognosis of diabetic patients with critical limb ischemia and foot ulcers (FUs).

Methods

Consecutive diabetic patients with ischemic FUs who referred to our Diabetic Foot Centre were prospectively included. All patients underwent a preset limb salvage protocol including peripheral revascularization. According to the presence of HF and D, they were divided in four groups: group 1 without HF and without D defined as ischemic foot (IF); group 2 with HF and without D defined as heart ischemic foot (H-IF); group 3 without HF and with D defined as renal ischemic foot (R-IF); group 4 with HF and with dialysis defined as heart-renal foot (HR-IF). Survival with limb salvage, survival with major amputation and death were reported after 1 year of follow-up.

Results

136 patient have been included: 66 with IF, 26 with H-IF, 24 with R-IF and 20 with HR-IF. The mean age was 68,9 ± 9,7 years, the diabetes duration 20,7 ± 11,6 years, the mean HbA1c 62,7 ± 22,3 mmol/mol. 103/136 (75,7%) survived with limb salvage, 10/136 (7,4%) survived with major amputation, 23/136 (16,9%) died. The outcomes for group IF patients, H-IF, R-IF and HR-IF were respectively: survival with limb salvage (92,4%, 61,5%, 79,2% and 35%), survival with major amputation (6,1%, 7,7%, 8,3% and 10%), death (1,5%, 30,8%, 12,5% and 55%) χ = 0.0001. Heart failure was an independent predictor of death.

Discussion

The presence of heart failure and dialysis in diabetic patients with ischemic foot ulcers was associated to high risk of amputation and mortality.

Association between estimated glomerular filtration rate and outcomes in patients with diabetic foot ulcers: a 3-year follow-up study

OBJECTIVE

End-stage renal disease and dialysis have been proven to be associated with poor prognoses in diabetic foot ulcers (DFUs). However, it has rarely been reported whether and to what extent milder renal insufficiency affects the prognosis. The purpose of this study was to investigate the categorized impact of estimated glomerular filtration (eGFR) on the outcomes of patients with DFU.

DESIGN AND METHODS

Three hundred and sixty-six DFU patients hospitalized in a Chinese tertiary hospital were recruited and classified into 4 groups according to the eGFRs as follows: normal (≥90), mildly reduced (60-89), moderately reduced (30-59), and severely reduced (<30). These patients were followed-up for an average of 37 months to observe the outcomes, including ulcer healing, amputation, ulcer recurrence, cardiac or cerebrovascular events and death. The associations between eGFR and the outcomes were analysed by Cox proportional-hazards models.

RESULTS

Compared to patients with normal eGFR, patients with moderately reduced eGFR had higher risk of healing failure (hazard ratio (HR) = 2.08, 95% confidence interval (CI): 1.13-3.82), cardiac events (HR = 5.25, 95% CI: 2.17-12.89) and death (HR = 3.54, 95% CI: 1.36-9.20). Severely reduced eGFR was associated with higher incidence of healing failure (HR = 2.84, 95% CI: 1.25-6.49) and death (HR = 4.45, 95% CI: 1.23-16.07). The impact of eGFR on ulcer recurrence and cerebrovascular events was not observed in all groups.

CONCLUSIONS

Moderately and severely reduced eGFR in patients with DFU were independent predictors for poor prognoses of both the limbs and the patients.

Prevalence and Risk Factors for Diabetic Lower Limb Amputation: A Clinic-Based Case Control Study

Objective. The aim of the study was to evaluate the prevalence of and risk factors for lower limb amputation in a specialist foot clinic-based setting. Methods. A retrospective quantitative study was conducted, using clinical and biochemical profiles of diabetic foot patients attending the High Risk Foot Clinic at The Townsville Hospital, Australia, between January 1, 2011, and December 31, 2013. Results. The total study sample included 129 subjects, comprising 81 males and 48 females with M : F ratio of 1.7 : 1. Twenty-three subjects were Indigenous Australians, representing 17.8% of the study population. The average age of the cohort was 63.4 years ± 14.1 years [CI 90.98-65.89]. Lower limb amputation was identified as a common and significant outcome (n = 44), occurring in 34.1%, more commonly amongst the Indigenous Australians (56.5% versus 29.2%; p = 0.94, OR 0.94). Risk factors most closely associated with amputation included diabetic retinopathy (p = 0.00, OR 4.4), coronary artery bypass graft (CABG) surgery (p = 0.01, OR 4.1), Charcot's arthropathy (p = 0.01, OR 2.9), and Indigenous ethnicity (p = 0.01, OR 3.4). Although average serum creatinine, corrected calcium, and glycosylated haemoglobin A1c (Hba1c) levels were higher amongst amputees they were statistically insignificant. Conclusions. Lower limb amputation is a common outcome and linked to ethnicity and neurovascular diabetic complications amongst subjects with diabetic foot ulcer. Further research is needed to identify why risk of lower limb amputation seems to differ according to ethnicity.

Incidence and risk factors of lower extremity amputations in people with type 2 diabetes in Taiwan, 2001-2010

BACKGROUND

Diabetic patients have an increased risk of lower extremity amputations (LEAs). In the present study we analyzed the incidence of LEA in patients with type 2 diabetes mellitus (T2DM) in Taiwan from 2001 to 2010, and determined risk factors for LEA.

METHODS

Data from the Taiwan National Health Insurance Research Database collected between 1 January 2001 and 31 December 2010 were analyzed. First, the incidence of LEA in the diabetic population was calculated. Subsequently, patients with new-onset T2DM during the study period were selected, and Cox's proportional hazards model was used to identify factors associated with LEA. The characteristics of patients who underwent major and multiple amputations were also analyzed.

RESULTS

From 2001 to 2010, 1588 non-traumatic LEAs were performed among the study subjects; 776 (48.9%) were minor and 812 (51.1%) were major LEAs. Over the period in question, the incidence of LEAs decreased from 3.08 to 1.65 per 1000 person-years. Factors associated with LEA included peripheral arterial occlusive disease (hazard ratio [HR] 4.134; 95% confidence interval [CI] 2.72-6.29), diabetic neuropathy (HR 2.34; 95% CI 1.62-3.38), diabetic retinopathy (HR 2.07; 95% CI 1.12-3.82), heart failure (HR 2.13; 95% CI 1.45-3.15), male gender (HR 1.64; 95% CI 1.24-2.18), and adult onset diabetes (HR 1.02; 95% CI 1.01-1.04). Patients with a history of stroke were more likely to undergo major and multiple amputations (P < 0.001 and P < 0.01, respectively).

CONCLUSIONS

The incidence of LEA in the Taiwan diabetic population decreased over the study period. The results indicate that efforts to improve diabetic care should be supported and sustainable, especially for those at high risk.

Presence and characterisation of anaemia in diabetic foot ulceration

Introduction. Diabetic foot ulceration (DFU) is the commonest cause of severe limb ischaemia in the western world. In diabetes mellitus, anaemia is frequently unrecognized, yet studies have shown that it is twice as common in diabetics compared with nondiabetics. We aimed to assess the incidence of anaemia and further classify the iron deficiency seen in a high-risk DFU patient group. Methods. An observational study was undertaken in a multidisciplinary diabetic foot clinic setting. All patients with DFU attending over a four-month period were included. Anaemia was defined as haemoglobin (Hb) levels <12 g/dL. Iron deficiency was classified according to definitions of AID (absolute iron deficiency) and FID (functional iron deficiency). Results. 27 patients had DFU; 14 (51.9%) were anaemic; two (7.41%) had severe anaemia (Hb < 10 g/dL). No patient had B12 or Folate deficiency. In patients with anaemia, there was significant spread of indices. Only one patient had “textbook” absolute iron deficiency (AID) defined as low Hb, MCV, MCH, and ferritin. Functional iron deficiency (FID) was seen in a further seven patients (25.5%). Conclusion. Anaemia and iron deficiency are a common problem in patients with DFU. With current clinical markers, it is incredibly difficult to determine causal relationships and further in-depth scientific study is required.

Diabetes-related foot ulcers and associated factors: results from the Nord-Trøndelag Health Survey (HUNT3) (2006-2008)

AIM

To determine the proportion of people with diabetes reporting a history of foot ulcer and investigate associated factors and healing time in the Nord-Trøndelag Health Survey (HUNT3), Norway.

METHODS

In 2006-2008, all inhabitants in Nord-Trøndelag County aged ≥ 20 years were invited to take part in this population-based study; 54% (n=50,807) attended. In participants reporting to have diabetes we examined the relationships between foot ulcers requiring more than 3 weeks to heal (DFU) and sociodemographic, lifestyle and clinical variables using logistic regression analysis.

RESULTS

Among participants with diabetes, 7.4% (95% confidence interval (CI) 6.2%-8.6%) reported a DFU. The median healing time was 6.0 weeks. In the final model, factors associated with a DFU were age ≥ 75 years (odds ratio (OR) 2.3, 95% CI 1.4-3.7), male sex (OR 2.0, 95% CI 1.3-3.1), waist circumference ≥ 102 cm (men) or 88 cm (women) (OR 1.95, 95% CI 1.2-3.2), insulin use (OR 2.1, 95% CI 1.3-3.4) and any macrovascular complication (OR 1.8, 95% CI 1.1-2.8).

CONCLUSIONS

The proportion of people with diabetes reporting a DFU was 7.4%, associated factors were age ≥ 75 years, male sex, waist circumference ≥ 102 cm (men) or 88 cm (women), insulin use and any macrovascular complication. The median healing time was 6 weeks.

Impact of diabetes and comorbidities on split-thickness skin grafts for foot wounds

BACKGROUND

Split-thickness skin grafts can be used for foot wound closure in diabetic and nondiabetic patients. It is unknown whether this procedure is reliable for all diabetic patients, with or without comorbidities of diabetes, including cardiovascular disease, neuropathy, retinopathy, and nephropathy.

METHODS

We retrospectively reviewed 203 patients who underwent this procedure to determine significant differences in healing time, postoperative infection, and need for revisional surgery and to create a predictive model to identify diabetic patients who are likely to have a successful outcome.

RESULTS

Overall, compared with nondiabetic patients, diabetic patients experienced a significantly higher risk of delayed healing time and postoperative complication/infection and, hence, are more likely to require revisional surgery after undergoing the initial split-thickness skin graft procedure. These differences seemed to be related more to the presence of comorbidities than to diabetic status itself. Diabetic patients with preexisting comorbidities experienced a significantly increased risk of delayed healing time and postoperative infection and a higher need for revisional surgery compared with nondiabetic patients or diabetic patients without comorbidities. However, there were no significant differences in outcome between diabetic patients without comorbidities and nondiabetic patients.

CONCLUSIONS

For individuals with diabetes but without exclusionary comorbidities, split-thickness skin grafting may be considered an effective surgical alternative to other prolonged treatment options currently used in this patient population.

[The vascular surgeon's role in interdisciplinary treatment of diabetic foot syndrome]

There are more than 6 million diabetes patients in Germany. Due to long-term neuropathic and angiopathic sequelae, the number of patients with "diabetic foot syndrome" has increased dramatically in recent years. Diabetic foot ulcers have become one of the most common pathologies in interdisciplinary wound care centers. Because of its complex pathogenesis, diabetic foot syndrome needs a multidisciplinary therapeutic approach. More than 150,000 diabetics per year develop foot ulcers that often heal slowly and progress into chronic wounds. Despite all efforts at prevention, early diagnosis, and adequate therapy, more than 20,000 diabetics suffer major limb amputation in Germany every year. Applying stringent standards of care in interdisciplinary wound care centers, the amputation rate in patients with diabetic foot syndrome can be reduced to less than 50%. This article describes the complexity of diabetic foot syndrome with respect to pathogenesis, diagnostics, and therapy from a vascular surgeon's point of view. The importance of an interdisciplinary approach is emphasized.