Prevention

Recommendations

Identify and Treat the Cause
1 Take a careful history (general history, diabetic control and complications). Level of Evidence
Not Assessed
2 Perform a foot examination at least annually in all people with diabetes over the age of 15 and at more frequent intervals for those at higher risk. Level of Evidence
Not Assessed
3 Determine risk category for all patients with a risk of diabetic ulcer or amputation. Level of Evidence
Not Assessed
4 Advise individuals at higher risk for foot ulcer/amputation of their risk status and refer them to their primary care provider, specialized diabetes or foot care treatment for additional assessment as appropriate. Level of Evidence
Not Assessed
5 Manage existing ulcers appropriately and treat infection aggressively. Level of Evidence
Not Assessed
6 Correct (if possible) risk factors for ulcer formation /amputation: ♦ Vascular supply ♦ Infection ♦ Pressure (including bony deformity) Remember the patient assessment / treatment mnemonic VIP Level of Evidence
Not Assessed


Address Patient-Centered Concerns
7 Provide individualized education to enhance Glycemic control, Adherence to treatment, Plantar pressure redistribution/daily foot inspection. Remember the patient education mnemonic GAP Level of Evidence
Not Assessed


Provide Local Wound Care
8 Institute appropriate local preventive strategies, including monitoring of pressure associated with bony deformities and use of appropriate accommodative footwear. Level of Evidence
Not Assessed
9 Obtain a vascular consultation for patients with limb ischemia and consider revascularization surgery. Level of Evidence
Not Assessed
10 Consider prophylactic surgery to correct bony deformities. Level of Evidence
Not Assessed


Provide Organizational Support
11 Establish and empower an interprofessional team to work with Persons With Diabetes (PWD). Level of Evidence
Not Assessed
12 Advocate for strategies and funding to assist patients in obtaining appropriate pressure redistribution devices Level of Evidence
Not Assessed


Background

A preventive approach can be applied to all patients at risk of diabetic foot ulcer or amputation, from patients with no current pathology and no history of ulceration to those who have ulcer, infection and ischemia. To determine appropriate preventive strategies, the clinician must first determine a risk category.

For patients in all categories, addressing co morbidities and systemic factors such as achieving or maintaining glycemic control is a key preventive strategy. Hyperglycemia is a major factor in the development and progression of microvascular complications, such as neuropathy, which are strongly linked to diabetic foot ulcers. Optimal management of vascular risk factors, such as hypertension and dyslipidemia is also recommended. Risk factor reduction can help to slow progression of atherosclerosis, peripheral arterial disease and vascular insufficiency, which also contribute to the development of diabetic foot ulcers. Patients who have ischemia of the limb require a vascular surgery consultation, as revascularization may be necessary. Effective patient education, encompassing glycemic control, risk factor management and foot care, is an important preventive strategy.

Patients who have bony or structural deformities of the foot and those who have neuropathy require regular assessment and possible shoe accommodation to prevent irritation or excessive pressure, which predisposes to ulceration. For patients with Charcot joint, thermometric and radiographic monitoring is indicated. Patients with both neuropathy and deformity may require more frequent assessment. They may also benefit from custom molded or extra deep shoe accommodation or from prophylactic surgery to correct the bony deformity of concern. If a history of ulceration is also present, custom shoe accommodation to prevent recurrence is recommended, along with consideration of prophylactic surgery to correct bony deformities.

References

Essential Publications
2 Prevention of foot ulcers Quality Indicator
 Type: Systematic review
Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005 Jan 12;293(2):217-28.
This systematic review of RCTs, case control studies and cohort studies was conducted to review the efficacy of methods recommended for preventing diabetic foot ulcers in the primary care setting. This review provides evidence that supports screening all patients with diabetes for risk for foot ulceration so that they might receive appropriate preventive interventions.
3 Prevention of foot ulcer Quality Indicator
 Type: RCT
Lavery LA, Higgins KR, Lanctot DR, Constantinides GP, Zamorano RG, Athanasiou KA, Armstrong DG, Agrawal CM. Preventing diabetic foot ulcer recurrence in high-risk patients: Use of temperature monitoring as a self-assessment tool. Diabetes Care 2007;30(1):14-20.
Patient self-monitoring of temperature to reduce the incidence of foot ulcers was evaluated in patients with diabetes and previous history of ulcers. Three interventions were compared: (I) standard therapy (n=58), (2) structured foot examination (n=56), and (3) enhanced therapy using an infrared skin thermometer (n=59). By notifying the study nurse and reducing activity if there was a temperature difference of more than 4oF (2.2oC) between left and right corresponding sites, the incidence of foot ulcers was significantly reduced. Incidence of foot ulcers in enhanced therapy group 8.5%, standard therapy group 29.3%(P=0.0046), and structured foot exam group 30.4% (P=0.0029). Patient infrared thermometer monitoring decreases the incidence of foot ulcers.
4 Prediction and prevention of foot ulcers Quality Indicator
 Type: Prospective Correlation study
Boyko EJ, Ahroni JH, Cohen V, Nelson KM, Heagerty PJ. Prediction of Diabetic Foot Ulcer Occurrence Using Commonly Available Clinical Information: The Seattle Diabetic Foot Study. Diabetes Care, June 1, 2006; 29(6): 1202 - 1207.
In this large prospective study, 1285 diabetic veterans without foot ulcers were evaluated to determine risk associated with clinical and laboratory information. A1C, impaired vision, prior foot ulcer, prior amputation monofilament insensitivity, tinea pedis and onychomycosis all are predictors for diabetic foot ulcers. Knowing these risk factors can help clinicians predict, and therefore prevent, the occurrence of diabetic foot ulcers.
5 Prevention of amputation Quality Indicator
 Type: Retrospective Analysis
Markowitz JS, Gutterman EM, Magee G, Margolis DJ. Risk of amputation in patients with diabetic foot ulcers: a claims-based study. Wound Rep Reg 2006;14:11-17.
In a retrospective analysis of claims data of diabetic foot ulcer patients with amputations were matched on follow-up days with non-amputated control subjects to determine risk factors for amputation. For 5911 eligible patients, the incidence density rate was 2.3 amputations per 100 person years (95% Confidence Interval 1.91-2.77). The significant risk factors (adjusted odds ratio) were male gender (1.98), Charlson co-morbidity score of 4-5 (2.89) or 6+ (5.36), renal disease (2.11), PVD (2.67), and 5+ out patient DFU services (2.17). Awareness of the risk factors associated with amputation may prompt clinicians to adopt a more aggressive approach to the care of patients with DFU.
6 Prevention of primary major amputation - determination of risk factors Quality Indicator
 Type: Retrospective Analysis
Dos Santos VP, da Silveira DR, Caffaro RA. Risk factors for primary major amputation in diabetic patients. Sao Paulo Med J 2006;124(2):66-70.
Patients in this retrospective analysis underwent major amputation (n=48) or minor amputation/debridement (n=51). Although numerous variables were investigated, ascending lymphangitis was seen significantly more often in patients with major versus amputation (88.2% versus 75%, χ2 = 3.86 P = 0.???); the probability of supra or infrapatellar amputation was 2.5 times greater than when it was absent. It is important to know the risk factors for amputation and to modify them if possible.
7 Prevention of major amputation in foot with gangree - determination of risk factors Quality Indicator
 Type: Retrospective Analysis
Miyajima S, Shirai A, Yamamoto S, Okada N, Matsushita T. Risk factors for major limb amputation in diabetic foot gangrene patients. Diabetes Research and Clinical Practice 2006;71:272-279.
In this retrospective analysis of 210 patients, independent risk factors for major limb amputations were arteriosclerosis obliterans, hemodialysis, and HbA1c.
8 Topical antifungal nail lacquer Quality Indicator
 Type: RCT
Armstrong DG, Holtz K, We S. Can the use of a topical antifungal nail lacquer reduce risk for diabetic foot ulceration? Results from a randomized controlled pilot study. International Wound Journal 2005;2(2):166-170.
In this randomized controlled pilot study to compare daily self-inspection with and without the use of a topical antifungal nail lacquer, the proportion of persons with ulceration were very similar and no significant difference was found. There was however an unexpected and interesting secondary finding of significantly lower proportion of patients with hyperkeratosis or tinea pedis.
9 Patient education for prevention Quality Indicator
 Type: Systematic review
Valk GD, Kriegsman DMW, Assendelft WJJ. Patient education for preventing diabetic foot ulceration. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD001488. DOI: 10.1002/14651858.CD001488.pub2.
Although the methodological quality of the RCTs in this systematic review was poor and the results were conflicting, there is weak evidence that educational interventions in high-risk patients reduced the incidence of foot ulceration and amputation.
10 Prediction of foot ulcers Quality Indicator
 Type: Systematic review
Crawford F, Inkster M, Kleijnen J and Fahey T. Predicting foot ulcers in patients with diabetes: a systematic review and meta-analysis. Q J Med 2007; 100:65–86.
This well-designed systematic review of case-control and cohort studies, with incidence of foot ulcers from 8% to 17%, indicated the predictive value of diagnostic tests of peripheral neuropathy and plantar pressure for diabetic foot ulceration. The predictive value of signs and symptoms has not been established.
11 Risk Factors for Diabetic Foot Complications Quality Indicator
 Type: Prevalence study
Lavery LA, Peters EJ, Williams JR, Murdoch DP, Hudson A, Lavery DC; International Working Group on the Diabetic Foot. Reevaluating the way we classify the diabetic foot: restructuring the diabetic foot risk classification system of the International Working Group on the Diabetic Foot. Diabetes Care. 2008 Jan;31(1):154-6. Epub 2007 Oct 12.
Following its analysis, this publication presents a modified version of the IWGDF classification system for diabetic feet, known as the Texas Classification System, which the publication shows is more effective than the original classification system.
12 Risk factors for Amputation Quality Indicator
 Type: Prospective Correlation study
Adler AI, Boyko EJ, Ahroni JH, Smith DG. Lower-extremity amputation in diabetes. The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers. Diabetes Care. 1999 Jul;22(7):1029-35.
This study examines potential risk factors for lower-extremity amputation. Through a prospective study, it identifies the following independent risk factors for amputation in patients with diabetes: peripheral sensory neuropathy, peripheral vascular disease, foot ulcers, previous amputation and treatment with insulin.
13 Incidence of ulceration and amputation Quality Indicator
 Type: Longitudinal study (1 group)
Armstrong DG, Harkless LB. Outcomes of preventative care in a diabetic foot specialty clinic. J Foot Ankle Surg. 1998 Nov-Dec;37(6):460-6.
The study’s purpose was to examine the incidence of ulceration and amputation in diabetic patients treated in a multidisciplinary clinic. The results demonstrated that a multidisciplinary approach and risk-based treatment are extremely beneficial in preventing and managing foot ulcers in diabetic patients.
14 Foot problems in patients on hemodialysis Quality Indicator
 Type: Prevalence study
Locking-Cusolito H, Harwood L, Wilson B, Burgess K, Elliot M, Gallo K, Ische J, Lawrence-Murphy JA, Ridley J, Robb M, Taylor C, Tigert J. Prevalence of risk factors predisposing to foot problems in patients on hemodialysis. Nephrol Nurs J. 2005 Jul-Aug;32(4):373-84.
The purpose of this study is to identify the prevalence of risk factors that predispose patients on hemodialysis to increased risk of foot ulceration. The results show that patients on hemodialysis are at increased risk for foot ulceration, and that nursing management should include foot assessment, patient education, and referral to foot specialists when necessary
15 Temperature Monitoring Quality Indicator
 Type: RCT
Armstrong DG, Holtz-Neiderer K, Wendel C, Mohler MJ, Kimbriel HR, Lavery LA. Skin temperature monitoring reduces the risk for diabetic foot ulceration in high-risk patients. Am J Med. 2007 Dec;120(12):1042-6.
The purpose of this study was to evaluate the clinical effectiveness of at-home temperature monitoring in the prevention of diabetic foot ulceration. The results show that if patients are provided sufficient education, at-home temperature monitoring can be an effective tool in preventing diabetic foot ulceration.
16 Temperature Monitoring Quality Indicator
 Type: Narrative Review
Lavery LA, Armstrong DG. Temperature monitoring to assess, predict, and prevent diabetic foot complications. Curr Diab Rep. 2007 Dec;7(6):416-9.
The purpose of this study is to review the literature examining the effect of home temperature monitoring on the onset of diabetic foot complications. The results show that using home temperature monitoring as a risk assessment tool can decreases ulceration by anywhere between 3 times and 10 times in high-risk patients.


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