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A Review of Adverse Events Related to Diabetic Foot Ulcers

Diabetic foot ulcers put patients at increased risk of falling.

In 2015, the American Diabetes Association reported that almost 10% (30.3 million adults) of the United States population was afflicted with diabetes mellitus and another

84.1 million adults had prediabetes. This staggering number continues to grow and has proven to be a tremendous burden on the healthcare system. With an estimated 1.5 million Americans diagnosed with diabetes each year programs designed to help reduce the number of adverse events are instrumental in preventing morbidity and mortality. While it is well known that the most common complications of diabetes include neuropathy, retinopathy, nephropathy, cardiovascular disease and skin disorders there have been few studies evaluating the risk of falls in this population.

Upwards of 70% of patients with diabetes experience peripheral neuropathy. Patients with peripheral neuropathy are at an increased risk of falls, fractures and contusions due to impaired proprioception and unsteady gait. Additionally, diabetic foot ulcers (DFU), another cause of concern for patients, also increase a patient’s chances of falling. In a previous prospective study that examined patients with a history of DFU reported that 63% of their 400-participant population had fallen over a 2-year follow-up period.

A retrospective study examining all VHA hospitalized patients determined that more than half of patients had a diagnosis of diabetes mellitus, and lower extremity ulcers and amputations accounted for more than one-half of hospitalizations. On average, veterans are at least 2 times more likely to be afflicted by diabetes. Researchers at the James A. Haley Veteran’s Administration Hospital in Tampa, Florida aimed to investigate the prevalence of DFU and the rate of adverse events such as amputations, falls, fractures and infection. Using the ICD-9 codes for DFU, lower extremity amputations, falls, fracture and infection all patient records were scanned for the aforementioned criteria. From there, researchers analyzed if the conditions were related to diabetes and if so, were included in the sample size. There were 3,586 individuals diagnosed with DFU and 40,938 individuals with diabetes and without DFU. Comorbidities were more prevalent among individuals with DFU than without.

A diagnosis of peripheral vascular disease was most common (39.5%) in patients with DFU followed by peripheral neuropathy (23.2%). A statistically significant difference was noted between the DFU and non-DFU groups with respect to the prevalence of PVD and peripheral neuropathy (P <0.0000001) The most common adverse events among patients with DFU were infection (39.5%), amputation (16%) and falls (14.6%). While an increased risk of infection and amputation is expected in patients with DFU the number of participants that had reported falls was much higher in the DFU group than in the non-DFU group.

This study shows that participants with diabetes and history of DFU were at an increased risk of infection, amputation, falls and fractures in comparison to the non-DFU group. It was also noted that patients with DFU were statistically significantly more likely to have a diagnosis of peripheral vascular disease and peripheral neuropathy. However, there are some limitations to this study and the results reported. First, it was not noted whether patients were diagnosed with DFU before or after a diagnosis of peripheral vascular disease or peripheral neuropathy. While it can be assumed that the DFU was due to these two complications it was not explicitly stated which occurred first. Second, it was reported that patients with DFU were more likely to experience the adverse events previously stated, however, more patient characteristics such as paralysis, prior limb loss unrelated to diabetes, morbid obesity and advanced age were not disclosed as possible reasons for the falls and fractures. It should also be noted that while there was an increase in comorbidities in the diabetes with DFU group, there was still incidence of falls and fractures in the non-DFU group, albeit it was less likely.

Further research is still warranted regarding the risk of falls and fractures in patients with diabetes who have DFU. For now, healthcare providers can educate patients on ways to mitigate the risk of experiencing these adverse events in diabetes populations with foot ulcers.

Practice Pearls:

  • Patients with diabetic foot ulcers were more likely to suffer from peripheral neuropathy and peripheral vascular disease in comparison to patients without DFUs
  • Almost 40% of patients with DFU experienced infection
  • Almost 15% of patients with DFU experienced a fall


Allen, L., et al. “A Retrospective Review of Adverse Events Related to Diabetic Foot Ulcers.” Osomy/wound management 63.6 (2017): 30.


Jessica Lambert, University of South Florida College of Pharmacy, Doctor of Pharmacy Candidate 2018