"The results strongly suggested that foot infections are common and complex. They are also costly in terms of morbidity," noted Dr. Lawrence A. Lavery of Texas A&M, the lead author on the study.

The study also found that nearly 9 in 10 amputations performed are instigated by an infection. "This was perhaps the most interesting figure in the study," noted David G. Armstrong, DPM, PhD, Professor of Surgery and Director of Scholl's Center for Lower Extremity Ambulatory Research at Rosalind Franklin University and one of the study's principal investigators.
We evaluated then followed 1,666 consecutive diabetic patients enrolled in a managed care–based outpatient clinic in a 2-year longitudinal outcomes study. At enrollment, patients underwent a standardized general medical examination and detailed foot assessment and were educated about proper foot care. They were then rescreened at scheduled intervals and also seen promptly if they developed any foot problem.

During the evaluation period, 151 (9.1%) patients developed 199 foot infections, all but one involving a wound or penetrating injury. Most patients had infections involving only the soft tissue, but 19.9% had bone culture–proven osteomyelitis. For those who developed a foot infection, compared with those who did not, the risk of hospitalization was 55.7 times greater (95% CI 30.3–102.2; P < 0.001) and the risk of amputation was 154.5 times greater (58.5–468.5; P < 0.001). Foot wounds preceded all but one infection. Significant (P < 0.05) independent risk factors for foot infection from a multivariate analysis included wounds that penetrated to bone (odds ratio 6.7), wounds with a duration >30 days (4.7), recurrent wounds (2.4), wounds with a traumatic etiology (2.4), and presence of peripheral vascular disease (1.9).

From the results it was concluded that foot infections occur relatively frequently in individuals with diabetes, almost always follow trauma, and dramatically increase the risk of hospitalization and amputation. Efforts to prevent infections should be targeted at people with traumatic foot wounds, especially those that are chronic, deep, recurrent, or associated with peripheral vascular disease. "It is infection that is the spark that led to nearly all amputations in this study," said Armstrong. "Poor circulation, while critically important, did not necessarily cause amputation. It determined the level of amputation. This subtlety makes a significant difference when designing strategies for prevention."
Diabetes Care June 2006

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