One area in which podiatry has led the medical profession is the care of diabetic lower extremity complications.  When it comes to limb preservation and wound care, podiatrists have been on the forefront.  I could list the names of internationally famous podiatric physicians, but that would take most of the page.  Among the great work that has been performed, several of our leaders have synthesized the research and clinical data to better our understanding of diabetes and its complications. 

I discovered one such synthesis —  that reinforced my own sense of the importance of what we do — after seeing a lecture by Jeffrey Robbins, DPM. I highly recommend it, it’s worth every minute of your time.  A portion of his lecture referred to an editorial by Armstrong, Wrobel, and Robbins (Armstrong, et al. 2007), in which he argued that diabetic lower extremity complications are worse than some cancers.  See below for a modified version of their graph comparing neuropathic complications to certain cancers.  I would suggest that this graph should be in ALL of our diabetic education lectures and in every discussion we have with our patients.  I also submit the media, as well as our politicians, should be aware of these figures when considering voting on such ideas as Medicare reimbursement and state-level scope of practice for podiatrists.

	Tonight's Premier Lecture is Getting Difficult Wounds to Heal – The Science of Advanced Wound Care by Robert Frykberg, DPM, FACFAS

Here are some striking statistics.  Consider that globally, diabetes mellitus has grown to pandemic proportions, affecting 194 million people worldwide and is expected to increase in prevalence to 344 million by the year 2030 (Wild, et al. 2004).  Of these patients, between 2 and 6% will develop a diabetic foot ulcer (DFU) yearly (Ramsey, et al. 1999).  The onset of a DFU often precipitates a complex chain of events that often leads to limb loss.  The long-term outcome for a diabetic patient after a major limb amputation is grave with 50% of these patients deceased at 5 years (Moulik, et al 2003). 

In America public discussion and much research money goes to the investigation and treatment of breast and prostate cancers, two common forms of cancer.  However, when we look at the 5 year mortality percentages a “simple” diabetic neuropathic ulcer has a worse survival rate than each of these cancers.  The same is true if a diabetic has had a prior amputation.  Add peripheral arterial disease into the mix and it gets worse yet.  In fact, having a neuropathic ulcer or prior amputation has about the same poor survival rate as colon cancer. 

Figure 1. Five year mortality percentages of several medical conditions.  Red arrows highlight the high mortality of patients with neuropathic ulcers, prior amputations, or ischemic ulceration (Modified from Armstrong, et al. 2007).

With the initiation of a comprehensive diabetes prevention program we can actually extend the life of our patients.  Let me say that again: 

"By preventing lower extremity complications we can significantly extend patients' lives."

This is the reason podiatric medicine is so important.  We are our patients’ lifeline to a longer, higher quality life.  Is there research to prove this?  Yup.  The research shows a seven-fold decreased risk of amputation in diabetic patients when treated using a vascular surgery-podiatry team approach with a 5 year rate of avoiding limb loss of 83% (Van Gils, et al. 1999). 

Need I say more? 

...well, I'd still like to hear what you have to say. Please share your thoughts on the importance of preventing lower extremity complications on our Practice Perfect Podiatry Service Announcement eTalk and help podiatry move into the forefront of medical care.

Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum. Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

• Armstrong, et al. Guest editorial: are diabetes-related wounds and amputations worse than cancer? International Wound Journal, Dec 2007; 4 (4): 286-287.
• Moulik, et al. Amputation and Mortality in New-Onset Diabetic Foot Ulcers Stratified by Etiology. Diabetes Care, Feb 2003; 26(2): 491-494.
• Ramsey, S, et al. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care; 22 (3): 382-387.
• Van Gils, et al. Amputation Prevention by Vascular Surgery and Podiatry Collaboration in High-Risk Diabetic and Nondiabetic Patients: The Operation Desert Foot Experience. Diabetes  Care, May 1999; 22(5): 678-683.
• Wild, S, et al. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care, 2004; 27 (5): 1047-1053.

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