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Prognostic value of the clinical examination of the diabetic foot ulcer

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Abstract

Objective

To determine the value of the history, physical examination, and magnetic resonance imaging (MRI) in predicting successful primary healing of a foot ulcer in a diabetic patient.

Design

Prospective cohort study.

Setting

Durham (NC) Veterans Affairs Medical Center.

Patients

Sixty-four consecutive diabetic patients with 78 dermal ulcers through the full thickness of the skin and at or distal to the malleoli of the ankle.

Measurements and main results

A structured clinical history and physical examination were performed by two examiners, a physician participating in the study and the refering physician. Fifty of these patients with 63 ulcers underwent MRI. Patients were followed prospectively for 6 months after enrollment to ascertain healing of the ulcer, amputation, and death. During the 6-month follow-up period, 8 (13%) of the patients died. Seventeen (22%) of the ulcers were amputated, 17 (22%) of the ulcers failed to heal, and 36 (47%) healed primarily. Univariate predictors of healing at 6 months included age less than 65 years, diagnosis of diabetes within the last 15 years, painless ulcer, palpable ankle pulse, anklebrachial index greater than 0.5, and the physician’s assessment of the overall likelihood of osteomyelitis. In a multivariable logistic regression model, predictors of healing included the presence of an audible pulse on Doppler examination (p=.01) and a painless ulcer (p=.04). The diagnosis of osteomyelitis on MRI did not predict healing in these patients.

Conclusions

Foot ulcers in patients with diabetes frequently have poor outcomes; fewer than half the patients in this study healed their ulcers within 6 months. The vascular components of the clinical examination are the best predictors of healing in patients with a diabetic foot ulcer.

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References

  1. Eckman ME, Greenfield S, Mackey WC, et al. Foot infections in diabetic patients. JAMA. 1995;273(9):712–20.

    Article  PubMed  CAS  Google Scholar 

  2. Levin ME. Preventing amputation in the patient with diabetes. Diabetes Care. 1995;18(10):1383–94.

    PubMed  CAS  Google Scholar 

  3. Lindholm C, Bjellerup M, Christensen OB, Žederfeldt B. Quality of life in chronic leg ulcer patients. Acta Derm Venereol Suppl (Stockh). 1993;73:440–3.

    CAS  Google Scholar 

  4. Pell JP, Donnan PT, Fowkes FGR, Ruckley CV. Quality of life following lower limb amputation for peripheral arterial disease. Eur J Vasc Surg. 1993;7:448–51.

    Article  PubMed  CAS  Google Scholar 

  5. Malone JM, Snyder M, Anderson G, Bernhard VM, Holloway GA Jr, Bunt TJ. Prevention of amputation by diabetic education. Am J Surg. 1989;158:520–4.

    Article  PubMed  CAS  Google Scholar 

  6. Edmonds ME, Blundell MP, Morris ME, Cotton JT, Watkins PJ. Improved survival of the diabetic foot: the role of a specialized foot clinic. QJM. 1986;60:763–71.

    PubMed  CAS  Google Scholar 

  7. Apelqvist J, Larsson J, Agardh C-D. The importance of peripheral pulses, peripheral oedema and local pain for the outcome of diabetic foot ulcers. Diabetes Med. 1990;7:590–4.

    Article  CAS  Google Scholar 

  8. Apelqvist J, Larsson J, Agardh CD. Medical risk factors in diabetic patients with foot ulcers and severe peripheral vascular disease and their influence on outcome. J Diabetes Complications. 1992: 6:167–74.

    Article  PubMed  CAS  Google Scholar 

  9. Yuh WTC, Corson JD, Baraniewski HM, et al. Osteomyelitis of the foot in diabetic patients: evaluation with plain film,199mTc-MDP scintigraphy, and MR imaging. AJR Am J Roentgenol. 1989;152: 795–800.

    PubMed  CAS  Google Scholar 

  10. Wang A, Weinstein D, Greenfield L, et al. MRI and diabetic foot infections. Magn Reson Imaging. 1990;8:805–9.

    Article  PubMed  CAS  Google Scholar 

  11. Horowitz JD, Durham JR, Nease DB, Lukens ML, Wright JG, Smead WL. Prospective evaluation of magnetic resonance imaging in the management of acute diabetic foot infections. Ann Vasc Surg. 1993;7:44–50.

    Article  PubMed  CAS  Google Scholar 

  12. Morrison WB, Schweitzer ME, Bock GW, et al. Diagnosis of osteomyelitis: utility of fat-suppressed contrast-enhanced MR imaging. Radiology. 1993;189:251–7.

    PubMed  CAS  Google Scholar 

  13. apelqvist J, Castenfors J, Larsson J, Stenstrom A, Agardh CD. Wound classification is more important than site of ulceration in the outcome of diabetic foot ulcers. Diabetes Med. 1989;6:526–30.

    CAS  Google Scholar 

  14. Hiatt WR, Marshall JA, Baxter J, et al. Diagnostic methods for peripheral arterial disease in the San Luis Valley Diabetes Study. J Clin Epidemiol. 1990;43(6):597–606.

    Article  PubMed  CAS  Google Scholar 

  15. Fleiss JL. Statistical Methods for Rates and Proportions. New York, NY: John Wiley and Sons; 1981.

    Google Scholar 

  16. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159–74.

    Article  PubMed  CAS  Google Scholar 

  17. Williams JW, Simel DL, Roberts L. Samsa GP. Clinical evaluation for sinusitis. Ann Intern Med. 1992;117(9):705–10.

    PubMed  Google Scholar 

  18. Gjorup T, Bugge PM, Jensen AM. Interobserver variation in assessment of respiratory signs. Acta Med Scand. 1984;216:61–6.

    Article  Google Scholar 

  19. Mulrow CD, Dolmatch BL, Delong ER, et al. Observer variability in the pulmonary examination. J Gen Intern Med. 1986;1:364–7.

    Article  PubMed  CAS  Google Scholar 

  20. Nice DA, Riddle DL, Lamb RL, Mayhew TP, Rucker K. Intertester reliability of judgments of the presence of trigger points in patients with low back pain. Arch Physiol Med Rehabil. 1992;73:893–8.

    CAS  Google Scholar 

  21. Stiell IG, McKnight RD, Greenberg GH, Nair RC, McDowell I, Wallace GJ. Interobserver agreement in the examination of acute ankle injury patients. Am J Emerg Med. 1992;10(1):14–7.

    Article  PubMed  CAS  Google Scholar 

  22. Ishmall AA, Wing S, Ferguson J, Hutchinson TA, Magder S, Flegel KM. Interobserver agreement by auscultation in the presence of a third heart sound in patients with congestive heart failure. Chest. 1987;91(6):870–3.

    Google Scholar 

  23. Boulton AJM. The diabetic foot. Med Clin North Am. 1988;72(6): 1513–30.

    PubMed  CAS  Google Scholar 

  24. Apelqvist J, Castenfors J, Larsson J, Stenstrom A, Agardh CD. Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer. Diabetes Care. 1989;12(6):373–7.

    Article  PubMed  CAS  Google Scholar 

  25. Gentry LO. Antibiotic therapy for osteomyelitis. Infect Dis Clin North Am. 1990;4:485–99.

    PubMed  CAS  Google Scholar 

  26. Nix DE, Cumbo TJ, Kuritzky P, Devito JM, Schentag JJ. Oral ciprofloxacin in the treatment of serious soft tissue and bone infections. Am J Med. 1987;82(S4A):146–53.

    PubMed  CAS  Google Scholar 

  27. Peterson LR, Lissack LM, Canter K, Fasching CE, Clabots C, Gerding DN. Therapy of lower extremity infection with ciprofloxacin in patients with diabetes mellitus, peripheral vascular disease, or both. Am J Med. 1989;86:801–8.

    Article  PubMed  CAS  Google Scholar 

  28. del Aguila MA, Pugh J, Reiber GE. How does delay in seeking care for a diabetic foot lesion influence outcome? In: Selected Abstracts for the 15th Annual VA Health Services Research and Development Meeting; February 12–14, 1997; Washington, DC. 1997:29.

  29. Edelman DE, Matchar DB, Oddone EŽ. Clinical and radiographic finding that lead to intervention in diabetic patients with foot ulcers. Diabetes Care. 1996;19(7):755–7.

    Article  Google Scholar 

  30. Gibbons GW, Marcaccio EJ, Burgess AM, et al. Improved quality of diabetic foot care, 1984 vs. 1990. Reduced length of stay and costs, insufficient reimbursement. Arch Surg. 1993;128(5):576–81.

    PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, the Center for Health Policy Research and Education, Ambulatory Care (11C), 508 Fulton St., 27705, Durham, NC

    David Edelman MD & Eugene Ž. Oddone MD

  2. Division of General Internal Medicine, Duke University Medical Center, Durham, NC

    David Edelman MD & Eugene Ž. Oddone MD

  3. Department of Radiology, Duke University Medical Center, Durham, NC

    David M. Hough MD & Katrina N. Glazebrook MD

Authors
  1. David Edelman MD
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  2. David M. Hough MD
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  3. Katrina N. Glazebrook MD
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  4. Eugene Ž. Oddone MD
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Additional information

Dr. Oddone is supported by the Veterans Affairs Health Services Research and Development Career Development and the Robert Wood Johnson Generalist Physician Faculty Scholars Programs.

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Edelman, D., Hough, D.M., Glazebrook, K.N. et al. Prognostic value of the clinical examination of the diabetic foot ulcer. J GEN INTERN MED 12, 537–543 (1997). https://doi.org/10.1046/j.1525-1497.1997.07108.x

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  • DOI: https://doi.org/10.1046/j.1525-1497.1997.07108.x

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