Epidemiology and Health Care Cost of Diabetic Foot Problems

  • Robert G. FrykbergEmail author
  • Jeremy J. Cook
  • Donald C. Simonson
Part of the Contemporary Diabetes book series (CDI)


The diabetic lower extremity has long been a cause for both morbidity and mortality in patients afflicted with this multisystem disease. Unfortunately, the global prevalence of diabetes mellitus has been projected to nearly double from a baseline of 2.8% in 2000 to 4.4% by 2030, affecting over 350 million individuals (Wild et al. Diabetes Care. 2004;27(5):1047–53). In the decade beginning in 1997, the prevalence of diabetes in the USA has increased by 48% ( Lower extremity morbidity contributes substantially to the toll diabetes takes on the individual and the health care system. This chapter focuses on the epidemiologic aspects of risk factors and complications in the diabetic lower extremity, particularly as they relate to the outcome of amputation. Included in the discussion is the influence of demographic factors, such as gender, age, race, and socioeconomic considerations, as well as the cost to the health care system of lower extremity disease in diabetes.


Diabetic peripheral neuropathy Peripheral vascular disease Diabetic ulcer pathway Musculoskeletal deformities Ulcerations Amputations Lower extremity disease Diabetic limb 


  1. 1.
    Joslin E. The menace of diabetic gangrene. N Engl J Med. 1934;211(1):16–20.CrossRefGoogle Scholar
  2. 2.
    Zimmet PZ. Kelly west lecture 1991. Challenges in diabetes epidemiology—from west to the rest. Diabetes Care. 1992;15(2):232–52.PubMedCrossRefGoogle Scholar
  3. 3.
    Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27(5):1047–53.PubMedCrossRefGoogle Scholar
  4. 4.
    Centers for Disease Control and Prevention (CDC). Diabetes data and trends. Updated 2010. Accessed 30 Aug 2010.
  5. 5.
    Centers for Disease Control and Prevention, National Diabetes Statistics Report: Estimates of diabetes and its burden in the United States, 2014. 2014, U.S. Department of Health and Human Services: Atlanta, GA.Google Scholar
  6. 6.
    Vigersky RA, et al. Barriers and potential solutions to providing optimal guideline-driven care to patients with diabetes in the U.S. Diabetes Care. 2013;36(11):3843–9.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013;36(4):1033–46.PubMedCentralCrossRefPubMedGoogle Scholar
  8. 8.
    Skrepnek GH, et al. Health care service and outcomes among an estimated 6.7 million ambulatory care diabetic foot cases in the U.S. Diabetes Care. 2017;40(7):936–42.PubMedCrossRefGoogle Scholar
  9. 9.
    LeQuesne P, Parkshouse N, Faris I. Neuropathy. In: Faris I, editor. The management of the diabetic foot. 2nd ed. Edinburgh: Churchill Livingstone; 1991. p. 41.Google Scholar
  10. 10.
    Dyck PJ, Kratz KM, Karnes JL, et al. The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: the Rochester diabetic neuropathy study. Neurology. 1993;43(4):817–24.PubMedCrossRefGoogle Scholar
  11. 11.
    Maser RE, Steenkiste AR, Dorman JS, et al. Epidemiological correlates of diabetic neuropathy. Report from Pittsburgh epidemiology of diabetes complications study. Diabetes. 1989;38(11):1456–61.PubMedCrossRefGoogle Scholar
  12. 12.
    Young MJ, Boulton AJ, MacLeod AF, Williams DR, Sonksen PH. A multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom hospital clinic population. Diabetologia. 1993;36(2):150–4.PubMedCrossRefGoogle Scholar
  13. 13.
    Tesfaye S, Stevens LK, Stephenson JM, et al. Prevalence of diabetic peripheral neuropathy and its relation to glycaemic control and potential risk factors: the EURODIAB IDDM complications study. Diabetologia. 1996;39(11):1377–84.PubMedCrossRefGoogle Scholar
  14. 14.
    Walters DP, Gatling W, Mullee MA, Hill RD. The prevalence of diabetic distal sensory neuropathy in an English community. Diabet Med. 1992;9(4):349–53.PubMedCrossRefGoogle Scholar
  15. 15.
    Gregg EW, Sorlie P, Paulose-Ram R, et al. Prevalence of lower-extremity disease in the US adult population >=40 years of age with and without diabetes: 1999–2000 national health and nutrition examination survey. Diabetes Care. 2004;27(7):1591–7.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Gregg EW, Gu Q, Williams D, et al. Prevalence of lower extremity diseases associated with normal glucose levels, impaired fasting glucose, and diabetes among U.S. adults aged 40 or older. Diabetes Res Clin Pract. 2007;77(3):485–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Centers for Disease Control and Prevention (CDC). Hospitalizations for lower extremity conditions. Updated 2007. Accessed 30 May 2010.
  18. 18.
    Cutting K. Glossary. In: Miller M, Glover G, editors. Wound management theory and practice. London: Johnson & Johnson Medical; 1999. p. 170.Google Scholar
  19. 19.
    Edmonds M, Foster A (eds). The high-risk foot. In: Managing the diabetic foot. London: Blackwell Science; 2000. p. 35–44.Google Scholar
  20. 20.
    Daousi C, MacFarlane IA, Woodward A, Nurmikko TJ, Bundred PE, Benbow SJ. Chronic painful peripheral neuropathy in an urban community: a controlled comparison of people with and without diabetes. Diabet Med. 2004;21(9):976–82.PubMedCrossRefGoogle Scholar
  21. 21.
    Hall GC, Carroll D, Parry D, McQuay HJ. Epidemiology and treatment of neuropathic pain: the UK primary care perspective. Pain. 2006;122(1–2):156–62.PubMedCrossRefGoogle Scholar
  22. 22.
    The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977–86.CrossRefGoogle Scholar
  23. 23.
    Partanen J, Niskanen L, Lehtinen J, Mervaala E, Siitonen O, Uusitupa M. Natural history of peripheral neuropathy in patients with non-insulin-dependent diabetes mellitus. N Engl J Med. 1995;333(2):89–94.PubMedCrossRefGoogle Scholar
  24. 24.
    Boulton AJ. The diabetic foot: from art to science. The 18th Camillo Golgi lecture. Diabetologia. 2004;47:1343.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Boulton AJ, Kirsner RS, Vileikyte L. Clinical practice. Neuropathic diabetic foot ulcers. N Engl J Med. 2004;351(1):48–55.PubMedCrossRefGoogle Scholar
  26. 26.
    Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376(24):2367–75.PubMedCrossRefGoogle Scholar
  27. 27.
    Rogers LC, et al. The Charcot foot in diabetes. Diabetes Care. 2011;34(9):2123–9.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Wukich DK, et al. Outcomes of ankle fractures in patients with uncomplicated versus complicated diabetes. Foot Ankle Int. 2011;32(2):120–30.PubMedCrossRefGoogle Scholar
  29. 29.
    Wukich DK, et al. Surgical site infections after foot and ankle surgery: a comparison of patients with and without diabetes. Diabetes Care. 2011;34:2211.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Lavery LA, et al. Risk factors for foot infections in individuals with diabetes. Diabetes Care. 2006;29(6):1288–93.PubMedCrossRefGoogle Scholar
  31. 31.
    Margolis DJ, et al. Diabetes, lower extremity amputation, loss of protective sensation, and neuronal nitric oxide synthase associated protein in the chronic renal insufficiency cohort study. Wound Repair Regen. 2013;21(1):17–24.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Reiber GE. Epidemiology of foot ulcers and amputations in the diabetic foot. In: Bowker JH, Pfeifer MA, editors. The diabetic foot. St. Louis: Mosby; 2001. p. 13–32.Google Scholar
  33. 33.
    Reiber GE, et al. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care. 1999;22(1):157–62.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Bruun C, et al. Amputations and foot ulcers in patients newly diagnosed with type 2 diabetes mellitus and observed for 19 years. The role of age, gender and co-morbidity. Diabet Med. 2013;30(8):964–72.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Wukich DK, et al. Postoperative infection rates in foot and ankle surgery: a comparison of patients with and without diabetes mellitus. J Bone Joint Surg Am. 2010;92(2):287–95.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Rogers LC, Frykberg RG. The Charcot foot. Med Clin North Am. 2013;97(5):847–56.PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Jia L, et al. Incidence and risk factors for developing infection in patients presenting with uninfected diabetic foot ulcers. PLoS One. 2017;12(5):e0177916.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Frykberg RG, et al. Role of neuropathy and high foot pressures in diabetic foot ulceration. Diabetes Care. 1998;21(10):1714–9.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Faris I. Vascular disease. In: Faris I, editor. The management of the diabetic foot. 2nd ed. Edinburgh: Churchill Livingstone; 1991. p. 9.Google Scholar
  40. 40.
    Abbott RD, Brand FN, Kannel WB. Epidemiology of some peripheral arterial findings in diabetic men and women: experiences from the Framingham study. Am J Med. 1990;88(4):376–81.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Abbott CA, Carrington AL, Ashe H, et al. The north-west diabetes foot care study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med. 2002;19(5):377–84.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    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. 2006;29(6):1202–7.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Prompers L, et al. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE study. Diabetologia. 2008;51(5):747–55.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Hingorani A, et al. The management of diabetic foot: a clinical practice guideline by the Society for Vascular Surgery in collaboration with the American podiatric medical association and the Society for Vascular Medicine. J Vasc Surg. 2016;63(2 Suppl):3S–21S.PubMedCrossRefGoogle Scholar
  45. 45.
    Grant WP, Sullivan R, Sonenshine DE, et al. Electron microscopic investigation of the effects of diabetes mellitus on the Achilles tendon. J Foot Ankle Surg. 1997;36(4):272–8. discussion 330PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Reddy GK. Cross-linking in collagen by nonenzymatic glycation increases the matrix stiffness in rabbit Achilles tendon. Exp Diabesity Res. 2004;5(2):143–53.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Reddy GK. Glucose-mediated in vitro glycation modulates biomechanical integrity of the soft tissues but not hard tissues. J Orthop Res. 2003;21(4):738–43.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Reiber GE, Vileikyte L, Boyko EJ, et al. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care. 1999;22(1):157–62.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Masson EA, Hay EM, Stockley I, Veves A, Betts RP, Boulton AJ. Abnormal foot pressures alone may not cause ulceration. Diabet Med. 1989;6(5):426–8.PubMedCrossRefPubMedCentralGoogle Scholar
  50. 50.
    Lavery LA, et al. Predictive value of foot pressure assessment as part of a population-based diabetes disease management program. Diabetes Care. 2003;26:1069–73.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Lavery LA, Armstrong DG, Boulton AJ. Ankle equinus deformity and its relationship to high plantar pressure in a large population with diabetes mellitus. J Am Podiatr Med Assoc. 2002;92(9):479–82.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Snyder RJ, et al. Consensus recommendations on advancing the standard of care for treating neuropathic foot ulcers in patients with diabetes. Ostomy Wound Manage. 2010;56(4 Suppl):S1–24.PubMedPubMedCentralGoogle Scholar
  53. 53.
    Frykberg RG, et al. Prevalence of equinus in diabetic versus nondiabetic patients. J Am Podiatr Med Assoc. 2012;102(2):84–8.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Lin SS, Lee TH, Wapner KL. Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients: the effect of tendo-achilles lengthening and total contact casting. Orthopaedics. 1996;19(5):465–75.Google Scholar
  55. 55.
    Van Gils CC, Roeder B. The effect of ankle equinus upon the diabetic foot. Clin Podiatr Med Surg. 2002;19(3):391–409. viPubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Francia P, et al. The role of joint mobility in evaluating and monitoring the risk of diabetic foot ulcer. Diabetes Res Clin Pract. 2015;108(3):398–404.PubMedCrossRefPubMedCentralGoogle Scholar
  57. 57.
    Moss SE, Klein R, Klein BE. The 14-year incidence of lower-extremity amputations in a diabetic population. The Wisconsin epidemiologic study of diabetic retinopathy. Diabetes Care. 1999;22(6):951–9.PubMedCrossRefPubMedCentralGoogle Scholar
  58. 58.
    Stratton IM, Adler AI, Neil HA, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000;321(7258):405–12.PubMedPubMedCentralCrossRefGoogle Scholar
  59. 59.
    Adler AI, et al. Association between glycated haemoglobin and the risk of lower extremity amputation in patients with diabetes mellitus-review and meta-analysis. Diabetologia. 2010;53(5):840–9.PubMedCrossRefPubMedCentralGoogle Scholar
  60. 60.
    Dorsey RR, Eberhardt MS, Gregg EW, Geiss LS. Control of risk factors among people with diagnosed diabetes, by lower extremity disease status. Prev Chronic Dis. 2009;6(4):A114.PubMedPubMedCentralGoogle Scholar
  61. 61.
    Schaper NC. Diabetic foot ulcer classification system for research purposes: a progress report on criteria for including patients in research studies. Diabetes Metab Res Rev. 2004;20(Suppl 1):S90–5.PubMedCrossRefGoogle Scholar
  62. 62.
    Lavery LA, Armstrong DG, Wunderlich RP, Tredwell J, Boulton AJ. Predictive value of foot pressure assessment as part of a population-based diabetes disease management program. Diabetes Care. 2003;26(4):1069–73.PubMedCrossRefPubMedCentralGoogle Scholar
  63. 63.
    Ramsey SD, Newton K, Blough D, et al. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care. 1999;22(3):382–7.PubMedCrossRefGoogle Scholar
  64. 64.
    Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2):217–28.PubMedCrossRefPubMedCentralGoogle Scholar
  65. 65.
    Apelqvist J, Larsson J, Agardh CD. Long-term prognosis for diabetic patients with foot ulcers. J Intern Med. 1993;233(6):485–91.PubMedCrossRefGoogle Scholar
  66. 66.
    Orneholm H, et al. Recurrent and other new foot ulcers after healed plantar forefoot diabetic ulcer. Wound Repair Regen. 2017;25(2):309–15.PubMedCrossRefPubMedCentralGoogle Scholar
  67. 67.
    Mantey I, Foster AV, Spencer S, Edmonds ME. Why do foot ulcers recur in diabetic patients? Diabet Med. 1999;16(3):245–9.PubMedCrossRefGoogle Scholar
  68. 68.
    Chantelau E, Kushner T, Spraul M. How effective is cushioned therapeutic footwear in protecting diabetic feet? A clinical study. Diabet Med. 1990;7(4):355–9.PubMedCrossRefGoogle Scholar
  69. 69.
    Pound N, Chipchase S, Treece K, Game F, Jeffcoate W. Ulcer-free survival following management of foot ulcers in diabetes. Diabet Med. 2005;22(10):1306–9.PubMedCrossRefPubMedCentralGoogle Scholar
  70. 70.
    Ali SM, Fareed A, Humail SM, et al. The personal cost of diabetic foot disease in the developing world—a study from Pakistan. Diabet Med. 2008;25(10):1231–3.PubMedCrossRefGoogle Scholar
  71. 71.
    Gershater MA, Londahl M, Nyberg P, et al. Complexity of factors related to outcome of neuropathic and neuroischaemic/ischaemic diabetic foot ulcers: a cohort study. Diabetologia. 2009;52(3):398–407.PubMedCrossRefPubMedCentralGoogle Scholar
  72. 72.
    Moulik PK, Mtonga R, Gill GV. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care. 2003;26(2):491–4.PubMedCrossRefPubMedCentralGoogle Scholar
  73. 73.
    Reiber GE, Lipsky BA, Gibbons GW. The burden of diabetic foot ulcers. Am J Surg. 1998;176(2A Suppl):5S–10.PubMedCrossRefPubMedCentralGoogle Scholar
  74. 74.
    Apelqvist J, Bakker K, van Houtum WH, Nabuurs-Franssen MH, Schaper NC. International consensus and practical guidelines on the management and the prevention of the diabetic foot. International working group on the diabetic foot. Diabetes Metab Res Rev. 2000;16(Suppl 1):S84–92.PubMedCrossRefPubMedCentralGoogle Scholar
  75. 75.
    Lavery LA, Armstrong DG, Wunderlich RP, Mohler MJ, Wendel CS, Lipsky BA. Risk factors for foot infections in individuals with diabetes. Diabetes Care. 2006;29(6):1288–93.PubMedCrossRefGoogle Scholar
  76. 76.
    Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care. 1990;13(5):513–21.PubMedCrossRefPubMedCentralGoogle Scholar
  77. 77.
    Margolis DJ, Allen-Taylor L, Hoffstad O, Berlin JA. Diabetic neuropathic foot ulcers and amputation. Wound Repair Regen. 2005;13(3):230–6.PubMedCrossRefPubMedCentralGoogle Scholar
  78. 78.
    Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care. 1990;13:513–21.PubMedCrossRefPubMedCentralGoogle Scholar
  79. 79.
    Kono Y, Muder RR. Identifying the incidence of and risk factors for reamputation among patients who underwent foot amputation. Ann Vasc Surg. 2012;26(8):1120–6.PubMedCrossRefGoogle Scholar
  80. 80.
    Morbach S, et al. Long-term prognosis of diabetic foot patients and their limbs: amputation and death over the course of a decade. Diabetes Care. 2012;35(10):2021–7.PubMedPubMedCentralCrossRefGoogle Scholar
  81. 81.
    Akhtar S, et al. A review of the Eurodiale studies: what lessons for diabetic foot care? Curr Diab Rep. 2011;11(4):302–9.PubMedCrossRefGoogle Scholar
  82. 82.
    Acar E, Kacira BK. Predictors of lower extremity amputation and Reamputation in the diabetic foot. J Foot Ankle Surg. 2017;56:1218.PubMedCrossRefGoogle Scholar
  83. 83.
    Faglia E, et al. The role of early surgical debridement and revascularization in patients with diabetes and deep foot space abscess: retrospective review of 106 patients with diabetes. J Foot Ankle Surg. 2006;45(4):220–6.PubMedCrossRefGoogle Scholar
  84. 84.
    Peters EJ, Lavery LA. International working group on the diabetic foot. Effectiveness of the diabetic foot risk classification system of the international working group on the diabetic foot. Diabetes Care. 2001;24(8):1442–7.PubMedCrossRefGoogle Scholar
  85. 85.
    Schade CP, Hannah KL. Quality of ambulatory care for diabetes and lower-extremity amputation. Am J Med Qual. 2007;22(6):410–7.PubMedCrossRefGoogle Scholar
  86. 86.
    Schofield CJ, Libby G, Brennan GM, et al. Mortality and hospitalization in patients after amputation: a comparison between patients with and without diabetes. Diabetes Care. 2006;29(10):2252–6.PubMedCrossRefGoogle Scholar
  87. 87.
    Siitonen OI, Niskanen LK, Laakso M, Siitonen JT, Pyorala K. Lower-extremity amputations in diabetic and nondiabetic patients. A population-based study in eastern Finland. Diabetes Care. 1993;16(1):16–20.PubMedCrossRefGoogle Scholar
  88. 88.
    Trautner C, Haastert B, Giani G, Berger M. Incidence of lower limb amputations and diabetes. Diabetes Care. 1996;19(9):1006–9.PubMedCrossRefGoogle Scholar
  89. 89.
    Willrich A, Pinzur M, McNeil M, Juknelis D, Lavery L. Health related quality of life, cognitive function, and depression in diabetic patients with foot ulcer or amputation. A preliminary study. Foot Ankle Int. 2005;26(2):128–34.PubMedCrossRefGoogle Scholar
  90. 90.
    Agency for Healthcare Research and Quality. 2009 State snapshots. Updated 2009. Accessed 30 Aug 2010.Google Scholar
  91. 91.
    Margolis DJ, et al. Incidence of diabetic foot ulcer and lower extremity amputation among Medicare beneficiaries, 2006 to 2008: Data Points #2, in Data Points Publication Series. 2011: Rockville (MD).Google Scholar
  92. 92.
    Centers for Disease Control and Prevention (CDC). Healthy people 2010 midcourse review. Updated 2007. Accessed 20 June 2010.
  93. 93.
    Alexandrescu V, Hubermont G, Coessens V, et al. Why a multidisciplinary team may represent a key factor for lowering the inferior limb loss rate in diabetic neuro-ischaemic wounds: application in a departmental institution. Acta Chir Belg. 2009;109(6):694–700.PubMedCrossRefGoogle Scholar
  94. 94.
    Drach-Zahavy A, Shadmi E, Freund A, Goldfracht M. High quality diabetes care: testing the effectiveness of strategies of regional implementation teams. Int J Health Care Qual Assur. 2009;22(7):709–27.PubMedCrossRefGoogle Scholar
  95. 95.
    Sumpio BE, Armstrong DG, Lavery LA, Andros G, SVS/APMA Writing Group. The role of interdisciplinary team approach in the management of the diabetic foot: a joint statement from the Society for Vascular Surgery and the American podiatric medical association. J Vasc Surg. 2010;51(6):1504–6.PubMedCrossRefGoogle Scholar
  96. 96.
    Moxey PW, Hofman D, Hinchliffe RJ, Jones K, Thompson MM, Holt PJ. Epidemiological study of lower limb amputation in England between 2003 and 2008. Br J Surg. 2010;97(9):1348–53.PubMedCrossRefGoogle Scholar
  97. 97.
    Resnick HE, Carter EA, Sosenko JM, et al. Incidence of lower-extremity amputation in American Indians: the strong heart study. Diabetes Care. 2004;27(8):1885–91.PubMedCrossRefGoogle Scholar
  98. 98.
    Centers for Disease Control and Prevention (CDC). CDC WONDER Data. Updated 2010. Accessed 10 July 2010.
  99. 99.
    Agency for Healthcare Research and Quality. 2008 National Healthcare Quality & Disparities Reports. Updated 2008. Accessed 10 Aug 2010.
  100. 100.
    U.S. Census Bureau. American Community Survey Web site. Updated 2004. Accessed 30 Aug 2010.
  101. 101.
    Wrobel JS, Charns MP, Diehr P, et al. The relationship between provider coordination and diabetes-related foot outcomes. Diabetes Care. 2003;26(11):3042–7.PubMedCrossRefGoogle Scholar
  102. 102.
    Resnick HE, Valsania P, Phillips CL. Diabetes mellitus and nontraumatic lower extremity amputation in black and white Americans: the National Health and nutrition examination survey epidemiologic follow-up study, 1971-1992. Arch Intern Med. 1999;159(20):2470–5.PubMedCrossRefGoogle Scholar
  103. 103.
    Agency for Healthcare Research and Quality. HCUP Quality Indicators Archive. AHRQ Quality Indicators, Rockville, MD. Updated 2004. Accessed 10 May 2010.
  104. 104.
    Izumi Y, Satterfield K, Lee S, Harkless LB, Lavery LA. Mortality of first-time amputees in diabetics: a 10-year observation. Diabetes Res Clin Pract. 2009;83(1):126–31.PubMedCrossRefGoogle Scholar
  105. 105.
    Izumi Y, Satterfield K, Lee S, Harkless LB. Risk of reamputation in diabetic patients stratified by limb and level of amputation: a 10-year observation. Diabetes Care. 2006;29(3):566–70.PubMedCrossRefGoogle Scholar
  106. 106.
    Tseng CL, Helmer D, Rajan M, et al. Evaluation of regional variation in total, major, and minor amputation rates in a national health-care system. Int J Qual Health Care. 2007;19(6):368–76.PubMedCrossRefGoogle Scholar
  107. 107.
    Apelqvist J, Ragnarson-Tennvall G, Larsson J, Persson U. Long-term costs for foot ulcers in diabetic patients in a multidisciplinary setting. Foot Ankle Int. 1995;16(7):388–94.PubMedCrossRefGoogle Scholar
  108. 108.
    Edmonds M, Foster A. Ulcer-free survival in diabetic foot patients. Diabet Med. 2005;22(10):1293–4.PubMedCrossRefGoogle Scholar
  109. 109.
    Hoffstad O, et al. Diabetes, lower-extremity amputation, and death. Diabetes Care. 2015;38(10):1852–7.PubMedCrossRefGoogle Scholar
  110. 110.
    Aulivola B, Hile CN, Hamdan AD, et al. Major lower extremity amputation: outcome of a modern series. Arch Surg. 2004;139(4):395–9. discussion 399PubMedCrossRefGoogle Scholar
  111. 111.
    Kald A, Carlsson R, Nilsson E. Major amputation in a defined population: incidence, mortality and results of treatment. Br J Surg. 1989;76(3):308–10.PubMedCrossRefPubMedCentralGoogle Scholar
  112. 112.
    Kazmers A, Perkins AJ, Jacobs LA. Major lower extremity amputation in veterans affairs medical centers. Ann Vasc Surg. 2000;14(3):216–22.PubMedCrossRefGoogle Scholar
  113. 113.
    Peng CW, Tan SG. Perioperative and rehabilitative outcomes after amputation for ischaemic leg gangrene. Ann Acad Med Singap. 2000;29(2):168–72.PubMedPubMedCentralGoogle Scholar
  114. 114.
    Subramaniam B, Pomposelli F, Talmor D, Park KW. Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics. Anesth Analg. 2005;100(5):1241–7. Table of contents.PubMedCrossRefPubMedCentralGoogle Scholar
  115. 115.
    Lavery LA, Peters EJ, Armstrong DG, Wendel CS, Murdoch DP, Lipsky BA. Risk factors for developing osteomyelitis in patients with diabetic foot wounds. Diabetes Res Clin Pract. 2009;83(3):347–52.PubMedCrossRefPubMedCentralGoogle Scholar
  116. 116.
    Stone PA, Flaherty SK, Hayes JD, AbuRahma AF. Lower extremity amputation: a contemporary series. W V Med J. 2007;103(5):14–8.PubMedPubMedCentralGoogle Scholar
  117. 117.
    Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet. 2005;366(9498):1719–24.PubMedCrossRefGoogle Scholar
  118. 118.
    Prompers L, Huijberts M, Schaper N, et al. Resource utilisation and costs associated with the treatment of diabetic foot ulcers. Prospective data from the Eurodiale study. Diabetologia. 2008;51(10):1826–34.PubMedCrossRefGoogle Scholar
  119. 119.
    Harrington C, Zagari MJ, Corea J, Klitenic J. A cost analysis of diabetic lower-extremity ulcers. Diabetes Care. 2000;23(9):1333–8.PubMedCrossRefGoogle Scholar
  120. 120.
    Ramsey SD, Newton K, Blough D, McCulloch DK, Sandhu N, Wagner EH. Patient-level estimates of the cost of complications in diabetes in a managed-care population. PharmacoEconomics. 1999;16(3):285–95.PubMedCrossRefGoogle Scholar
  121. 121.
    Stockl K, Vanderplas A, Tafesse E, Chang E. Costs of lower-extremity ulcers among patients with diabetes. Diabetes Care. 2004;27(9):2129–34.PubMedCrossRefGoogle Scholar
  122. 122.
    Apelqvist J. Wound healing in diabetes. Outcome and costs. Clin Podiatr Med Surg. 1998;15(1):21–39.PubMedGoogle Scholar
  123. 123.
    Apelqvist J, Ragnarson-Tennvall G, Persson U, Larsson J. Diabetic foot ulcers in a multidisciplinary setting. An economic analysis of primary healing and healing with amputation. J Intern Med. 1994;235(5):463–71.PubMedCrossRefGoogle Scholar
  124. 124.
    Holzer SE, Camerota A, Martens L, Cuerdon T, Crystal-Peters J, Zagari M. Costs and duration of care for lower extremity ulcers in patients with diabetes. Clin Ther. 1998;20(1):169–81.PubMedCrossRefGoogle Scholar
  125. 125.
    Van Acker K, Oleen-Burkey M, De Decker L, et al. Cost and resource utilization for prevention and treatment of foot lesions in a diabetic foot clinic in Belgium. Diabetes Res Clin Pract. 2000;50(2):87–95.PubMedCrossRefGoogle Scholar
  126. 126.
    Ragnarson Tennvall G, Apelqvist J. Health-economic consequences of diabetic foot lesions. Clin Infect Dis. 2004;39(Suppl 2):S132–9.PubMedCrossRefGoogle Scholar
  127. 127.
    Agency for Healthcare Research and Quality. Measuring healthcare quality. Updated 2009. Accessed 30 Aug 2010.
  128. 128.
    McCabe CJ, Stevenson RC, Dolan AM. Evaluation of a diabetic foot screening and protection programme. Diabet Med. 1998;15(1):80–4.PubMedCrossRefGoogle Scholar
  129. 129.
    Habacher W, Rakovac I, Görzer E, Haas W, Gfrerer RJ, Wach P, Pieber TR. A model to analyse costs and benefit of intensified diabetic foot care in Austria. J Eval Clin Pract. 2007;13:906–12.PubMedGoogle Scholar
  130. 130.
    Li R, Zhang P, Barker LE, Chowdhury FM, Zhang X. Cost-effectiveness of interventions to prevent and control diabetes mellitus: a systematic review. Diabetes Care. 2010;33(8):1872–94.PubMedPubMedCentralCrossRefGoogle Scholar
  131. 131.
    Ortegon MM, Redekop WK, Niessen LW. Cost-effectiveness of prevention and treatment of the diabetic foot: a Markov analysis. Diabetes Care. 2004;27(4):901–7.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Robert G. Frykberg
    • 1
    Email author
  • Jeremy J. Cook
    • 2
  • Donald C. Simonson
    • 3
  1. 1.Podiatry SectionPhoenix VA Healthcare SystemPhoenixUSA
  2. 2.Department of SurgeryMount Auburn Hospital, Harvard Medical SchoolCambridgeUSA
  3. 3.Division of Endocrinology, Diabetes, and HypertensionBrigham and Women’s Hospital, Harvard Medical SchoolBostonUSA

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