To evaluate the recurrence of foot ulcers as well as the cumulative amputation and
mortality rates in diabetic patients with previous foot ulcers.
A prospective study of consecutively presenting diabetic patients admitted to the
Department of Internal Medicine because of foot ulcer with a median follow-up of 4
years.
A multidisciplinary foot-care team.
Five-hundred-and-fifty-eight consecutive diabetic patients with foot ulcers treated
between 1 July 1983 and 31 December 1990 were followed to final outcome. Out of these
patients, 468 healed either primarily (n = 345) or after minor or major amputations
(n = 123) and 90 died before healing had occurred. Those 468 patients who healed were
included in this prospective study from the time of healing.
Patients were followed according to a standardized protocol with registration of foot
lesions, amputation, morbidity and mortality. Clinical examination was performed twice
yearly.
After 1, 3 and 5 years of observation 34%, 61% and 70% of the patients, respectively,
had developed a new foot ulcer. The recurrence rate of foot lesions was slightly higher
among patients who previously had had an amputation (P < 0.05, P < 0.01 and non-significant,
respectively). Among patients with previous primary healing the cumulative amputation
rates were 3%, 10% and 12% after 1, 3 and 5 years of follow-up compared with 13%,
35% and 48% among those who previously healed after amputation, irrespective of previous
amputation level (P < 0.001 at all time-points). All amputations except three were
initiated by a foot ulcer deteriorating to deep infection or progressive gangrene.
The long-term survival ratio was lower among patients healed after previous amputation
(80%, 59%, 27%) compared with patients with previously primary healing (92%, 73%,
58%) after 1, 3 and 5 years of observation, respectively (P < 0.001, P < 0.01 and
P < 0.001 respectively). The mortality rate was twice as high among primarily healed
and four times as high among patients with amputation compared to an age- and sex-matched
Swedish population.
These findings stress the need for life-long surveillance of the diabetic foot at
risk and the necessity of preventive foot care among diabetic patients with previous
foot lesions, and particularly among those who had had a previous amputation.