If, as a podiatrist, you weren’t certain about the significance of the diseases you treat or the seriousness of what you do, read Dr David Armstrong and colleagues’ new paper1 about the significance of diabetic complications as compared with cancer. This is a paper that all lower extremity specialists should read.
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In 2007 Armstrong, Wrobel, and Robbins published a short but very powerful editorial in the International Wound Journal in which they compared the 5-year mortality rates of lower extremity ulcers, amputations, and peripheral arterial disease to certain types of cancer. Examine Figure 1 and note that a neuropathic ulcer has a worse 5-year mortality rate than breast or prostate cancer.
Figure 1. Five-year mortality percentages of lower extremity complications compared with certain types of cancer2 (taken directly from Armstrong 2007).
In December 2020, Armstrong’s group updated and expanded their original work, and if the first study put a period on the sentence “lower extremity complications can be as bad as cancer,” their new study ended this same statement with a giant exclamation point!
If the first study put a period on the sentence “lower extremity complications can be as bad as cancer,” their new study ended this same statement with a giant exclamation point!
They expanded on the original study by re-examining new data published since the first paper and additionally examined 5-year mortality rates of Charcot arthropathy. They presented pooled data from a number of studies that assessed outcomes of diabetic foot ulcers, major and minor amputations, and critical limb ischemia and compared these numbers with all cancer as well as breast and lung cancer.
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To quickly emphasize the new information Armstrong, et al. provide in their second paper:
Inclusion of Charcot mortality rates
Comparison to “all cancer” mortality rates
Addition of newer studies since publication of the first editorial
Figure 2 artistically reports their outcomes. A diagnosis of Charcot or diabetic foot ulcer have the same 5-year mortality as the pooled cancer diagnoses. The mortality rates compared with cancer are even worse for minor or major amputations or chronic limb threatening ischemia.
Figure 2. This figure taken directly from the Armstrong paper1 tells almost the entire story.
The authors additionally go one step beyond their original editorial by saying that diabetic foot ulcers and lower extremity amputations are “independent risk factors associated with premature death.”1[SIC]
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This statement is supported by a 2014 study by Martins-Mendez, et al3 in which they performed a retrospective cohort study on 644 patients in a tertiary referral clinic. They examined the incidence of diabetic foot ulcer, lower extremity amputations (LEA), and death, performing a multi-variate analysis and found, “DFU seems more than a marker of complication status, having independent impact on LEA and mortality risk.”
Phasic Activity of the Muscles of the Lower Extremity Biomechanics
Harold Schoenhaus, DPM, FACFAS
Surgical Editor for PRESENT e-Learning Penn-Presbyterian Medical Center Philadelphia, PA
Harold Schoenhaus, DPM discusses the effects of extrinsic muscles on the lower leg during gait as well as describing the concept of antagonist and synergistic muscle activity.
Available Credits: CPME 0.5
Understand that this is a step beyond where we were in 2007, when Armstrong’s editorial was first published. In the past, the best we could say was that having a diabetic foot ulcer was a stigma of severe disease (termed “malignant diabetes” by Jeff Robbins, DPM [personal communication], and these patients died from the cardiovascular effects of diabetes. Now, this updated study supports the very significant statement that a diabetic foot ulcer is in itself a risk factor for a decreased life span. Martins-Mendez and his group opine that this direct effect occurs from decreased mobility and quality of life, increased infection risk, and physiological decline3.
A diabetic foot ulcer is in itself a risk factor for a decreased life span
Several conclusions can be drawn from this very important new study:
Diabetic lower extremity research is extremely underfunded compared with that of cancer, despite its equally devastating effect on human life.
Preventing a diabetic foot ulcer may literally add years to patients’ lives.
When treating diabetic foot ulcers, patient mobility and general health must be maximized.
Healing an ulcer is a race against time that requires a more aggressive approach than the current paradigm. We must find faster ways to heal ulcers that also allow patients to remain active. For example, surgical approaches may present an underutilized treatment option (think surgical off weighting and plastic surgical techniques for wound closure).
More research is necessary in both prevention and treatment to help our patients live the lives they could live.
References
Armstrong DG, Swerdlow MA, Armstrong AA, Conte MS, Padula WV, Bus SA. Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. J Foot Ankle Res. 2020 Dec;13(1):1-4. Follow this link
Armstrong DG, Wrobel J, Robbins JM. Guest Editorial: Are diabetes‐related wounds and amputations worse than cancer? Int Wound J. 2007 Dec;4(4):286-287. Follow this link
Martins-Mendes D, Monteiro-Soares M, Boyko EJ, Ribeiro M, Barata P, Lima J, Soares R. The independent contribution of diabetic foot ulcer on lower extremity amputation and mortality risk. J Diabetes Complications. 2014;28(5):632-638. Follow this link
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