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This material is from Keep the Legs You Stand On (Provided with permission by Nightengale Press. All rights reserved.) by Dr. Mark Hinkes. For more information or to order this book, visit http://www.nightengalepress.com/.

Keep the Legs You Stand On

Skin ulcers and wounds are the most expensive dermatological problems followed second by acne.
Peter Cavanagh, Cleveland Clinic, Cleveland, Ohio

At any given time, approximately 5 percent of the diabetic population will have a foot ulcer, and almost half of them are infected by the time a patient seeks medical attention. A foot ulcer can develop and escalate quickly into a significant problem and if an infection occurs, it may require hospitalization, intravenous antibiotics and perhaps vascular surgery to avoid an amputation.

The foot is the crossroad of several pathological processes. Because each of these components can contribute to foot ulcers, a multi-disciplinary approach is needed.
Dr. Nicolass Schaper

A 2007 study by Peters, Armstrong, and Lavery showed that 71.6 percent of ulcers healed; 12.3 percent did not heal; and 16 percent had lower extremity amputations. Healing the foot ulcer is much like solving a puzzle because ulcers are complex wounds, and usually there are multiple contributing factors. If each of these factors has not been identified and treated correctly, the ulcer usually fails to heal. A healed ulcer might return, or worse, the patient might lose a limb.

Therefore, understanding the reason the patient has developed the ulcer helps us decide how to treat it. Numerous factors contribute to the development of the diabetic foot wound. The most common factors for re-ulceration include:

• Being male
• Being older than sixy
• Having type 2 diabetes
• Duration of diabetes longer than ten years
• Alcohol abuse
• Tobacco abuse
• Nephropathy (kidney disease)
• Retinopathy (eye disease of retina)
• Neuropathy (nervous system disease)
• Peripheral Vascular Disease
• History of amputation
• Elevated A1c (higher than 9%)
• Elevated pressure on foot
• Rigid toe deformity or Charcot foot
• Extra sesamoid bone in the big toe

No matter what type of injury a patient has, PAD delays or prevents wound healing. In the best-case scenario, the circulatory problem can be repaired and the wound will heal. In the worst-case scenario, the circulatory problem cannot be repaired, the wound will not heal, and the patient will pay the ultimate price: the loss of a leg.

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