The Diabetic Foot

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Perspectives on the News commentaries are part of a free monthly CME activity. The Mount Sinai School of Medicine, New York, New York, designates this activity for 2.0 AMA PRA Category 1 credits. If you wish to participate, review this article and visit www.diabetes.procampus.net to complete a posttest and receive a certificate. The Mount Sinai School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians . This is the sixth in a series of articles based on presentations at the American Diabetes Association's 67th Scientific Sessions, 22–26 June 2007, Chicago, Illinois, that discuss aspects of the diabetic foot. At a symposium on wound healing, Harold Brem (New York, NY) noted that nearly 100,000 lower-limb amputations are performed annually on individuals with diabetes in the U.S. (1). Lower-extremity ulcers occur in 4–10% of people with diabetes, with a lifetime risk that may be as high as 25% (2). Brem reviewed an approach to diabetic foot wounds based on debridement, offloading, and moist wound healing, and suggested that such an approach to diabetic foot ulcers would lead to “a dramatic decrease in amputations.” He pointed out that often the diabetic foot wound “does not look bad,” contributing to inadequate treatment, and asked why “these good-looking wounds” do not heal. Two factors are underlying osteomyelitis, often with relatively little evidence of inflammation, and arterial insufficiency. Brem reviewed data from the treatment of >250 patients, approximately one-fifth of whom required amputation, with over half ischemic and over half having underlying osteomyelitis. Debridement needs to include not only the wound and the surrounding callus, but also the “physiologically impaired area.” Abnormal keratinocyte products may be demonstrated outside the area of callus (3), suggesting that typical debridement is insufficient to reach the actual “healing edge” …