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Risk score predicts foot ulcer outcomes

Diabetes

Diabetes

Patients with diabetes are at increased risk of lower limb amputations, which are often the end point of diabetic foot ulcers. It is important to detect foot ulceration early and refer any detected ulcers to a specialist foot clinic urgently.

A study, published in Diabetes Care, has assessed patients attending a foot clinic to determine if a risk score accurately predicts which patients develop ulcers and, equally importantly, who will respond to treatment.

The authors used the Scottish Foot Ulcer Risk Score (see table 1, attached), developed by the Scottish Care Information–Diabetes Collaboration (SCI-DC). All patients attending the foot clinic had been categorised using this score as being at low, medium or high risk of developing a foot ulcer.

The study included 221 referrals made during the study period, involving 198 patients with a mean age of 67.3 (± 12.7 years).

The study recorded information on foot pulses, neuropathy, foot deformity, previous ulcer, ulcer site, depth and the presence of sepsis and related this to ulcer outcome.

Patients were followed up until outcome was achieved, a median of three months (range 1-33 months). These were all simultaneous episodes, and if there were several ulcers, the one that took longest to heal was taken as the index ulcer.

Of the 221 ulcers, 165 (74.7%) healed, seven became chronic nonhealing ulcers, eight healed after minor amputation, 18 required major amputation and 23 patients died with their ulcer.

Seventy-four per cent of the study population had been classified as being at high risk of ulceration before presentation and 98% at high or moderate risk. Although three quarters of the ulcers healed, the healing rate was significantly lower in the high-risk group (68% compared with 93%).

Absent pulses, neuropathy, increased age and deep ulcers were associated with poor healing. The combination of neuropathy and ischaemia correlated strongly with poor foot ulcer outcome.

The authors conclude that the Scottish Foot Ulcer Risk Score predicts both ulcer development and healing. The risk score can be a useful initial guide to determine the likelihood of poor healing.

At the diabetes clinic where I work we have been classifying our patients' feet as low, medium or high risk for some time. The early detection of diabetic foot ulcers is important, both for individual patient care and because of the financial burden that poor outcomes represent.

This study underlines the importance of a structured clinical examination of the foot in patients with diabetes in surgery-based diabetes clinics and a low threshold for further examination of high-risk patients. All clinicians seeing patients with diabetes should be aware of how to access a local specialist diabetic foot clinic.

Leese G, Schofield C, McMurray B et al. Scottish Foot Ulcer Risk Score Predicts Foot Ulcer Healing in a Regional Specialist Foot Clinic. Diabetes Care 2007;30:2064-9

Table 1: Scottish Foot Ulcer Risk Score Reviewer

Dr Matthew Lockyer
GP, Suffolk and hospital practitioner in diabetic medicine

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