C. J. Abularrage1, J. K. Canner2, N. Mathioudakis3, C. Lippincott4, R. L. Sherman1, C. W. Hicks1 1The Johns Hopkins University School Of Medicine,Division Of Vascular Surgery And Endovascular Therapy,Baltimore, MD, USA 2The Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 3The Johns Hopkins University School Of Medicine,Division Of Endocrinology And Metabolism,Baltimore, MD, USA 4The Johns Hopkins University School Of Medicine,Division Of Infectious Diseases,Baltimore, MD, USA
Introduction:
Recent studies demonstrate favorable diabetic foot ulcer (DFU) healing outcomes with the implementation of a multidisciplinary team. However, the long-term outcomes of this approach to DFU care are unknown. We aimed to describe the incidence of and risk factors associated with ulcer recurrence after initial complete healing among a cohort of DFU patients treated in a multidisciplinary setting.
Methods:
All patients presenting to our multidisciplinary diabetic limb preservation service from 6/2012-04/2018 were enrolled in a prospective database. Wounds were classified according to the SVS-WIfI at initial presentation. The incidence of ulcer recurrence after complete wound healing was assessed per limb using the Kaplan Meier method, and a stepwise multivariable Cox proportional hazards model was created to identify independent predictors of ulcer recurrence.
Results:
A total of 244 patients with 304 affected limbs were included. Mean age was 59.2±3.8 years, 62.7% of patients were male, and 61.9% were black. Nearly all (95.1%) of patients has loss of protective sensation, with abnormal proprioception in 23.9%. Ulcer recurrence occurred in 38.5% of limbs at a mean time of 310±30 days. Only 12.8% of recurrent ulcers occurred at the same site as the initial wound. Ulcer recurrence rates at one- and three-years post-healing were 30.6±3.0% and 64.4±5.2%, respectively (Figure), and did not significantly differ by the WIfI stage of the initial wound (P=.34). Recurrent ulcers were smaller (4.4±1.1cm2 vs. 8.2±1.2cm2; P=0.04) and had a lower WIfI stage (stage 4: 7.7% vs. 22.4%; P<0.001) than initial ulcers. Time from ulcer onset to assessment was lower for recurrent ulcers (0.9±0.3 vs. 2.4±0.2 months; P<0.001), and wound healing time was significantly reduced (95.0±9.8 vs. 131.8±7.0 days; P=0.004). Independent predictors of ulcer recurrence included abnormal proprioception [HR 1.57 (95%CI 1.02-4.43); P=.04] and younger age [HR 1.02 per year (95%CI 1.01-1.04). Patient race, BMI, socioeconomic status, comorbidities, blood sugar control (hemoglobin A1c), and wound location were not independently associated with ulcer recurrence.
Conclusion:
In this prospective cohort of diabetic foot ulcer patients, ulcer recurrence occurred in nearly two-thirds of limbs within three years. Importantly, time to diagnosis and healing was significantly lower for recurrent ulcers, and downstaging was common. These data suggest that engaging DFU patients in a multidisciplinary care model with frequent follow-up and focused patient education may serve to decrease DFU morbidity.
