Of the 463 million people with diabetes across the globe, about 6% will develop a diabetic foot ulcer (DFU). This subgroup has a three times higher risk of mortality than other diabetes patients, explained Tammer Elmarsafi, DPM, MBBCh, during the Scientific Sessions symposium Surgical Considerations in Diabetes Foot Management, which was originally presented Monday, June 28.

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DFU prevalence is highest in North America (13% of people with diabetes), followed by Africa (7.2%), Asia (5.5%), Europe (5.1%), and Oceania (3%), noted Dr. Elmarsafi, Potomac Podiatry Group and Founder, Tagmar Health. The countries with the highest prevalence of DFU are Belgium (16.6% of people with diabetes), Canada (14.8%), and the United States (13%).

“It’s happening in greater prevalence in places that have high resources, great hospitals, and a great emphasis on prevention,” Dr. Elmarsafi said.

Risk factors for DFU include advanced age, higher blood pressure, longer duration of diabetes, smoking history, diabetic retinopathy, and peripheral neuropathy. Surgical options for recalcitrant DFU include nerve decompression, tendo-Achilles lengthening, single or pan metatarsal head resection, first metatarsophalangeal joint arthroplasty, digital flexor tenotomy, tendon transfer/fascia release, and Charcot reconstruction.

Michael D. VanPelt, DPM, Associate Professor, Department of Orthopaedic Surgery, UT Southwestern Medical Center, and Adjunct Assistant Professor, William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, discussed considerations for Charcot reconstruction surgery.

A quarter to half of patients with Charcot neuroarthropathy, which affects the midfoot more commonly than other parts of the foot and ankle, will require surgery, he said. There are several factors that could necessitate surgical intervention, including deformities causing instability, the inability to brace a deformity, impending compromise of the skin, non-healing ulcers, recurrent ulcers due to malalignment, and pain.

“Surgery is critical to treating the diabetic foot,” said Garneisha Torrence, DPM, MHMS. “Surgery—specifically podiatric surgery—is paramount to saving limbs.”

Before proceeding with Charcot surgery, an A1C of 8 or lower is recommended to reduce perioperative complications, Dr. VanPelt noted. After surgery, patients should expect lifetime bracing to provide the stability needed to be ambulatory.

Patients with Charcot neuroarthropathy and DFU have an increased risk of amputation. The overall amputation rate in patients with Charcot neuroarthropathy is about 8.9%. That increases to about 28% for people with Charcot neuroarthropathy and ulceration.

“The goal is prevention of ulceration. It’s critical for limb salvage,” Dr. VanPelt said.

Surgeons who manage the diabetic foot often find themselves in situations where urgent or emergent surgery is required, said Dr. Torrence, Assistant Professor of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, and Director, Podiatry Fellowship Quality Improvement and Patient Safety Program, University of Michigan Medical School.

“These surgeries are often infection-related,” she said. “They can range from incision and drainage, which is, in the simplest terms, washing the infection out. It is very common, however, for an urgent surgery to require an amputation to treat an infection.”

Dr. Torrence described the psychological impact of diabetes foot surgery. Amputation, specifically, is associated with depression, anxiety, social discomfort, and body image anxiety, she said.

“We must acknowledge there is a correlation between psychology and diabetes-related surgery,” Dr. Torrence said. “Because of these correlations, we need to counsel patients on reasonable expectations and goals to decrease their psychological distress.”

Foluso Fakorede, MD, CEO, Cardiovascular Solutions of Central Mississippi and Fusion Vascular, discussed racial disparities in amputation outcomes.

Racial disparities are especially present in the cardiovascular spectrum when it comes to amputation rates, peripheral arterial disease (PAD), and the impact of diabetes, and primarily affect African American, Hispanic, and Native American patients, he said.

“A disproportionate amount of American minorities undergo an amputation-first strategy rather than giving them preventative and limb-sparing procedures like an angiogram,” said Dr. Fakorede, co-chair of the Association of Black Cardiologists’ PAD initiative. An angiogram increases the chances of avoiding an amputation by about 90%, he added.

“Knowing the evils of amputation is very important,” Dr. Fakorede said. “These patients—the majority of whom cannot walk afterward—they have significant impact on quality of life.”

While Dr. Fakorede is pushing for policy changes to address racial disparities in diabetes foot management, he made a call to action that diabetes care providers can implement immediately.

“Just take off the socks and check pulses. Check monofilaments. Check for neuropathy,” he said. “Make sure these patients are treated like family members at all times.”