Managing diabetic foot ulcers and preventing limb amputation

Diabetology · Endocrinology

Diabetic foot ulcers (DFUs) are among the most serious complications of diabetes mellitus and a major cause of morbidity, often leading to infection, tissue necrosis and lower-extremity amputation. Approximately 34% of individuals with diabetes develop a DFU during their lifetime, with affected patients facing a substantially increased risk of amputation compared with the general population. The development and progression of DFUs are multifactorial, involving peripheral neuropathy, peripheral artery disease (PAD), repetitive mechanical pressure and impaired wound healing. Delayed diagnosis, inadequate wound management and poor infection control can further contribute to limb-threatening complications. Despite advances in diabetic foot care, preventable amputations remain a significant clinical challenge, particularly in populations facing socioeconomic and healthcare access disparities. Therefore, early identification of high-risk feet, comprehensive wound management, timely infection control, pressure offloading and appropriate vascular assessment and intervention are essential to promote ulcer healing, preserve limb function and prevent avoidable amputations.[1]Clinical assessment and early identificationA comprehensive foot examination should be performed at least annually in all individuals with diabetes to identify ulceration risk factors, including peripheral neuropathy, PAD, skin abnormalities, and structural deformitiesProtective sensation should be assessed using a 10-g monofilament test alongside another neurological assessment, such as vibration, temperature, or pinprick sensationVascular assessment should include palpation of pedal pulses and evaluation for signs of ischemia, with ankle-brachial index and toe pressure measurements when indicatedExisting ulcers should be evaluated for location, size, depth, tissue involvement, infection, and evidence of underlying osteomyelitis[2]Management of diabetic foot ulcersWound care and debridement: Appropriate wound cleansing, removal of devitalized tissue, and maintenance of a suitable wound environment are important components of ulcer management. Sharp debridement should be performed when clinically appropriatePressure offloading: Mechanical pressure should be reduced to facilitate healing, particularly in neuropathic plantar ulcers. A non-removable knee-high offloading device, such as a total contact cast, is the preferred approach when appropriate and toleratedInfection management: Clinical signs of infection, including erythema, warmth, swelling, purulent discharge, and systemic manifestations, should be assessed promptly. Systemic antibiotic therapy should be reserved for clinically infected ulcers rather than used routinely for uninfected woundsVascular management: Individuals with suspected ischemia or impaired wound healing should undergo appropriate vascular evaluation. Revascularization should be considered when significant PAD compromises tissue perfusion and limb viabilityMetabolic management: Appropriate glycemic management, nutritional support, and control of associated cardiovascular risk factors should complement local wound treatmentPreventing infection-related complications and amputationEarly recognition of deep tissue infection, abscess formation, gangrene, and suspected osteomyelitis is essential to prevent progressive tissue destructionModerate or severe infections, extensive necrosis, and suspected deep-space involvement require urgent specialist assessment and consideration of surgical interventionIndividuals with limb-threatening ischemia should receive prompt vascular specialist evaluation to determine the suitability and timing of revascularizationAn interdisciplinary approach involving diabetes specialists, podiatrists, vascular surgeons, infectious disease specialists, and wound care professionals can facilitate coordinated treatment and improve limb preservationLong-term prevention and surveillanceIndividuals should be educated to inspect their feet daily and report new blisters, wounds, discoloration, swelling, or changes in skin temperatureProperly fitted therapeutic footwear and pressure-relieving orthoses should be considered in individuals with loss of protective sensation, foot deformities, or previous ulcerationSmoking cessation, appropriate diabetes management, and regular follow-up are important components of long-term limb preservationIndividuals with previous ulceration or amputation require ongoing specialist surveillance because of their increased risk of recurrent ulcerationRisk-based foot surveillanceRisk categoryClinical characteristicsSuggested examination frequency0 – Very lowNo loss of protective sensation or PADAnnually1 – LowLoss of protective sensation or PADEvery 6–12 months2 – ModerateLoss of protective sensation, PAD, or foot deformity in combinationEvery 3–6 months3 – HighLoss of protective sensation or PAD with previous ulceration, amputation, or kidney failureEvery 1–3 monthsSurveillance intervals are based on the International Working Group on the Diabetic Foot risk classification.[3]ConclusionEffective diabetic foot ulcer management requires early risk identification, appropriate wound care, pressure offloading, infection control, and timely restoration of blood flow when indicated. Regular surveillance and coordinated multidisciplinary care are essential to prevent recurrent ulceration, reduce infection-related complications, and minimize the risk of lower-extremity amputation. Early intervention remains central to successful limb preservation.[2][3]Reference(s):1. Muro AFP, Myong E, Crocker R, et al. Advice From Patients to Improve Diabetic Foot Ulcer Management and Amputation Prevention. Int Wound J. 2026;23(3):e70862. doi:10.1111/iwj.70862. https://pmc.ncbi.nlm.nih.gov/articles/PMC12935492/2. American Diabetes Association Professional Practice Committee for Diabetes*. 12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes-2026. Diabetes Care. 2026;49(Suppl 1):S261-S276. doi:10.2337/dc26-S012. https://pubmed.ncbi.nlm.nih.gov/41358886/3. Schaper NC, van Netten JJ, Apelqvist J, et al. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3657. doi:10.1002/dmrr.3657. https://pubmed.ncbi.nlm.nih.gov/37243927/