A new, and instant classic, review article was published this week in one of the most important medical journals of all, the New England Journal of Medicine. In seven pages filled with their enormous experience and knowledge, David Armstrong, Andrew Boulton and Sicco Bus review the problem of diabetic foot ulcers and their recurrence. They conclude that the lifetime incidence of foot ulcers in people with diabetes lies between 19% and 34%. Ulcer recurrence is 40% after one year, and almost 60% after three years.
The majority of the review is relatively well-known information for insiders in the field. However, the importance of repeating this knowledge on diabetic foot ulcers, their cause and their treatment as outlined in international guidelines, should not be underestimated. This is the first time in its history the New England Journal of Medicine publishes such an extensive paper on diabetic foot disease. It can be expected that this will lead to greater recognition of the burden diabetic foot disease poses on our society. Additionally, it is a citation clinicians and researchers in the field can use for many years to come, as background in their papers, grant applications or discussions with health authorities.
Apart from this, the paper also presents new data underlying two of the most important statistics in the field. The lifetime incidence of foot ulcers in people with diabetes is higher than previously thought (from 15-25% to 19-34%). In the additional online materials the authors also present the data analysis underlying this number.
Figure 2 is perhaps even more important. For the first time, data from nine prospective observational studies, one retrospective study and nine trials are combined, showing the enormous burden of ulcer recurrence. In the first year after closure, an ulcer recurs in 40% of patients. This is almost 60% after three years, and 65% after five years. We have discussed the concept of remission before, and advocated that clinicians stop using the word “healed”. The review of 19 studies with data from thousands of patients gives this argument some rock solid epidemiological evidence .
As always when we discuss new papers here, we encourage you to read the publication in full. That encouragement is even stronger this time, because this is not only a classic paper, it is also well-written and filled with other interesting points that we cannot all discuss here.