We undertook a prospective cohort study to assess risk factors associated with hallux ulceration, and to determine the incidence of healing or amputation, in consecutive patients with diabetes mellitus who were treated over the observation period extending from September 2004 to March 2005, at the Jabir Abu Eliz Diabetic Centre, Khartoum City, Sudan. There were 122 diabetic patients in the cohort (92 males and 30 females) with an overall mean age of 58 ± 9 years. Fifty-three percent of patients had complete healing within 8 weeks and 43% healed within 20 weeks. The overall mean time to healing was 16 ± 8 weeks. In 32 (26.2%) patients, osteomyelitic bone was removed, leaving a healed and boneless hallux. The hallux was amputated in 17 (13.9%) patients; in 2 (1.6%) patients it was followed by forefoot amputation and in 7 (5.7%) patients by below-the-knee amputation. In 90 (73.8%) patients the initial lesion was a blister. In conclusion, hallux ulceration is common in patients with diabetes mellitus and is usually preceded by a blister. Neuropathy, foot deformity, and wearing new shoes are common causative factors; and ischemia, osteomyelitis, any form of wound infection, and the size of the ulcer are main outcome determinants. Complete healing occurred in 103 (85%) of diabetic patients with a hallux ulcer. Vascular intervention is important relative to limb salvage when ischemia is the main cause of the ulcer.
Level of Clinical Evidence
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- The aetiology of diabetic neuropathic ulceration of the foot.Br J Surg. 1985; 72: 1-6
- Pressure gradient and subsurface shear stress on the neuropathic forefoot.Clin Biomech. 2008; 23: 342-348
- Non-enzymatic glycoslation of keratin from the diabetic foot.Br J Dermatol. 1985; 112: 547-554
- Glycoslation of human collagen in aging and diabetes mellitus.J Clin Invest. 1980; 66: 1179-1181
- The 14-year incidence of lower extremity amputation in a diabetic population. The Wisconsin Epidemiologic Study of Diabetic Retinopathy.Diabetes Care. 1999; 22: 951-959
International Consensus on the Diabetic Foot. International Working Group on the Diabetic Foot. Amsterdam, 1999. p. 41.
- The risk factors for diabetic foot ulceration.The Foot. 2003; 13: 125-129
- Biomechanical abnormalities and ulcers of the great toe in patients with diabetes.J Foot Ankle Surg. 2002; 41: 359-364
- The role of limited joint mobility in diabetic patients with an at-risk foot.Diabetes Care. 2004; 27: 942-946
- Foot structure and function: aetiological risk factors for callus formation in diabetic and non-diabetic subjects.The Foot. 1999; 9: 120-127
- Clinical efficacy of the first metatarsophalangeal joint arthroplasty as a curative procedure for hallux interphalangeal joint wounds in patients with diabetes.Diabetes Care. 2003; 26: 3284-3287
- Treating macro and micro wound environment of the diabetic patient: managing the whole patient, not the hole in the patient.Foot and Ankle Quarterly–The Seminar Journal. 2004; 16: 47-56
- Diabetic foot disorders: a clinical practice guideline (2006 revision).J Foot Ankle Surg. 2006; 45: 5
- Pathways to diabetic limb amputation. Basis for prevention.Diabetes Care. 1990; 13: 513-521
- Change in amputation rate in a Turkish diabetic foot population.J Diabetes Complicat. 2004; 18: 169-172
- Aguila M del, Smith DG, Lavery LA, Boulton AJ. Casual pathway for incident lower extremity ulcers in patients with diabetes from two settings.Diabetes Care. 1999; 22: 157-162
- Who is at risk of limb loss and what to do about it?.J Rehabil Res Dev. 1994; 31: 357-362
- Manufactured shoes in the prevention of diabetic foot ulcers.Diabetes Care. 1995; 18: 1376-1378
- Foot pathology and risk for diabetic foot in elderly men.Diabetes Res Clin Pract. 1996; 32: 103-109
- Biomechanical risk factors associated with neuropathic ulceration of the hallux in people with diabetes mellitus.J Am Podiatr Med Assoc. 2006; 96: 189-197
- Peripheral neuropathy, hypertension, foot ulcer and amputation among Saudi Arabian patients with type II diabetes.Diabetes Res Clin Pract. 1998; 41: 83-89
- Difference in treatment of foot ulceration in Boston, USA and Pisa, Italy.Diabetes Res Clin Pract. 1997; 35: 21-26
- The association between callus formation, high pressures and neuropathy in diabetic foot ulceration.Diabet Med. 1996; 13: 979-982
- Factors associated with diabetic patients at high risk of foot ulceration.Diabetes Metab. 2005; 31: 603-605
- Debridement: choices and challenges.Adv Wound Care. 1997; 10: 32-37
- Surgical debridement: the key to successful wound healing and reconstruction.Clin Podiatr Med Surg. 2000; 17: 599-630
- Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial.Diabetes Care. 2003; 26: 1879-1882
- Conservative surgical approach versus non-surgical management for diabetic neuropathic foot ulcers: a randomized trial.Diabet Med. 1998; 15: 412-417
- Diabetic foot ulcers.Lancet. 2003; 361: 1545-1551
- Hallux amputation for diabetic osteomyelitis.J Foot Surg. 1987; 26: 141-148
- Treatment of osteomyelitis in the diabetic foot: contribution of conservative surgery.Diabetes Care19. 1996; : 1257-1260
- Diagnosis and treatment of diabetic foot infections.Clin Infect Dis. 2004; 39: 885-910
- The development of foot deformities and ulcer after great toe amputation in diabetes.Diabetes Care. 1996; 19: 165-167
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Conflict of Interest: None reported.
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