Exp Clin Endocrinol Diabetes 2019; 127(06): 385-386
DOI: 10.1055/a-0584-6396
Letter to the Editor
© Georg Thieme Verlag KG Stuttgart · New York

Infected Diabetic Foot Ulcers: No Laterality?

Maria Demetriou
1   Diabetic Foot Clinic, Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
2   Microbiology Laboratory, Democritus University of Thrace, Alexandroupolis, Greece
,
Nikolaos Papanas
1   Diabetic Foot Clinic, Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
,
Periklis Panagopoulos
3   Unit of Infectious Diseases, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
,
Maria Panopoulou
2   Microbiology Laboratory, Democritus University of Thrace, Alexandroupolis, Greece
,
Efstratios Maltezos
1   Diabetic Foot Clinic, Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
3   Unit of Infectious Diseases, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
› Author Affiliations
Further Information

Publication History

received 18 December 2017
revised 25 February 2018

accepted 01 March 2018

Publication Date:
11 June 2018 (online)

The aim of this study was to examine if there is a right:left laterality of ulcer location in patients with clinically infected neuropathic vs. neuroischaemic diabetic foot ulcers. Foot ulcers were defined as wounds beneath the malleoli penetrating through all skin layers [1]. Infection was diagnosed clinically by the presence of local swelling or induration; erythema greater than 0.5 cm around the ulcer; local tenderness or pain; local increase of temperature; pus discharge [1]. Ulcers were classified as neuropathic or neuroischaemic, based on their clinical manifestations, as previously described [1].

Overall, 113 diabetic patients were included: group A included 63 patients (35 men, mean age 61.2 years, mean diabetes duration 12.4 years) with neuropathic foot ulcers; group B included 50 patients (35 men, mean age 73.4 years, mean diabetes duration 16.9 years) with neuroischaemic foot ulcers.

Right:left ulcer location was 32:31 in group A and 24:26 in group B. No laterality, i. e. no preponderance of any foot was seen in either group. There was no difference in the right:left foot ratio between the groups (p=0.768). In group A, ulcer locations were as follows: 4 on the right hallux, 2 on the left hallux, 3 on the right heel, 2 on the left heel, 5 on the right 1st metatarsal head, 4 on the left 1st metatarsal head, 2 on the right 5th metatarsal head, 1 on the left 5th metatarsal head, 9 on the other right metatarsal heads, 6 on the other left metatarsal heads and 25 miscellaneous. In group B, ulcer locations were as follows: 11 on the lateral border of the 5th toe, 9 on the right hallux, 2 on the left hallux, 6 on the right heel, 5 on the left heel, 1 on the right 1st metatarsal head, 2 on the left 1st metatarsal head, 2 on the right 5th metatarsal head, 3 on the left 5th metatarsal head and 9 miscellaneous.

Interestingly, Coxon and Gallen [2] carried out a large audit of lower-limb amputations and found a higher prevalence of amputations on the right lower limb. This may be attributed to the fact that the right lower limb is dominant in the vast majority of subjects, and, therefore, it might be more prone to injury during standing and walking [2]. However, one might argue that this explanation would be more applicable to patients with neuropathic foot ulcers, bet less so to those with neuroischaemic foot ulcers, in whom peripheral arterial disease would also be important. Conversely, one might even expect the non-dominant foot (i. e. the left, in the majority of subjects) to be more clumsy during daily activities, and therefore more prone to ulceration and even amputation. All these speculations hitherto remain unanswered.

In our study, ulcers were mainly located on high-pressure areas (right hallux, left hallux, right and left metatarsal heads) in group A, but this was not the case in group B. This finding agrees with the pathogenic principle that neuropathic ulcers occur through strain of pressurised areas in insensate feet and neuroischaemic ulcers in other foot areas [3].

Generally, ulcer location on the right vs. left foot is not known to affect outcomes. Indeed, the same therapeutic principles apply in both cases. However, there is no concrete data to confirm this notion. It is also not known if it is easier to maintain off-loading and to ensure patient compliance on the right vs. left foot. A speculation may be that off-loading of the dominant limb might be less well tolerated by patients, leading, perhaps, to lower compliance rates. Again, more information is needed.

In conclusion, we have found no right:left laterality of infected diabetic foot ulcers. There was no difference between those with neuropathic and those with neuroischaemic foot ulcers. These results appear interesting in the discussion about the pathogenesis and aetiology of the diabetic foot [3] [4], and they merit re-examination in a larger study. Meanwhile, a clear message is that both feet may equally develop ulcers in diabetes mellitus. Thus, both feet (not only the dominant one) require careful hygiene by patients themselves as well as meticulous examination by their physicians, in order to diagnose any lesions early and to minimise further complications [5].

 
  • References

  • 1 Demetriou M, Papanas N, Panopoulou M. et al. Tissue and swab culture in diabetic foot infections: Neuropathic versus neuroischemic ulcers. Int J Low Extrem Wounds 2013; 12: 87-93
  • 2 Coxon JP, Gallen IW. Laterality of lower limb amputation in diabetic patients: Retrospective audit. BMJ 1999; 318: 367
  • 3 Morbach S, Müller E, Reike H. et al. Diabetic foot syndrome. Exp Clin Endocrinol Diabetes 2014; 122: 416-424
  • 4 Wilbek TE, Jansen RB, Jørgensen B. et al. The diabetic foot in a multidisciplinary team setting. Number of amputations below ankle level and mortality. Exp Clin Endocrinol Diabetes 2016; 124: 535-540
  • 5 Vas PRJ, Edmonds M, Kavarthapu V et al. The diabetic foot attack: "'Tis too late to retreat!". Int J Low Extrem Wounds 2018 Feb 1 [Epub ahead of print]