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Cited by 1,658Diabetic Foot Ulcer Assessment and ManagementSkin Diseases and DiabetesFoot and Ankle Surgery

Diabetic Foot Ulcers

Open access
Armstrong, David G., Tan, Tze-Woei, Boulton, Andrew J. M., Bus, Sicco A.·2023·JAMA
DOI 10.1001/jama.2023.10578PMC PMC10723802
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Abstract

Importance: Approximately 18.6 million people worldwide are affected by a diabetic foot ulcer each year, including 1.6 million people in the United States. These ulcers precede 80% of lower extremity amputations among people diagnosed with diabetes and are associated with an increased risk of death. Observations: Neurological, vascular, and biomechanical factors contribute to diabetic foot ulceration. Approximately 50% to 60% of ulcers become infected, and about 20% of moderate to severe infections lead to lower extremity amputations. The 5-year mortality rate for individuals with a diabetic foot ulcer is approximately 30%, exceeding 70% for those with a major amputation. The mortality rate for people with diabetic foot ulcers is 231 deaths per 1000 person-years, compared with 182 deaths per 1000 person-years in people with diabetes without foot ulcers. People who are Black, Hispanic, or Native American and people with low socioeconomic status have higher rates of diabetic foot ulcer and subsequent amputation compared with White people. Classifying ulcers based on the degree of tissue loss, ischemia, and infection can help identify risk of limb-threatening disease. Several interventions reduce risk of ulcers compared with usual care, such as pressure-relieving footwear (13.3% vs 25.4%; relative risk, 0.49; 95% CI, 0.28-0.84), foot skin measurements with off-loading when hot spots (ie, greater than 2 °C difference between the affected foot and the unaffected foot) are found (18.7% vs 30.8%; relative risk, 0.51; 95% CI, 0.31-0.84), and treatment of preulcer signs. Surgical debridement, reducing pressure from weight bearing on the ulcer, and treating lower extremity ischemia and foot infection are first-line therapies for diabetic foot ulcers. Randomized clinical trials support treatments to accelerate wound healing and culture-directed oral antibiotics for localized osteomyelitis. Multidisciplinary care, typically consisting of podiatrists, infectious disease specialists, and vascular surgeons, in close collaboration with primary care clinicians, is associated with lower major amputation rates relative to usual care (3.2% vs 4.4%; odds ratio, 0.40; 95% CI, 0.32-0.51). Approximately 30% to 40% of diabetic foot ulcers heal at 12 weeks, and recurrence after healing is estimated to be 42% at 1 year and 65% at 5 years. Conclusions and Relevance: Diabetic foot ulcers affect approximately 18.6 million people worldwide each year and are associated with increased rates of amputation and death. Surgical debridement, reducing pressure from weight bearing, treating lower extremity ischemia and foot infection, and early referral for multidisciplinary care are first-line therapies for diabetic foot ulcers.

AI snapshot

Written from the paper’s full text.

TL;DR

This JAMA review summarizes the epidemiology, evaluation, and management of diabetic foot ulcers, emphasizing their high amputation and mortality burden. It reports that off-loading, infection and ischemia treatment, preventive footwear, and multidisciplinary care reduce ulcer and amputation risk.

Key findings

  • Approximately 18.6 million people worldwide are affected by a diabetic foot ulcer each year, including 1.6 million in the United States; ulcers precede 80% of lower extremity amputations among people with diabetes, and the 5-year mortality rate is approximately 30%, exceeding 70% after major amputation.
  • Approximately 50% to 60% of ulcers become infected, and about 20% of moderate to severe infections lead to lower extremity amputations; WIfI scores of 1, 2, 3, and 4 were associated with 1-year amputation rates of 0%, 8%, 11%, and 38%, respectively.
  • Pressure-relieving footwear reduced ulcer incidence compared with usual care (13.3% vs 25.4%; RR, 0.49; 95% CI, 0.28-0.84), and at-home skin temperature monitoring with off-loading for hot spots reduced ulcer risk (18.7% vs 30.8%; RR, 0.51; 95% CI, 0.31-0.84).
  • Recurrence risk was 42% at 1 year, 58% at 3 years, and 65% at 5 years; multidisciplinary team care was associated with reduced major amputation relative to usual care (pooled OR, 0.40; 95% CI, 0.32-0.51).

Methods

  • Design: narrative review synthesizing published literature; no primary data collection.
  • Evidence base: includes meta-analyses, randomized clinical trials, prospective and retrospective cohort studies, guidelines, and registry data, with sample sizes cited where reported.
  • Analysis: qualitative synthesis of epidemiology, pathophysiology, screening and risk classification, infection and peripheral artery disease evaluation, wound and off-loading management, revascularization, and long-term outcomes.

Limitations

  • Stated in the paper: non-English-language articles were not included; some relevant publications may have been missed; not all aspects of diabetic foot ulcer treatment or screening were covered.
  • Evident from the text: as a narrative review, no systematic search strategy, inclusion criteria, or risk-of-bias assessment is reported, and effect estimates are drawn from heterogeneous study designs and populations.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1001/jama.2023.10578

Cites

103 of 103 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

103 of 158 cited sources checked · 5 supported · 4 flagged · accuracy not yet measured

  • Premisecitation

    Pooled data from 14 randomized clinical trials (1083 patients) showed that nonremovable devices were associated with improved healing compared with removable devices (81.9% vs 66.1%; RR, 1.24; 95% CI, 1.09-1.41).

    “Pooled data from 14 randomized clinical trials (1083 patients) showed that nonremovable devices were associated with improved healing compared with removable devices (81.9% vs 66.1%; RR, 1.24; 95% CI, 1.09-1.41;P = .001).58”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [58] source

      Split into 2 atoms — 0 confirmed, 0 partially supported, 1 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

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  • Premisecitation

    A meta-analysis of 943 patients with diabetic foot ulcers from 9 randomized clinical trials reported that negative pressure wound therapy was associated with improved healing, compared with treatment with moist wound healing (OR, 3.60; 95% CI, 2.38-5.45).

    “A meta-analysis of 943 patients with diabetic foot ulcers from 9 randomized clinical trials reported that negative pressure wound therapy was associated with improved healing, compared with treatment with moist wound healing (OR, 3.60; 95% CI, 2.38-5.45;P < .001).74”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [74] source

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  • Premisecitation

    A meta-analysis of randomized clinical trials with 1587 participants reported that therapeutic footwear, relative to usual care, significantly reduced incidence of diabetic foot ulcers (13.3% vs 25.4%; RR, 0.49; 95% CI, 0.28-0.84; P < .01).

    “A meta-analysis of randomized clinical trials with 1587 participants reported that therapeutic footwear, relative to usual care, significantly reduced incidence of diabetic foot ulcers (13.3% vs 25.4%; RR, 0.49; 95% CI, 0.28-0.84;P < .01).87”
    • Also stated in: § Description Outcome/benefit · plain
      “Meta-analysis of 8 randomized clinical trials including 1587 participants showed reduced incidence of diabetic foot ulcer (relative risk, 0.49; 95% CI, 0.28-0.84)with therapeutic footwear relative to those not wearing prescriptive shoes and custom insoles.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [87] source

      Split into 2 atoms — 0 confirmed, 0 partially supported, 1 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

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  • Premisecitation

    Placenta-derived products have a higher likelihood of complete healing at 12-16 wk compared with control dressing (relative risk, 2.0; 95% CI, 1.67-2.39; P < .001), based on a meta-analysis of 11 multicenter randomized clinical trials involving 655 people with diabetic foot ulcers.

    “Placenta-derived products Contain growth factors, collagen-rich extracellular matrix, and cells that might accelerate wound healing Higher likelihood of complete healing at 12-16 wk compared with control dressing (relative risk, 2.0; 95% CI, 1.67-2.39;P < .001).[66][67][68] Data from a meta-analysis of 11 multicenter randomized clinical trials involving 655 people with diabetic foot ulcers.”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [66] source

      Split into 2 atoms — 0 confirmed, 0 partially supported, 1 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

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    • cites [67] source
    • cites [68] source
  • Premisecitation

    Among Medicare beneficiaries, patients identifying as non-Hispanic Black had twice the odds of lower extremity amputation within 1 year of foot ulcer diagnosis after adjusting for multiple covariates (OR, 1.98; 95% CI, 1.93-2.03) compared with those identifying as non-Hispanic White.

    “Among Medicare beneficiaries (total sample, 643 287), patients identifying as non-Hispanic Black had twice the odds of lower extremity amputation within 1 year of foot ulcer diagnosis after adjusting for multiple covariates (odds ratio [OR], 1.98; 95% CI, 1.93-2.03;P < .001[absolute rates not provided]) compared with those identifying as non-Hispanic White.19”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [19] source

      The 'Factors Associated With a Major Amputation' section reports higher adjusted odds for Black than White patients, but gives OR 1.12 (95% CI 1.08–1.16), not 1.98. The Abstract describes hospitalized U.S. adults in the National Inpatient Sample, not a Medicare cohort followed for one year after foot-ulcer diagnosis. Page numbers were not supplied for these passages. (LLM, conf=0.89)

      Experimental — accuracy not yet measured
  • May combine two claims. 35
  • Classified as probably not a substantial claim. 14
  • The quote only partly states this claim. 2

  • May combine two claims.

    Premisecitation

    Diabetic foot ulcers disproportionately affect people with lower socioeconomic status and those living in rural areas.

    “In addition, diabetic foot ulcers disproportionately affect people with lower socioeconomic status and those living in rural areas.20”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [20] source

      The Introduction and Discussion (pages not provided) address disparities in major leg amputation or death among people already hospitalized with diabetic foot ulcers. A search for ulcer incidence or prevalence by socioeconomic status and rural residence found no passage establishing that these groups are more likely to develop diabetic foot ulcers. (LLM, conf=0.77)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    People identifying as non-Hispanic Black and Hispanic of any race have more advanced diabetic foot ulcers and peripheral artery disease at initial presentation and are more likely to undergo lower extremity amputation without a lower extremity revascularization attempt.

    “People identifying as non-Hispanic Black and Hispanic of any race have more advanced diabetic foot ulcers and peripheral artery disease at initial presentation and are more likely to undergo lower extremity amputation without a lower extremity revascularization attempt.[16][17][18]”
    Quote in the paperSubstantial claim3 of 3 sources checked
    • cites [16] source

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    • cites [17] source

      Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

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    • cites [18] source

      Split into 2 atoms — 0 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In a prospective study of 1666 people with diabetes, equinus deformity was present in 10.3%.

    “In a prospective study of 1666 people with diabetes, equinus deformity was present in 10.3% .31”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [31] source

      The review’s Population section (2.2.1) defines eligible studies involving people with diabetes and foot ulcers, while its Eurodiale scores section (3.2.13) discusses amputation prediction, not equinus prevalence. Searches of our full-text copy for “equinus,” “1666,” and “10.3%” found no passage reporting the claimed prospective-study result. (LLM, conf=0.75)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Charcot arthropathy affects approximately 0.3% of people with diabetes, can lead to significant deformity, and increases the risk of a diabetic foot ulcer, particularly in the midfoot and ankle/hindfoot.

    “Charcot arthropathy, defined as a foot fracture with possible joint dislocation in people with peripheral neuropathy, affects approximately 0.3% of people with diabetes, can lead to significant deformity, and increases the risk of a diabetic foot ulcer, particularly in the midfoot and ankle/hindfoot.32”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [32] source

      The Clinical question section mentions acute Charcot neuro-osteoarthropathy only as a possible cause of skin inflammation, and the Rationale section lists foot deformity as a variable in a separate ulcer score (page numbers not supplied). Searches for Charcot, 0.3%, and midfoot/ankle/hindfoot found no passage supporting the claimed prevalence, definition, deformity, or ulcer risk. (LLM, conf=0.76)

      Experimental — accuracy not yet measured

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    Premisecitation

    Motor neuropathy causes foot deformity and biomechanical abnormalities.

    “Sensory neuropathy leads to loss of protective sensation; motor neuropathy causes foot deformity and biomechanical abnormalities, while autonomic neuropathy leads to vis-coelastic changes in the skin, such as skin dryness. 2”
    Quote in the paperSubstantial claim1 of 1 sources checked

  • May combine two claims.

    Premisecitation

    Other mechanisms by which diabetic foot ulcers develop include constant low pressure (e.g., from tight shoes causing tissue necrosis) or extremely high pressure (e.g., a sharp object causing direct mechanical damage).

    “Other mechanisms by which diabetic foot ulcers develop include constant low pressure, eg, from tight shoes causing tissue necrosis, or extremely high pressure, such as a sharp object causing direct mechanical damage. 2”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [2] source

      The paper says diabetic foot ulcers are commonly caused by repetitive vertical or shear stress in people with peripheral neuropathy (opening text labelled Abstract in our copy), and its discussion on p. 2372 says properly fitting shoes help prevent recurrence. It does not describe constant low pressure from tight shoes causing tissue necrosis or extremely high pressure from a sharp object causing direct mechanical damage as the two mechanisms claimed. (LLM, conf=0.82)

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  • May combine two claims.

    Premisecitation

    Approximately 40% of people with Charcot arthropathy have concomitant tissue loss; a unilateral red, hot, swollen foot without a wound or diagnosis of deep vein thrombosis may indicate Charcot arthropathy.

    “Although approximately 40% of people with Charcot arthropathy have concomitant tissue loss, a unilateral red, hot, swollen foot without a wound or diagnosis of deep vein thrombosis may indicate Charcot arthropathy.32”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [32] source

      The Clinical question section (Table 3, p. 8) lists acute Charcot neuro-osteoarthropathy and thrombosis as possible causes of skin inflammation, alongside swelling, erythema and warmth. It does not report that approximately 40% of people with Charcot arthropathy have tissue loss or state the proposed diagnostic rule involving a unilateral foot without a wound or deep vein thrombosis. (LLM, conf=0.81)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    The Wound, Ischemia, Foot Infection (WIfI) classification system was developed and validated as a method to combine wound, ischemia, and foot infection and to accurately assess the risk of limb loss for patients with diabetic foot ulcers.

    “TheWound, Ischemia, Foot Infection (WIfI) classification system was developed and validated as a method to combine all 3 variables (wound, ischemia, and foot infection)and to accurately assess the risk of limb loss for patients with diabetic foot ulcers.38,39”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [38] source

      The Abstract discusses diabetic foot infection, osteomyelitis, and amputation, while the Methods assess imaging tests for osteomyelitis. Searches for WIfI and for a classification predicting limb loss found no passage about the system’s development, validation, or predictive accuracy; no page numbers are available in our copy. (LLM, conf=0.77)

      Experimental — accuracy not yet measured
    • cites [39] source

      The Study selection section lists eight noninvasive tests evaluated for healing and amputation outcomes, but not WIfI. Searches for WIfI and for a classification combining wound, ischemia, and infection found no passage about its development, validation, or accuracy in assessing limb-loss risk. Page numbers were unavailable in our copy. (LLM, conf=0.76)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    The diagnosis of diabetic foot infection is primarily based on clinical assessment and is suggested by presence of more than 2 signs of inflammation, such as erythema, swelling and possibly purulence, fluctuance, or lymphangiitis.

    “The diagnosis of diabetic foot infection is primarily based on clinical assessment and is suggested by presence of more than 2 signs of inflammation, such as erythema, swelling and possibly purulence, fluctuance, or lymphangiitis.7,13”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [7] source

      The Conclusion discusses how often diabetic foot ulcers become infected, but not how infection is diagnosed. A search for clinical assessment, signs of inflammation, and the named signs found no diagnostic criteria in our copy; the References list an infection guideline without stating its criteria. (LLM, conf=0.75)

      Experimental — accuracy not yet measured
    • cites [13] source

      The Study cohort section (page unavailable) identifies patients using ICD-9 codes, but does not describe clinical diagnostic criteria. The Introduction and additional passages found by searching for the listed inflammatory signs and clinical assessment do not address a threshold of more than two signs or the listed findings. (LLM, conf=0.76)

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  • May combine two claims.

    Premisecitation

    The sensitivity and specificity of transcutaneous oxygen pressure for ulcer healing were 0.72 (95% CI, 0.61-0.81) and 0.86 (95% CI, 0.68-0.95), respectively, with a diagnostic OR of 15.81 (95% CI, 3.36-74.45).

    “The sensitivity and specificity of transcutaneous oxygen pressure for ulcer healing were 0.72 (95% CI, 0.61-0.81)and 0.86 (95% CI, 0.68-0.95),respectively, with a diagnostic OR of 15.81 (95% CI, 3.36-74.45).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [44] source

      The Hyperbaric oxygen therapy section (page unavailable) reports that preintervention TcPO2 correlated with ulcer healing. It does not report the claimed sensitivity, specificity, diagnostic odds ratio, or their confidence intervals, so the numerical claim is unsupported by the available copy. (LLM, conf=0.78)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Off-loading repetitive mechanical stress on the foot, consisting of reducing weight bearing on the ulcer, reduces pressure over the wound by spreading force over a larger unit area, thus providing an environment for healing.

    “Off-loading repetitive mechanical stress on the foot, consisting of reducing weight bearing on the ulcer, is an important aspect of treatment and reduces pressure over the wound by spreading force over a larger unit area, thus providing an environment for healing.55”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [55] source

      The Offloading Devices section describes offloading footwear as part of standard treatment, and the Conclusions say pressure can be relieved from a toe. The Ulcer Group results report better healing with tenotomy. The paper does not explain offloading as spreading force over a larger area or establish that mechanism for healing. (LLM, conf=0.86)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Debridement is a standardized approach used to facilitate healing.

    “Debridement |: Debridement is a standardized approach used to facilitate healing.52”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [52] source

      The Background and Results discuss offloading to promote healing of diabetic foot ulcers, not debridement. A search of our full-text copy for “debridement” found no passage addressing whether it is a standardized approach used to facilitate healing. (LLM, conf=0.77)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    Although guidelines recommend regular debridement, defined as weekly or every other week, randomized clinical trials are lacking.

    “Although guidelines recommend regular debridement, defined as weekly or every other week, randomized clinical trials are lacking.52,53”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [52] source

      The Conclusions discuss a need for randomized trials of felt-padding offloading, not debridement. Searches for debridement and the claimed weekly or every-other-week schedule found no passage in our copy addressing those points or a lack of debridement trials. (LLM, conf=0.76)

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    • cites [53] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Negative pressure wound therapy has been widely used as an adjunct therapy in the treatment of complicated and postoperative wounds in the diabetic foot for the last 2 decades.

    “Negative pressure wound therapy has been widely used as an adjunct therapy in the treatment of complicated and postoperative wounds in the diabetic foot for the last 2 decades. 52,64”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [52] source

      The Background and Conclusions discuss pressure offloading for diabetic foot ulcers, not negative pressure wound therapy. Searches for that term and for vacuum-assisted closure found no passage addressing its use for complicated or postoperative wounds or the claimed two-decade history. (LLM, conf=0.77)

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    • cites [64] source

      The Abstract discusses hyperbaric oxygen therapy as an adjunct to diabetic foot-ulcer care, not negative pressure wound therapy. Searches for “negative pressure wound therapy” and “vacuum-assisted closure” found no passage addressing its use for complicated or postoperative diabetic foot wounds, or the claimed two-decade history. (LLM, conf=0.76)

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  • The quote only partly states this claim.

    Premisecitation

    In 1434 patients who were candidates for either surgery or endovascular treatment (71.8% had diabetes), surgical bypass appeared superior to endovascular therapy for major adverse limb events or death (42.6% vs 57.4%; HR, 0.68; 95% CI, 0.59-0.79).

    “In 1434 patients who were candidates for either surgery (including a singlesegment great saphenous vein for bypass) or endovascular treatment (71.8% had diabetes), surgical bypass appeared to be superior to endovascular therapy based on the risk of major adverse limb events, defined as major amputation or a major limb reintervention (repeat bypass graft, graft revision, thrombectomy, or thromboly”
    • Also stated in: § Surgical bypass vs endovascular therapy 84 · hedged
      “In a randomized clinical trial of 1434 patients who were candidates for either surgery bypass (including single-segment great saphenous vein for bypass) or endovascular treatment (71.8% had diabetes), surgical bypass appeared superior to endovascular therapy in patients with adequate great saphenous vein (hazard ratio, 0.68; 95% CI, 0.59-0.79)for composite outcome of a major adverse limb event (am”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [84] source

      Split into 2 atoms — 0 confirmed, 0 partially supported, 0 disputed, 0 misattributed, 2 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Removable knee-high and ankle-high walkers reduce pressure effectively but do not promote healing as well as nonremovable walkers or total contact cast.

    “Removable knee-high and ankle-high walkers 51 Off-loading devices that can be removed by the patient Reduces pressure effectively but does not promote healing as well as nonremovable walkers or total contact cast.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [51] source

      The Abstract (page unavailable) identifies removable cast walkers as an offloading method, and the Conclusions (page unavailable) describe their removability and call total contact casts a gold standard. The paper does not distinguish knee-high from ankle-high walkers or state that removable walkers reduce pressure effectively but heal ulcers less well than nonremovable walkers or casts. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    The recurrence rate of diabetic foot ulcers after treatment of any kind is estimated to be 42% at 1 year, 58% at 3 years, and 65% at 5 years.

    “The recurrence rate of diabetic foot ulcers after treatment of any kind is estimated to be 42% at 1 year and 65% at 5 years. 2”
    • Also stated in: § Description Outcome/benefit · plain
      “Pooled data from 8 prospective studies with 1738 participants, 1 retrospective studywith 46 participants, and the usual care groups of 9 randomized clinical trials with 636 participants reported that the risk of recurrence of diabetic foot ulcer was 42% at 1 year, 58% at 3 years, and 65% at 5 years.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [2] source

      The “Ulcer Recurrence and Remission” section estimates recurrence after ulcer healing at roughly 40% within 1 year, almost 60% within 3 years, and 65% within 5 years. These approximate the claimed rates, but the paper does not give 42% or 58% as exact estimates or establish a rate after treatment of any kind. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Ankle-brachial index is less useful in patients with diabetes, kidney disease, and diabetic foot ulcers due to falsely elevated ankle pressure from medial calcinosis; low prognostic accuracy for ulcer healing.

    “Less useful in patients with diabetes, kidney disease, and diabetic foot ulcers due to falsely elevated ankle pressure from medial calcinosis; low prognostic accuracy for ulcer healing.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [44] source

      In ‘Definitions and nomenclature > CLTI’ and ‘Diagnosis and limb staging in CLTI > Noninvasive hemodynamic tests’ (page unavailable), the guidelines say medial calcinosis can falsely elevate ankle pressure and ABI, particularly in people with diabetes or kidney disease. They recommend toe measurements when ABI may be misleading. The passages do not establish low prognostic accuracy of ABI for diabetic foot-ulcer healing; the outcome comparison given concerns one-year amputation risk. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Transcutaneous oximetry is 72% sensitive and 86% specific; diagnostic odds ratio, 15.81.

    “Transcutaneous oximetry 44 Measurement of oxygen tension at the skin surface 72% sensitive; 86% specific; diagnostic odds ratio, 15.81 a”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [44] source

      The CLTI and noninvasive-diagnosis sections discuss transcutaneous oxygen pressure (TcPO2) as a measure of limb perfusion, but give no sensitivity, specificity, or diagnostic odds ratio for it. Searches for the stated figures and diagnostic-performance terms found no supporting passage in our copy; the copy is truncated. (LLM, conf=0.70)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Felted foam in appropriately fitting shoes reduces pressure and heals plantar ulcers less effectively than nonremovable and removable devices.

    “Felted foam in appropriately fitting shoes Felted foam applied to at least the ulcer region Reduces pressure and heals plantar ulcers less effectively than nonremovable and removable devices.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [51] source

      The Abstract lists felted foam as an offloading method, and the Conclusions say shoe modifications are not effective means of offloading. But the paper does not establish that felted foam in appropriately fitting shoes reduces pressure or heals plantar ulcers less effectively than both nonremovable and removable devices. The Conclusions discuss healing efficacy for instant total-contact casts, not that comparison. (LLM, conf=0.83)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Toe systolic blood pressure measurement is 86% sensitive and 58% specific.

    “Toe systolic blood pressure 46,47 Measurement of systolic blood pressure at the toe 86% sensitive; 58% specific”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [46] source

      The cited guideline discusses offloading devices and plantar pressure (Below ankle-high offloading device, p. 6), not the diagnostic accuracy of toe systolic blood pressure measurement. Searches for toe systolic blood pressure and the stated 86% sensitivity and 58% specificity found no passage addressing those figures. (LLM, conf=0.76)

      Experimental — accuracy not yet measured
    • cites [47] source

      The guideline discusses vascular measures such as the ankle-brachial index and transcutaneous oxygen pressure in §4.1.5, but the passages found do not report diagnostic performance for toe systolic blood pressure. Searches for “toe systolic blood pressure,” “toe pressure,” “86%,” and “58%” found no passage supporting the claimed sensitivity or specificity (page numbers unavailable). (LLM, conf=0.74)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Ankle-brachial index is 48% sensitive and 52% specific; diagnostic odds ratio, 1.02.

    “Ankle-brachial index 44 Ankle pressure compared with arm pressure 48% sensitive; 52% specific; diagnostic odds ratio, 1.02 a”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [44] source

      The 'Noninvasive hemodynamic tests—AP and ABI' section defines the ankle-brachial index and discusses its limitations, but gives no 48% sensitivity, 52% specificity, or diagnostic odds ratio of 1.02. Searches for those figures and for ABI diagnostic accuracy found no matching passage in our copy, whose end may be missing. (LLM, conf=0.72)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Transcutaneous oxygen pressure ≥25 mm Hg is associated with higher rates of ulcer healing and high accuracy in predicting ulcer healing and limb amputation.

    “Transcutaneous oxygen pressure ≥25 mm Hg is associated with higher rates of ulcer healing and high accuracy in predicting ulcer healing and limb amputation.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [44] source

      The Hyperbaric oxygen therapy section (page unavailable) reports that preintervention TcPO2 correlated with ulcer healing and that patients below 25 mm Hg did not heal. It does not establish a higher healing rate specifically at ≥25 mm Hg or high predictive accuracy for either healing or limb amputation. The Level of amputation section (page unavailable) says no single tissue-perfusion method accurately predicts healing or failure at an amputation site. (LLM, conf=0.86)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based). May combine two claims.

    Findingnone given

    Although there are no comparative data, skin grafting may be considered.

    “Although there are no comparative data, skin grafting may be considered”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    A higher score on the WIfI scale is associated with lower extremity amputation and morbidity and can be used to determine the need for revascularization.

    “A higher score on the WIfI scale is associated with lower extremity amputation and morbidity and can be used to determine the need for revascularization.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    The tip of a toe exposed to increased pressure in contact with the ground or shoe is also a common site of ulceration.

    “The tip of a toe exposed to increased pressure in contact with the ground or shoe is also a common site of ulceration.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Placenta-derived products contain growth factors, collagen-rich extracellular matrix, and cells that might accelerate wound healing.

    “These products contain growth factors, collagen-rich extracellular matrix, and cells that might accelerate wound healing.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    People with diabetes often have medial calcinosis of lower extremity peripheral vessels, resulting in falsely elevated peripheral pressures and a high ankle-brachial index that is insensitive to presence of peripheral artery disease.

    “However, people with diabetes often have medial calcinosis of lower extremity peripheral vessels, resulting in falsely elevated peripheral pressures and a high ankle-brachial index that is insensitive to presence of peripheral artery disease.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    A skin perfusion pressure greater than 40 mm Hg showed a positive likelihood ratio ranging from 4.86 to 6.40 and corresponding negative likelihood ratios between 0.03 and 0.40 for ulcer healing.

    “A skin perfusion pressure greater than 40 mm Hg showed a positive likelihood ratio ranging from 4.86 to 6.40 and corresponding negative likelihood ratios between 0.03 and 0.40 for ulcer healing.45”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [45] source

  • May combine two claims.

    Premisecitation

    Toe pressure of 30 mm Hg or greater, transcutaneous oxygen pressure of 25 mm Hg or greater, and skin perfusion pressure of 40 mm Hg or greater have been associated with higher rates of ulcer healing.

    “Toe pressure of 30 mm Hg or greater, transcutaneous oxygen pressure of 25 mm Hg or greater, and skin perfusion pressure of 40 mm Hg or greater have been associated with higher rates of ulcer healing.35”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [35] source

  • May combine two claims.

    Premisecitation

    An ankle-brachial index less than 0.90 is approximately 98% specific and approximately 85% sensitive for peripheral artery disease.

    “An ankle-brachial index less than 0.90 is approximately 98% specific and approximately 85% sensitive for peripheral artery disease.35”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [35] source

  • May combine two claims.

    Premisecitation

    Removable walkers can reduce pressure effectively but do not promote healing as well as nonremovable walkers or total contact casts.

    “Alternatively, removable walkers can reduce pressure effectively but do not promote healing as well as nonremovable walkers or total contact casts.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisenone given

    The 5-year mortality rate for individuals with a diabetic foot ulcer is approximately 30%, exceeding 70% for those with a major amputation.

    “The 5-year mortality rate for individuals with a diabetic foot ulcer is approximately 30%, exceeding 70% for those with a major amputation.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Premisenone given

    Surgical debridement, reducing pressure from weight bearing on the ulcer, and treating lower extremity ischemia and foot infection are first-line therapies for diabetic foot ulcers.

    “Surgical debridement, reducing pressure from weight bearing on the ulcer, and treating lower extremity ischemia and foot infection are first-line therapies for diabetic foot ulcers.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Negative pressure wound therapy is most effective in resolving wound depth and creating a bed of predominant granulation tissue.

    “Negative pressure wound therapy is most effective in resolving wound depth and creating a bed of predominant granulation tissue, at which point it may be discontinued and replaced with skin grafting or wound dressings as described above.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Diabetic foot ulcers precede 80% of lower extremity amputations among people diagnosed with diabetes and are associated with an increased risk of death.

    “These ulcers precede 80% of lower extremity amputations among people diagnosed with diabetes and are associated with an increased risk of death.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Approximately 50% to 60% of diabetic foot ulcers become infected, and about 20% of moderate to severe infections lead to lower extremity amputations.

    “Approximately 50% to 60% of ulcers become infected, and about 20% of moderate to severe infections lead to lower extremity amputations.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    Classifying ulcers based on the degree of tissue loss, ischemia, and infection can help identify risk of limb-threatening disease.

    “Classifying ulcers based on the degree of tissue loss, ischemia, and infection can help identify risk of limb-threatening disease.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    This Review did not include non-English-language articles.

    “First, non-English-language articles were not included.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    A recent longitudinal study of 129 patients in diabetic foot ulcer remission found that only 17% had wound recurrence at the identical location, with 48% having a recurrence on the contralateral foot.

    “A recent longitudinal study of 129 patients in diabetic foot ulcer remission found that only 17% had wound recurrence at the identical location, with 48% having a recurrence on the contralateral foot.96”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [96]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Study design and conductnone given

    Some relevant publications may have been missed in this Review.

    “Second, some relevant publications may have been missed.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Skin perfusion pressure ≥40 mm Hg is associated with higher rates of ulcer healing; positive likelihood ratios range from 4.86 to 6.40 and corresponding negative likelihood ratios from 0.03 to 0.40.

    “Skin perfusion pressure ≥40 mm Hg is associated with higher rates of ulcer healing; positive likelihood ratios range from 4.86 to 6.40 and corresponding negative likelihood ratios from 0.03 to 0.40.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [45] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Not all aspects of diabetic foot ulcer treatment or screening were covered in this Review.

    “Third, not all aspects of diabetic foot ulcer treatment or screening were covered.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Palpation of anterior tibial or posterior tibial pulse is 35% sensitive and 100% specific.

    “Palpation of pulses 45 Palpation of anterior tibial or posterior tibial pulse 35% sensitive; 100% specific”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [45] source

  • The quote only partly states this claim.

    Premisecitation

    In a single-center randomized clinical trial of 16 patients with diabetic foot ulcers at the distal plantar digits, flexor tendon tenotomy resulted in 100% vs 37.5% healing compared with debridement, moisture-retentive dressings, and nonsurgical offloading (P = .03).

    “Flexor tendon tenotomy Surgical procedure for ulcers on the apex of the lesser toes 100% vs 37.5% healing ((P = .03)in a single-center randomized clinical trial of 16 patients with diabetic foot ulcers at the distal plantar digits; flexor”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [60] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In people with diabetes, the prevalence of moderate risk for diabetic foot ulceration (having ≥2 factors among loss of protective sensation, peripheral artery disease, and foot deformity) is 4.3%.

    “| 2 | Moderate | ≥2 Factors among loss of protective sensation, peripheral | 3-6 mo | 4.3 |”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Stang and Leese.29

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In people with diabetes, the prevalence of low risk for diabetic foot ulceration (having loss of protective sensation or peripheral artery disease) is 14.2%.

    “| 1 | Low | Loss of protective sensation or peripheral artery disease | 6-12 mo | 14.2 |”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Stang and Leese.29

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In people with diabetes, the prevalence of high risk for diabetic foot ulceration (in remission with a history of diabetic foot ulcer, amputation, or end-stage renal disease) is 1.8%.

    “| 3 | High | In remission: history of diabetic foot ulcer, amputation | 1-3 mo | 1.8 |”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Stang and Leese.29

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In people with diabetes, the prevalence of active diabetic foot pathology (active ulcer, Charcot arthropathy, or infection with or without peripheral artery disease) is 1.4%.

    “| Active | Active | Active ulcer, Charcot arthropathy, or infection with or | Rapid referral to specialist/ | 1.4 |”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Stang and Leese.29

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

49 of 49

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Table says off-loading rates are unavailable despite reporting them

    Minor

    The text supplies healing rates of 81.9% and 66.1% for the nonremovable-versus-removable-device comparison, but Table 3 says absolute rates were not provided.

  • Different control-group healing rates for the EXPLORER trial

    Minor

    The text reports a 30% control-group healing rate at 20 weeks, while Table 5 reports 34% for the same trial and outcome.

  • Table says amputation rates are unavailable despite reporting them

    Minor

    The text gives major-amputation rates of 3.2% and 4.4% for the multidisciplinary-care comparison, but Table 7 says absolute data are unavailable.

3 of 3

Cited works that were retracted

Works this paper cites that were later retracted, from the retraction notices publishers deposit. Major when the notice came out before this paper was published.

  • Cites a retracted work: 10.1111/iwj.13836

    Info

    The cited work was retracted on 2025-03-26 (notice 10.1111/iwj.70427), not before this paper was published (2023-07-03).

    Cited work 10.1111/iwj.13836 · retracted 2025-03-26 · notice 10.1111/iwj.70427 · this paper published 2023-07-03

1 of 1

Cites

1 retracted

Flagged first, then by citations

Research works printed but not linked: 1

  1. Stang? D, Leese? GP. The Scottish Diabetes Foot Action Group 2016 Update of the Diabetic Foot Risk Stratification and Triage System. Published March 1, 2017. Accessed July 1, 2022. https://woundsinternational.com/journal-articles/the-scottish-diabetes-foot-action-group-2016-update-of-the-diabetic-foot-risk-stratification-and-triage-system/

Cited by

Sorted by citations

Related

Authors
Armstrong, D. G., Tan, T.-W., Boulton, A. J. M., & Bus, S. A.
Affiliations
  • University of Southern California (US)
  • University of Manchester (GB)
  • Amsterdam University Medical Centers (NL)
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2023-07-03
Volume
330
Issue
1
Pages
62
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2023.10578
PMC
PMC10723802
OpenAlex
W4382918816
Semantic Scholar
c4e2be1c774d3fb243044a0ed9110c292b776b18
Cited by
1,658
References
103
Citations by year
2026: 646 · 2025: 660 · 2024: 314 · 2023: 38
FWCI
277.41
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (submittedVersion)
  • Pure Amsterdam UMC (submittedVersion)
Funders
  • National Science Foundation (2052578)
  • National Institutes of Health (1R01124789-01A1)
  • National Institute of Diabetes and Digestive and Kidney Diseases (R01DK124789, 1R01124789, 1R01124789‐01A1, 1K23DK122126, K23 DK122126)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetic Foot Ulcer Assessment and Management
  • Health Sciences › Medicine › Dermatology › Skin Diseases and Diabetes
  • Health Sciences › Medicine › Orthopedics and Sports Medicine › Foot and Ankle Surgery
Keywords
diabetic foot ulcer, lower limb amputation, foot infection, osteomyelitis, offloading, surgical debridement, multidisciplinary care, wound healing
MeSH terms
Anti-Bacterial Agents, Diabetes Mellitus, Foot, Humans, Wound Healing, Diabetic Foot, Lower Extremity

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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