Lower extremity wounds such as diabetic foot ulcers (DFUs), venous ulcers, and arterial ulcers have been linked to poor patient outcomes, such as patient mortality and recurrence of the wound.¹ Although precise recurrence rates can be difficult to determine and can vary across different patient populations, we do know that the recurrence rates of lower extremity wounds are quite high.

Overview of Lower Extremity Wounds

One analysis of 19 different studies found the following overall recurrence rates²:

• 40% of patients developed a recurrence of the ulcer within one year of healing.
• Nearly 60% had a recurrence within three years of wound healing.
• 65% developed a recurrence within five years.

Similarly, venous ulcers are often characterized by repeated cycles of ulceration and recur in 60% to 70% of patients.³ When ulceration is caused by severe arterial compromise, healing rates are unlikely to exceed 50%.⁴ The presence or recurrence of an ulcer is closely linked to substantial morbidity, amputation of the lower extremity, and increased mortality.¹ In addition to direct patient outcomes, the economic costs of treating lower extremity wounds are extremely high, and minimizing wound recurrences has the potential to reduce the nearly $1 billion annual cost of DFUs in the United States.⁵ Patients with DFUs frequently require hospital admission and inpatient care, particularly when infection, sepsis, or gangrene requires amputation of the limb. Although 15% of all DFUs require an amputation, this event can increase the mortality rate for this patient group to 15% in the first year.⁵

Preventing Lower Extremity Wound Recurrence

The recurrence of lower extremity wounds comes at a high cost to the health care system and to the patients who have these wounds. Successfully preventing the recurrence of these wounds can be supported by educating patients on the presence and importance of neuropathy, encouraging patient vigilance and attention to skin care, recognizing skin breakdown, trimming calluses, and engaging in routine podiatric care.⁵

In addition to these overall best practices, the use of compression therapy can be highly effective in preventing lower extremity wound recurrence. Without additional intervention, the rates of wound recurrence in patients who adhere to compression therapy are 28% at one year and 56% at four years. These rates are substantially lower than those in patients who forgo compression therapy. When combined with additional therapies, such as venous surgery, compression therapy can contribute to recurrence rates as low as 12% at one year and 31% at four years.⁴

Adherence to wearing prescribed and appropriate footwear at all times can also aid in preventing recurrences of these types of wounds. Ill-fitting footwear can cause mechanical stress and contribute to the recurrence of ulcers. Proper footwear is especially important for patients who have a newly healed ulcer or experience neuropathy because the skin can be abnormally weak, and patients may not feel the warning symptoms, including pain.² In addition to the role of compression therapy and prescribed footwear, the most significant component of preventing lower extremity wound recurrence is patient education on related foot problems and conditions and on proper foot care techniques.²

Adherence to compression treatment plans and therapeutic footwear can be challenging, and this is another reason that patient education is vital in the quest for better outcomes. Focused intervention and intensive patient education efforts for populations that have been identified as potentially non-adherent may improve patient behaviors that contribute to lower recurrence rates. Patients who follow recommendations have significantly better outcomes than patients who do not follow their recommended treatment plan, and overall treatment effects can be dampened by 50% to 98% by non-adherence to the care plan.

Conclusion

Lower extremity wounds, such as DFUs, venous ulcers, and arterial ulcers are highly susceptible to recurrence. Recurrence of these wounds comes at a high price to the patient and to the health care system. Adherence to prescribed treatment plans that focus on patient education and the implementation of therapies that reduce recurrence rates—such as compression therapy and the use of proper footwear—can greatly reduce rates of recurrence of these painful and costly wounds.

References

1. Ndosi M, Wright-Hughes A, Brown S, et al. Prognosis of the infected diabetic foot ulcer: a 12-month prospective observational study. Diabet Med. 2107;35:78-88.

2. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376(24):2367-2375.

3. Parker CN, Finlayson KJ, Edwards HE. Predicting the likelihood of delayed venous ulcer healing and recurrence: development and reliability testing of risk assessment tools. Ostomy Wound Manage. 2017;63(10):16-33.

4. Langer V. Preventing leg ulcer recurrence. Indian Dermatol Online J. 2014;5(4):534-535.

5. Rankin TM, Miller JD, Gruessner AC, Nickerson DS. Illustration of cost saving implications of lower extremity nerve decompression to prevent recurrence of diabetic foot ulceration. J Diabetes Sci Technol. 2015;9(4):873-880.