365 Day

365 The etiology of pedal ulceration among patients with diabetes mellitus is usually multifactorial. While the initiating element may be singular, there are usually coexisting factors that help to lower the threshold for pedal ulceration. Thus, the precipitating event produces tissue breakdown and ultimately ulceration. There have been numerous studies of the risk factors for amputation in the diabetic patient, factors that parallel those for ulceration. While several studies have shown the associated contribution of local physiologic and structural factors that lead to pedal ulceration, other systemic physiologic and relative socioeconomic elements have been shown to contribute to the risk of ulceration (Table 1). In 1992, Reiber et al1 proposed the causal pathway to amputation model consisting of component causes that, in and of themselves, do not typically produce ulceration and the sufficient cause, which is the accumulation of component causes that lead to amputation. That model showed that component factors such as neuropathy, vasculopathy, and impaired wound healing provided the underlying environment that facilitated progression to amputation in the lower extremity following some traumatic event. It is important to understand this model when considering the risk factors for ulceration in that these factors rarely occur alone.