OBJECTIVEThere is a dearth of long-term data regarding patient and limb survival in patients with diabetic foot ulcers (DFUs). The purpose of our study was therefore to prospectively investigate the limb and person survival of DFU patients during a follow-up period of more than 10 years.RESEARCH DESIGN AND METHODSTwo hundred forty-seven patients with DFUs and without previous major amputation consecutively presenting to a single diabetes center between June 1998 and December 1999 were included in this study and followed up until May 2011. Mean patient age was 68.8 ± 10.9 years, 58.7% were male, and 55.5% had peripheral arterial disease (PAD). Times to first major amputation and to death were analyzed with Kaplan-Meier curves and Cox multiple regression.RESULTSA first major amputation occurred in 38 patients (15.4%) during follow-up. All but one of these patients had evidence of PAD at inclusion in the study, and 51.4% had severe PAD [ankle-brachial pressure index ≤0.4]). Age (hazard ratio [HR] per year, 1.05 [95% CI, 1.01–1.10]), being on dialysis (3.51 [1.02–12.07]), and PAD (35.34 [4.81–259.79]) were significant predictors for first major amputation. Cumulative mortalities at years 1, 3, 5, and 10 were 15.4, 33.1, 45.8, and 70.4%, respectively. Significant predictors for death were age (HR per year, 1.08 [95% CI, 1.06–1.10]), male sex ([1.18–2.32]), chronic renal insufficiency (1.83 [1.25–2.66]), dialysis (6.43 [3.14–13.16]), and PAD (1.44 [1.05–1.98]).CONCLUSIONSAlthough long-term limb salvage in this modern series of diabetic foot patients is favorable, long-term survival remains poor, especially among patients with PAD or renal insufficiency.

Response to Hambleton et al.A larmingly high mortality rates have been reported in diabetic patients with ulcerations-especially if complicated by amputation. In a recent issue of Diabetes Care, Hambleton et al.(1) raise the possibility of a "different hierarchy" of postamputation complications and causes of death in patients with diabetes from developed and developing areas of the world, comparing their data with published work from the U.S. (2).To examine this further we have analyzed data from a cohort of German and Tanzanian patients in an ongoing multinational follow-up study of diabetic foot ulcer patients (3) and compared them with the patients of Hambleton et al. Diabetic foot patients from Germany and Tanzania were included in a prospective study conducted between 1998 and 1999. Initial results of this study showed significant differences in age at the onset of first foot ulcer and in prevalence of coronary heart disease, stroke, and peripheral arterial disease (3). Our conclusion from the short-term results was that favorable outcomes in populations from industrialized nations seem to be closely linked to the presence and management of peripheral arterial disease, whereas uncontrolled infections appear to be the major problem in developing countries, as reflected by high amputation rates in the absence of evident vascular disease (4).Five-year follow-up data from this study were evaluated for available German and Tanzanian patients. The survival rates at 6, 12, and 60 months were 96, 87, and 42%, respectively, in the German cohort and 75, 75, and 50% in the Tanzanian cohort for patients suffering minor amputation. The rates following major amputation were 78, 61, and 11% (Germany) and 75, 62, and 12% (Tanzania). In the Barbadian cohort the corresponding numbers were 86, 81, and 59% for minor and 57, 49, and 21% for major amputees.The direct causes of death in the patients from Barbados were due to stroke (10%), cardiac disease (25%), and sepsis (27%). In the German cohort, 10% were related to stroke and 60% to cardiac disease but only 3% directly to sepsis. By contrast in the Tanzanian cohort sepsis was responsible for 52% of the deaths that occurred within 5 years, while cardiac events and stroke combined caused only 19%. Comparing the causes of deaths, Barbados seems to take an intermediate position between Germany and Tanzania. This placement of Barbados in the middle of a spectrum from developing to industrialized countries is a model that has previously been used in investigating hypertension and obesity in the International Collaborative Study on Hypertension in Blacks (5) and also correlates with the relative positions these countries occupy in the human development index (Germany: position 22, human development index 0.935; Barbados: 31, 0.892; Tanzania: 159, 0.467; http://hdr.undp. org/en).To conclude, a comparison of our data with those from the study of Hambleton et al. supports the speculation that a different hierarchy between industrialized and developing countries is not only obvious for...