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The Controversial Use of Apligraf in the Treatment of Diabetic Foot Ulcers

Foot complications are major causes of hospital admissions for diabetes, and they often demand surgical procedures and prolonged length of stay. Indeed, diabetic foot complications are major global public health problems in that these foot lesions and amputations represent the most important of all long-term problems associated with the disease of diabetes and have medical, social, and economic implications. Three great pathologies come together in the diabetic foot: neuropathy, ischemia, and infection. Their combined impact is so great that it causes more amputations than any other lower limb disease. As diabetic foot problems quickly reach the point of no return, it is vital to diagnose them early and provide rapid and intensive treatment. Furthermore, it is important to achieve early recognition of the at-risk foot so as to institute prompt preventive measures. The late sequelae of diabetic peripheral neuropathy are recognized to be foot ulceration and Charcot’s neuroarthropathy. It has been the fact that the risk of developing foot ulceration as a result of end-stage complications of neuropathy and vascular disease in diabetes is much greater than the other end-stage sequelae of diabetes, namely, retinopathy and nephropathy. The prevalence of foot ulceration in the general diabetic population is 4–10%, being lower in young and the highest in older patients. The lifetime risk for foot ulcers in diabetic patients is about 15%. Rothman’s model of causation defines a combination of neuropathy, trauma, and foot deformity to be the commonest pathways to foot ulceration and faulty healing may eventually lead to amputation. Foot ulceration and amputation affect the quality of life for patients and create an economic burden for both the patient and the health care system. Therefore, efforts to identify the patient who is at risk for foot ulceration, prevention, and appropriate treatment must, of necessity, become a major priority for healthcare providers. Peripheral neuropathy and vascular disease alone do not cause foot ulceration.