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Development of a multivariable prediction model for plantar foot ulcer recurrence in high-risk people with diabetes
  1. Wouter B aan de Stegge1,
  2. Ameen Abu-Hanna2,
  3. Sicco A Bus1
  1. 1Department of Rehabilitation Medicine, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
  2. 2Department of Medical Informatics, Universitiy of Amsterdam, Amsterdam UMC⁠, Amsterdam, The Netherlands
  1. Correspondence to Dr Sicco A Bus; s.a.bus{at}


Introduction Forty per cent of people with diabetes who heal from a foot ulcer recur within 1 year. The aim was to develop a prediction model for plantar foot ulcer recurrence and to validate its predictive performance.

Research design and methods Data were retrieved from a prospective analysis of 171 high-risk patients with 18 months follow-up. Demographic, disease-related, biomechanical and behavioral factors were included as potential predictors. Two logistic regression models were created. Model 1 for all recurrent plantar foot ulcers (71 cases) and model 2 for those ulcers indicated to be the result of unrecognized repetitive stress (41 cases). Ten-fold cross-validation, each including five multiple imputation sets, was used to internally validate the prediction strategy; model performance was assessed in terms of discrimination and calibration.

Results The presence of a minor lesion, living alone, increased barefoot peak plantar pressure, longer duration of having a previous foot ulcer and less variation in daily stride count were predictors of the first model. The area under the receiver operating curve was 0.68 (IQR 0.61–0.80) and the Brier score was 0.24 (IQR 0.20–0.28). The predictors of the second model were presence of a minor lesion, longer duration of having a previous foot ulcer and location of the previous foot ulcer. The area under the receiver operating curve was 0.76 (IQR 0.66–0.87) and the Brier score was 0.17 (IQR 0.15–0.18).

Conclusions These validated prediction models help identify those patients that are at increased risk of plantar foot ulcer recurrence and for that reason should be monitored more carefully and treated more intensively.

  • foot plantar ulcers
  • prediction
  • biomechanics

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  • Contributors WBadS, AA-H, SAB conceived and designed the analysis for this study, using existing data. AA-H performed the statistical analysis. WBadS wrote the manuscript. AA-H and SAB critically reviewed and edited the manuscript. All authors have read and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The research ethics committee of all 10 participating centers in the trial approved this study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request.

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