Published online Aug 15, 2026. doi: 10.4239/wjd.121505
Revised: June 8, 2026
Accepted: July 2, 2026
Published online: August 15, 2026
Processing time: 131 Days and 14.9 Hours
Diabetic foot ulcer (DFU) is one of the severe complications of diabetes mellitus, with a lifetime prevalence ranging from 15% to 25% in diabetic patients. Most studies that have evaluated the association of wound closure with DFU healing are well designed and show high rates of initial healing, between 75% to 95%, nonetheless the recurrence in some reports can be as high as 40% to 65% within a year after successful wound closure. Recurrent foot ulcers are a high burden on patients due to a high rate of hospitalisation, higher amputation risk and lower quality of life and they result in much higher costs. Currently, risk prediction models incorporate clinical, metabolic and biological factors which are features linked to ulcer recurrence but aggregation of these parameters in a composite measure has not been performed.
To create a model for predicting DFU recurrence after wound healing based on nomogram-based risk stratification in individuals with type 2 diabetes.
This study was a single-center retrospective cohort analysis of patients with type 2 diabetes mellitus who achieved complete healing of their first DFU at Shanghai Municipal Hospital of Traditional Chinese from January 2019 to July 2023. A median of 24 months follow up was performed to assess ulcer recurrence in patients. In detail, comprehensive clinical parameters and laboratory biomarkers along with metabolic indices were assessed during their first ulcers healed. Independent predictors and a risk stratification nomogram were identified using a two-stage statistical approach combining Least Absolute Shrinkage and Selection Operator regression for variable selection and Cox proportional hazards modeling for risk estimation.
Over the follow-up period, DFU recurred in 128 (41.0%) patients. Multivariate analysis revealed independent predictors: Prior ulcer duration > 8 weeks [hazard ratio (HR) = 3.24, 95% confidence interval (CI): 2.15-4.88], peripheral arterial disease (HR = 2.87, 95%CI: 1.92-4.29), peripheral neuropathy severity score ≥ 7 (HR = 2.45, 95%CI: 1.63-3.68), median hemoglobin A1c ≥ 8.0% (HR = 2.18, 95%CI: 1.46-3.25), ankle-brachial-index < 0.9 (HR = 2.56, 95%CI: 1.71-3.83 ), serum albumin < 35 g/L (HR = 1.92; 95%CI: 1.28-2.88) and offloading compliance insufficiently sufficient (HR = 2.73, 95%CI: 1.82-4.09). The C-index of the developed nomogram was 0.826 (95%CI: 0.787-0.865), indicating good discrimination, and also showed satisfactory calibration. A simple risk stratification of patients on the basis of points accorded to each variable as follows: 0-100 = low, 101-180 = intermediate, and > 180 points = high-risk groups translated into 2-year recurrence rates of; low: 12.3%, intermediate: 38.7% and high: 71.2%. Heavy temporal validation (C-index 0.814; 95%CI: 0.764-0.864) on an independent cohort (n = 156) from the same institution confirmed strong model performance.
This study developed a risk stratification model for predicting recurrence of DFUs after initial wound healing in type 2 diabetes. This model combines easily obtainable clinical and metabolic characteristics of patients, outperforming established risk scores to serve as an easily accessible tool for derivation of sex-specific personalized individual risk profiles and targeted prevention efforts in the clinic.
Core Tip: This study introduces a new risk stratification model for recurrent diabetic foot ulcer based on clinical parameters, metabolic biomarkers and vascular assessments. The tool, based on a nomogram, achieves a high predictive accuracy (C-index 0.826) and successfully divides patients into three well-differentiated groups with statistically significant dissimilar recurrence values. This clinically relevant model allows for recognition of patients at high risk, and will guide targeted prevention efforts in this patient population and could lead to a substantial reduction in the burden of recurring diabetic foot ulcers.