We’ve been saying for years that a healed diabetic foot ulcer isn’t “cured.” It’s in remission. And just like in oncology, the period right after you declare remission is when the risk of relapse is highest.
Our new systematic review and meta-analysis with George Theodorakopoulos, just published in Diabetology, puts a tighter number on that risk than we’ve had before. Across three strictly defined remission cohorts totaling 469 patients, roughly one in three people developed a recurrent ulcer within 12 months. The pooled estimate was 29.3% (95% CI 24.9–34.1%), with low heterogeneity.
That’s somewhat lower than the approximately 40% one-year recurrence figure Andrew Boulton, Sicco Bus, and I reported in our 2017 NEJM review. But the difference isn’t really reassuring — it mostly reflects how tightly this analysis defined remission at baseline and insisted on an exact 12-month endpoint rather than mixing follow-up windows. When you look at broader populations — tertiary referral centers, wound care clinics in Japan, community cohorts — one-year recurrence can range from 31% to over 54%, depending on who you’re counting and how you define a recurrence.
The point isn’t the precise number. The point is that it’s high. One in three. In the first year.
Think about what that means practically. A patient walks out of your clinic with a closed wound. They feel great. Their primary care provider may check a box and move on. But that patient has roughly the same short-term relapse risk as several common cancers. Natalie, Alexandria, and I showed this explicitly in our recent International Wound Journal paper — three-year DFU recurrence and CLTI reintervention rates are comparable to breast, colorectal, prostate, and lung cancer outcomes. Yet nobody would send a cancer patient home after remission without a structured surveillance plan.
This review also reinforces something we see in clinic every day: biomechanics matter even when patients do everything right. Keukenkamp and colleagues showed that patients with Charcot midfoot deformity who were 94% adherent to custom footwear still had a 40% recurrence rate over 18 months. That tells you offloading alone isn’t enough for every patient. Some feet need more — surgical correction, better orthotic strategies, technology-assisted monitoring.
On the monitoring front, the evidence is building in interesting directions. The DIATIME trial from López-Moral and Lázaro-Martínez’s group in Madrid demonstrated that 4-week screening intervals beat 8- and 12-week intervals for preventing recurrence. The DIATEMP trial showed that home temperature monitoring reduced recurrence at any foot site, particularly in patients who actually modified their activity when they detected a hotspot. And Abbott’s intelligent insole trial showed that real-time pressure feedback reduced high-pressure events during daily life, with effects emerging after about 16 weeks as patients essentially learned which activities to avoid.
What ties all of this together is the survivorship model. Remission from a DFU should be managed the way we manage remission from cancer: structured surveillance, mechanical optimization, behavioral support, and — where feasible — objective monitoring tools. The first 90–180 days after closure are probably the most volatile period, though we need better data to confirm that.
This review has limitations the authors are upfront about. Only three cohorts met the strict inclusion criteria for pooling. The protocol wasn’t registered. Definitions of recurrence varied between studies. These are honest acknowledgments, and they underscore how badly we need larger, preregistered, multicenter remission cohorts with standardized definitions. We’re working on exactly this with the REBOOT trial.
But even with those caveats, the message is clear: healing is the beginning of the next chapter, not the end of the story. If we want to break the cycle of ulceration, healing, re-ulceration, and eventual amputation, we need to treat remission with the same intensity and intentionality we bring to the acute wound.
One in three. In one year. We can do better.
Theodorakopoulos G, Armstrong DG. The First Year of Remission: A Systematic Review and Meta-Analysis of 12-Month Diabetic Foot Ulcer Recurrence. Diabetology. 2026;7(3):61. doi:10.3390/diabetology7030061
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