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DIABETIC FOOT ULCERS: CURRENT TRENDS IN MANAGEMENT

*E. Igbinovia*Department of Orthopaedics and Trauma, University of Benin Teaching Hospital,Benin City,

Correspondence:Dr Igbinovia E.Department of Orthopaedics and TraumaUniversity of Benin Teaching HospitalP.M.B 1111 Benin CityEdo State, NigeriaEmail: [email protected]

ABSTRACTThe Diabetic foot is the commonestcomplication of Diabetes and is aleading cause of hospitalization and

prolonged in patient treatment.Diabetic foot ulcer is far and away themost frequent indication for nontraumatic lower limb amputations.Appropriate preventive measures aswell as patient education will markedlyreduce ulcer formation and thefrequency of amputations in addition tocutting down on healthcare costs.Key words: Amputation, Multi-disciplinary team, Patient education,Prevention

INTRODUCTIONDiabetes mellitus is a chronicendocrine illness that manifests withelevated blood sugar levels resultingfrom an absolute or relative lack ofinsulin fraught with complications suchretinopathy, nephropathy,macroangiopathy and the diabetic footulcers.As at 2000, about 177 million persons

were afflicted by diabetes which theWHO has predicted will rise to 300million by 2025.1 Fifteen percent ofdiabetics develop foot ulcers duringtheir life time2 with significant healthrelated decrease in quality of life andconsumption of a great deal ofhealthcare resources,3,4 while diabetic

foot ulcers account for between 50% to80% of non traumatic amputations.2,4Presently substantial progress is beingachieved in the treatment of diabetic

foot ulcers in centres that base theirmanagement on the twin pillars ofpreventive measures / patienteducation and a multi-disciplinary teamapproach from the onset.

PATHOPHYSIOLOGYThe aetiological factors that contributeto the formation of ulcers includePeripheral Neuropathy; which ispresent in about four fifths of thepatients.5 It may manifest as a sensoryimpairment (glove and stockingdistribution), motor or autonomicneuropathy. Several mechanisms areinvolved in development of neuropathyviz, accumulation of harmfulmetabolites intracellularly, membraneconduction defects and nervecompression arising from swellingassociated with water accumulation inthe nerve. The patient is unaware ofsmall injuries from repeated trauma

and does not take protective actionbecause the normal pain and traumarecognition response is lost.3 Thedeformities which may followneuropathy include charcot(neuropathic) foot, claw and hammertoes, hallux valgus / rigidus, pesplanus, prominent metatarsal heads

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and pressure at these points deformedbony prominences might lead to skinbreakdown and ulceration.Vascular disease; this could be bothmacro and microangiopathy.Atherosclerotic changes may result in

ischaemia and impaired woundhealing.6

Infection; in addition to the foregoing isimpaired response to infectionoccasioned by deficiency in phagocyticactivity of leucocytes, diminishedbacterial killing and a defect in normalchemotactic mechanisms5. (Fig. I)

Infection leads to microthrombiformation, causing further ischaemia,necrosis, and progressive gangrene.4

Fig. I: PATHOPHYSIOLOGIC PATHWAYS IN THE DEVELOPMENT OFCOMPLICATIONS OF THE DIABETIC FOOT.5

CLINICAL FEATURESDiabetic foot ulcers may bepredominantly neuropathic orischaemic; rarely does one form existto the total exclusion of the other

however neuropathic ulcers arecommoner. Neuropathic ulcers mightbe painless (though this is not alwaysthe case), with callus formation thatprogress to ulcer formation at the tip ofthe toes, plantar aspect of themetatarsal head; infections maysupervene (usually polymicrobial gram +ve, gram-ve and anaerobes)

4

leading to cellulitis, abscesses,osteomyelitis and even sepsis. Sepsiscan lead to thrombosis withconsequent gangrene. Pulses arepresent and the limb is warm.

Ischaemic foot ulcers on the otherhand are characterized by absentpulses, cold extremities and trophicchanges.ULCER GRADINGGrading is important in order to plantreatment and prognosticate. Mostgrading systems are based on thepresence or absence of skin lesions,

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depth of the lesion, presence of deepinfections and presence or absence ofgangrene. 7, 8, 9 the system developedby Prof Wagner of the University ofSouthern California enjoys popularfollowership. He classified the ulcers

into six grades from 0 (foot at risk) to 5(entire foot gangrene)8,9. (Fig. II)

Others include Brodsky,2 TexasUniversity9 and the Diabetic footseverity score designed by Umebeseand Ogbemudia10 of the University ofBenin to predict whether a limb shouldbe salvaged or not. (Fig. III), here the

patient can score between 6 and 21,with

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Fig III: DIABETIC FOOT SEVERITY SCORE (DFSS) INDEX by Umebese andOgbemudia10

Parameters Description Score

Colour of FootLesion

NormalDark DiscolourationBlack

321

Peripheral Pulses Dorsalis Pedis & Posterior Tibial Pulses PalpablePosterior Tibial onlyDorsalis Pedis onlyNone

4321

Sensation Light Touch, Pin prickHypoaesthesiaInsensate

321

Ulcer Grading Ulcer/ gangrene of 1 or 2 toesFull thickness ulcer of dorsal skin onlyUlcer>2 toes+ ball of footOpen putrid ulcer> 50% of the sole of the footWhole foot gangrene + supramalleolar necrotizingcellulites

54321

Foot X-Ray NormalChronic Osteomyelitis or calcified peripheral vesselsBoth

321

Age 40 yrs41-60 yrs>60 yrs

321

TOTAL

Semmes-Weinstein 5.07 (10 g) monofilament testing: assesses the touchsensation of the patient, it ideally should be done during clinical evaluation (Fig. IV)

Fig. IV: Semmes-Weinstein 5.07 (10 g) monofilament; the monofilament is applied tothe high-risk areas on the plantar surface of the foot (i.e., toe pulps, metatarsalheads, heel). Patients who cannot feel pressure from the monofilament have lostprotective sensation and are at risk of developing a diabetic foot ulcer.Imaging techniques: soft-tissuepathology, such as abscesses andsinus tracts, can be better definedthrough ultrasonography, computedtomography (CT) scanning, and

magnetic resonance imaging (MRI);while plain radiography is usefulfor detection of bone pathology andthe confirmation of the development ofosteomyelitis. However in the hands of

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an experienced radiologist MRI issuperior to plain radiography in thediagnosis of bone infections2

Vascular examination: Dopplersonographyestablishes the patency of

the vascular tree and the nature andlocation of block if any while the anklebrachial index (ABI, the ratio of systolicblood pressure in the ankle to that inthe brachial artery which is also theischaemic index) predicts the ability ofthe wound to heal if amputation isbeing considered. An ischaemic indexof 0.6, an absolute ankle pressure of70 mm Hg or more, and an absolutetoe pressure of 40 mm Hg or more arestrong indicators that a limited foot

amputation should heal, providedcalcification of arteries is thought not tocause falsely high values.7

Furthermore, a transcutaneous O2tension of 30 mmHg is also regardedas a strong indicator that anamputation stump should heal4.

TREATMENTCurrently treatment is strongly biasedin favour of preventive measures aswell as patient education and amultidisciplinary team approach.Centres that practice these haverecorded significant drop in morbiditiesgenerally and amputationspecifically3,6, 8.

Prevention and patient education:organizing a diabetic foot clinic wherepatients are seen regularly and theirfeet examined to pick up any sensoryimpairment or pre-ulcerative lesions(calluses blisters etc) is an important

step. They are also educated here ondos and donts which should includeabstaining from smoking (not justgiven a list). (Tab. I). Rigorousattempts are to keep the patienteuglycaemic since this has beenshown to reduce the incidence ofdiabetic complications including footlesions4, 5, 6

Multi-disciplinary team approach: asmuch as possible this should beadopted and potential members of theteam should include6, 11

Orthopaedic surgeon

Endocrinologist

Podiatrist Infectious disease specialist

Diabetic nurse

Vascular surgeon

Interventional radiologist

Pedorthotist

Physical therapist

Occupational therapist

Members of the patients familySpecific treatment depends on thestage of disease which also

determines at what point differentmembers of the team are consulted.

In the at risk foot with the skinintact, measures are taken toeliminate such risk or minimize them;ranging from comfortable well paddedshoes with in-soles and wide toe boxto surgeries for correcting deformitiesAntibiotics should be used whenclinically indicated and should bebroad spectrum; giving coverage

against gram +ve and ve as well asanaerobes until sensitivity result isknown.Wound debridement involvesremoving infected and devitalizedtissues in order to allow for granulationtissue to form. There after a walkingcast or total contact cast is appliedwhich helps to redistribute the weightin order to minimize weight bearing astrong factor in ulcer perpetuation.12Depending on the grade (II or III), the

debridement can be quite extensiveafter which the wound may be closedover a drain or left open to granulateand closure may be achieved by skingrafts or by raising flaps.8

Wound dressings with materials thatare not toxic to the soft tissues whilestill carrying out their functions is what

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is in vogue now. Honey, medical grademaggots, cytokine (e.g. granulocytestimulating growth factors)impregnated dressing pads,crystalloids all help to render a woundclean with healthy granulation13

Amputation unfortunately, even in thebest of centres and with the mosthighly motivated of patients,gangrenous limbs (IV and V) are stillencountered.The approach here thenis to ablate at the most distal levelwhere wound healing will be achieved.Clinical experience as well asangiography and Doppler will dictatethe need for revascularizationprocedures since they will help making

the site of election as caudad aspossible and also increase thechances of good healing. Establishingthe ischaemic index as well as thepercutaneous O2 levels will further helpto assure healing at the site of electionor decide in favour of a different levelaltogether2,4,7,8. Life-threatening,rapidly progressive infection such asgas gangrene or necrotizing fasciitis;chronic ulceration or infection thatpersists despite other treatment;gangrene; or severe, uncontrollabledeformity or instability that precludes

fitting in footwear or brace are some ofthe indications for amputation

Prosthetic fitting and rehabilitationshould be incorporated into thedecision and planning for the

amputation as this will prepare thepatient psychologically and as wellshorten his time in rehabilitation.Amputation is the first step in therehabilitation process; a good stump isimportant in ensuring a properprosthetic fitting and the patient willneed to be taught to ambulate with thenew limb, in addition he may evenrequire cutting down on his activitylevel as more energy is needed forambulation following an amputation1.

CONCLUSIONThere is obviously meaningful room forupgrading the quality of care thatpatients with diabetes receive,particularly with respect to theprevention and treatment of footcomplications. This will only come froma multidisciplinary approach thatembraces patient education andmotivation, preventive measures,vigilance for risk factors, and utilizationof the most effective therapeuticoptions.

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Table I: HOW PATIENTS WITH DIABETES CAN CARE FOR THEIR FEET

How Patients with Diabetes Can Care for Their Feet

1. Wash the feet every day Feet should be washed gently but thoroughly every day. After washing, pat dry with a clean soft towel. Do not put lotions between the toes. Discuss any foot powders with a healthcare professional prior to use.

2. Check the feet every day The top, bottom, sides, and areas between the toes should be

checked every day. A mirror can be used to look at the bottom of the feet if necessary. Red spots, wounds, bruises, rashes, or injuries are all cause for

concern, and if any are identified the healthcare professional shouldbe informed immediately.

Only allow a healthcare professional to remove calluses or corns.3. Obtain regular foot exams

The ADA recommends that all diabetic patients have at least one

professional foot exam each year. Patients with neuropathy or any deformities of the foot (egg,

bunions, and hammer toes) should have more frequent exams. Early identification of conditions that could pose a risk of developing

foot ulcers can help prevent serious consequences. Monofilament test will assess nerve function and protective

sensation. A thorough evaluation of foot structure, mechanics, and circulation,

as well as skin health and integrity, is essential. Patients can remind their healthcare professional to examine their

feet by removing their shoes upon entering the exam room.4. Control blood sugars

The DCCT clearly demonstrated that good blood sugar control canreduce the risk of diabetic neuropathy by 40% to 60%.

Prevention of neuropathy will help avoid the progression of manyother foot problems in diabetic patients.

5. Ensure proper shoe fit Shoes should be comfortable from the moment they are purchased,

and not require breaking in. Ensure that they do not rub or constrict any part of the foot. Buy shoes at the end of the day when the feet are slightly swollen,

and try them with socks that are the same as those with which theshoes are likely to be worn.

Own two pairs of shoes that can be alternated, allowing each pair to

dry out naturally between uses.6. Consider prescription footwear

Foot deformities, a history of foot ulcers, prior amputation, severevascular disease in the feet, nerve damage with calluses, andinsensate feet are all indications for prescription footwear.

Medicare and many insurance providers will reimburse forprescription footwear.

7. Check inside shoes before wearing

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It is wise to check inside shoes before wearing them to ensure thatthere is nothing inside that could cause abrasion of the foot, such asforeign objects or pieces of leather or fabric.

Discard shoes when they show signs of wear and tear.8. Wear clean socks

Socks should be changed every day and not wrinkle when worn. Seamless socks and socks with flat, unobtrusive, soft seams should

be selected, not socks with bulky seams.9. Plan for the weather

A healthcare professional should be consulted before exposing thefeet to extreme temperatures.

Toe warmers, electric blankets, and heating or cooling gels all posea risk to the feet, and should not be used without prior consultationwith a healthcare professional.

10. Never walk barefoot Diabetic individuals should keep their feet protected at all times. Even at the beach or swimming pool, sandals or swimming shoes

are essential to avoid damage that could have seriousconsequences.

Adapted from http://www.diabetes.org/.

REFERENCES1. The Projection of prevalence

and cost in Diabetes inCanada 2000 to 2016.Canadian Journal ofDiabetes 2004

2. Pinzur MS. Diabetic Foot.

Available athttp://www.emedicine.com/orthoped/topic 387.htmAccessed 21/07/08.

3. Wieman TJ. Principles ofManagement: The Diabeticfoot. American Journal ofSurgery 2005; 190:295- 299.

4. Levin ME. An Overview ofthe Diabetic Foot:

Pathogenesis, Managementand Prevention of Lesions.Int J Diabetes. DevCountries 1994; 14.

5. Cutaneous DiabeticComplications in the LowerExtremities. At

http://www.powerpak.com/courses/2857. Accessed20/07/ 08.

6. Solomon L, Warwick D,Nayagam S. The Ankle andFoot. In Apleys System ofOrthopaedics and Fractures

8th ed. 2001, Hodder Arnold.

7. Richardson EG DiabeticFoot. In Canale ST, editor.Campbells OperativeOrthopaedics 10th ed. 2003,Mosby Inc.

8. Wagner FM Infections of thefoot in Diabetes. InChapman WM, editor.Operative Orthopaedics 2nd

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9. Oyibo SO, Jude EB,Tarawneh I, Nguyen HC etal A Comparison of TwoDiabetic Foot UlcerClassification Systems: The

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Wagner and the Universityof Texas woundclassification systems.Diabetes Care 2001; 24.

10. Umebese PFA, Ogbemudia

AO. Management of diabeticfoot: Objective results in 40patients using a newdiabetic foot severity score.Nig. J. Surg. 1998; 5:10-12.

11. Mann JA, Chou LB, RossDKR Foot and AnkleSurgery. In Skinner HB,editor. Current Diagnosisand Treatment inOrthopaedics 4th ed. 2006,

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12. Calhoun JH, Mader JTDiabetic Foot Care. InChapman MW, editor.Chapmans OperativeOrthopaedics 3rd ed. 2001,

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13. Jones JL Diabetes Watch:Treatment Options forDiabetic Foot Infections.Podiatry Today 2003; 16.

14. Greene WB Rehabilitation.In Greene WB, editor.Netters Orthopaedics 2006,Saunders Elsevier

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