The Diabetic foot: state of

the artBY

MAHMOUD ZAGHLOUL RASLAN, MD

CONSULTANT SURGEON, MGH

MADINA

Defining the magnitude of the problem

- The incidence of diabetes mellitus DM is increasing globally.

- Patients with DM have a 12-25% lifetime risk of developing a foot ulcer.

- Foot ulcers have become a major and increasing public health problem.

- The related morbidities, impairment of life quality of patients together with the implied costs for their management have attracted the attention of health care providers.

 

- Fortunately, most of foot problems in patients with DM can be prevented with careful foot care.

- If complications do occur, daily attention will ensure that they are detected before they become serious.

- It may take time and effort to build good foot care habits, but self-care is essential.

- In fact, when it comes to foot care, the patient is a vital member of the medical team.

- According to the Centers for Disease Control and Prevention, 7.8% of the United States population had DM in 2007, which equals almost 24 million persons.

- In 2007, DM and its complications cost the US $174 billion; $116 billion in direct costs and $58.3 billion in indirect costs such as disability and loss of productivity.

- Peripheral vascular and neurologic complications that are closely linked to foot ulceration, account for 31% and 24% of the expenses respectively.

- Every year, 82,000 limb amputations are performed in patients with DM in US.

- The majority of these amputations are performed in the elderly.

- Amputations resulting from DM may be due to multiple etiologies including foot ulcers, ischemia and heel ulcers.

- Although amputation may become necessary in certain cases of ischemia or infection, ablative surgery is rarely necessary for treatment of neuropathic ulceration and is to be avoided.

- Decreased limb length correlates with increased energy expenditure for ambulation.

- Amputation in a diabetic patient is associated with a 50-66% incidence of contralateral amputation within 5 years.

Possible diabetic foot complications:

•Skin changes (Dermopathy)

•Poor circulation (Angiopathy) •Nerve damage (P.neuropathy)

•Deformities (Chacot’s arthropathy)

•Infection

•Gangrene

 

PREVENTING FOOT PROBLEMS IN DIABETICS

 - Controlling blood sugar levels

- Quit smoking 

- Avoid activities that can injure the feet 

- Use care when trimming the nails 

- Wash and check the feet daily

- Choose socks and shoes carefully

- Ask for foot exams

Pathogenesis

Clinical picture

History

Examination

Investigations

Classification

Management

GRADE 0 LESIONS — Counseling regarding preventive foot care should be given to any patient whose feet are at risk for ulcer development, particularly patients with existing neuropathy.

GRADE 1 AND 2 LESIONS — Extensive debridement, good local wound care, relief of pressure on the ulcer, and control of infection (when present) are believed to be important components of therapy for grade 1 and 2 foot ulcers.

- Method of debridementMay be mechanical, chemical and/or biological.

- Local wound care: After debridement, ulcers should be kept clean and moist but free of excess fluids. Moisture accelerates tissue healing.

Dressings should be selected based upon wound characteristics, such as the extent of exudate, desiccation, or necrotic tissue.

Modern dressing

Off-loading

- Mechanical off-loading

-Total contact castEffective for relief of pressure to allow diabetic ulcer healing.

- Cast walkers Cast walkers appear to have a similar

ability to off-load the foot compared with total contact casting.

- Therapeutic shoes

After healing of the ulcer is achieved, extra-depth and -width shoes with orthotic inserts are often prescribed to prevent recurrent ulceration.

- Wedge shoes Also called half shoes, are available as a forefoot wedge and heel wedge shoes to off-load the forefoot and heel, respectively

- Knee walkers Knee walkers are ambulatory assist devices that may be indicated for anyone with a lower extremity issue where weight bearing needs to be avoided .

GRADE 3 LESIONS

Assessment for peripheral artery disease

- Clinically, by asking about H/O symptoms suggesting LL ischemia and looking for its physical signs and by ABI measurement.

-Doppler US as a non-invasive test to assess LL vascularity.

-MRI angiography or arteriography if indicated in Doppler +ve

Assessment for osteomyelitis

- Clinically, osteomyelitis is likely to be present if bone can be seen at the floor of a deep ulcer, or if it can be easily detected by probing the ulcer with a sterile, blunt stainless steel probe.

- Radiologic tests Radiologic tests may be useful if the diagnosis of osteomyelitis remains uncertain including bone scan.

- Bone biopsy C/S If clinical and radiographic assessments fail to provide a diagnosis, then bone biopsy can be considered.

- Treatment

Debridement and local wound careAs described before

Antimicrobial therapy Parenteral antibiotic therapy based upon the culture results has traditionally been given for four to six weeks in patients with osteomyelitis. The optimal regimen and when to transition to oral therapy are dependent upon the clinical features of each case.

Mechanical off-loading — Mechanical off-loading relieves pressure on the ulcer and enhances healing.

Revascularization — Revascularization plays an important role in the management of diabetic foot ulcers in patients with documented peripheral artery disease (to avoid the need for amputation)

GRADE 4 AND 5 LESIONS

— Patients with these more advanced lesions require urgent hospital admission and surgical management. The following advanced therapies may be used in addition to the previous management lines. However, amputation may sometimes be required.

ADVANCED THERAPIES:—

Negative pressure wound therapy Negative pressure wound therapy (NPWT), also called vacuum-assisted closure (VAC), involves the application of controlled subatmospheric pressure to the surface of the wound. NPWT enhances wound healing by increasing wound perfusion, reducing edema, reducing the local bacterial burden and increasing the formation of granulation tissue.

Vacuum assisted closure (VAC)

Hyperbaric oxygen therapy (HBOT)

— Hyperbaric oxygen therapy, as a component of diabetic ulcer management, may be associated with improved healing but the indications for hyperbaric oxygen in the treatment of nonhealing diabetic foot ulcers remain uncertain.

Ultrasonic wound therapy

Other agents — Use of honey, larva (muggets) and herbs have been reported with promising results.

Skin substitutes — Human skin equivalents have been studied in diabetic patients with noninfected, nonischemic chronic plantar ulcers .

Growth factors — A platelet-derived growth factor gel preparation (becaplermin) is approved by the US Food and Drug Administration as an adjuvant therapy for diabetic foot ulcers . It promotes cellular proliferation and angiogenesis and thereby improves wound healing.

Multimodal treatment

Charcot’s foot

Amputation

Health education

Summary and recommendations

- Diabetic foot complications are common and serious.

- They represent a major impact on patients’ health. In addition, they can affect adversely both patients and the society economically and socially.

- Fortunately, most of these complications can be prevented by controlling the blood sugar level and daily foot care.

- Health education programs for the patients, relatives and the whole society are mandatory to improve the prognosis. In these programs all authorities should share including heath care centers, cultural centers, mosques and media.

Summary and recommendations (cont.)

- Screening of high risk groups is essential to detect the complications early.

- Management of diabetic foot complications needs a specialized center with general, vascular, plastic, orthopedic surgery facilities together with podiatrist, dietirian and internists and endocrinologists to achieve a favorable outcome.

- The earlier the diagnosis and management the better the prognosis

- Encourage the medical research activities that may lead to development of new diagnostic and management tools for better prognosis

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