diabetic foot emedicine
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DIABETIC FOOT emedicine
Introduction
Diabetic foot ulcers (DFUs) precede 85% of nontraumatic lower extremity amputations (LEAs).
Approximately 3-4% of individuals with diabetes currently have foot ulcers ordeep infections.
Semmes-Weinstein 5.07 (10 g) monofilament; the monofilament is applied to the high-risk areason the plantar surface of the foot (ie, toe pulps, metatarsal heads, heel). Patients who
cannot feel pressure from the monofilament have lost protective sensation and are at
risk of developing a diabetic foot ulcer.
Among persons with diabetes, 15% develop foot ulcers during their lifetime. Their risk of LEA
increases by a factor of 8 once an ulcer develops. At 2 years following transtibial amputation,
36% of these patients are known to have died.
Patient education
Patients should be provided the following information regarding daily foot care1
:
Wash feet every day with mild soap and warm water. Test the water temperature with
your hand first. Don't soak your feet. When drying them, pat each foot with a towel and
be careful between your toes.
Use quality lotion to keep the skin of your feet soft and moist, but don't put any lotion
between your toes.
Trim your toenails straight across. Avoid cutting the corners. Use a nail file or emery
board. If you find an ingrown toenail, see your doctor.
Don't use antiseptic solutions, drugstore medications, heating pads, or sharp instruments
on your feet. Don't put your feet on radiators or in front of the fireplace.
Always keep your feet warm. Wear loose socks to bed. Don't get your feet wet in snow or
rain. Wear warm socks and shoes in winter. Don't smoke or sit cross-legged. Both decrease blood supply to your feet.
Never walk barefoot or in sandals or thongs.
Choose and wear your shoes carefully. Buy new shoes late in the day when your feet are
larger. Buy shoes that are comfortable without a "breaking in" period. Check how your
shoe fits in width, length, back, bottom of heel, and sole. Avoid pointed-toe styles and
high heels. Try to get shoes made with leather upper material and deep toe boxes. Wear
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new shoes for only 2 hours or less at a time. Don't wear the same pair every day. Inspect
the inside of each shoe before putting it on. Don't lace your shoes too tightly or loosely.
Choose socks and stockings carefully. Wear clean, dry socks every day. Avoid socks with
holes or wrinkles. Thin cotton socks are more absorbent for summer wear. Square-toe
socks will not squeeze your toes. Avoid stockings with elastic tops.
Frequency
Among persons with diabetes, 15% develop diabetic foot ulcers (DFUs) during their lifetimes.
Currently, 3-4% of individuals with diabeteshave deep infections or DFUs.
Etiology
Peripheral neuropathy
Peripheral neuropathy affects sensory, motor, and autonomic pathways. Sensory neuropathy
deprives the patient of early warning signs of pain or pressure from footwear, from inadequate
soft-tissue padding, or from infection. This neuropathy appears in a stocking-glove distribution,with many patients complaining of burning or searing pain.2
Optimal control of blood glucose levels decreases the incidence of most diabetes-associated
organ system morbidity. The primary risk factor for the development of diabetic foot ulcers
(DFUs) is loss of protective sensation, best measured by insensitivity to the Semmes-Weinstein
5.07 (10 g) monofilament (see Image 1). Abnormal white blood cell (WBC) function and thepresence of peripheral vascular disease allow wounds to become contaminated and infected by
organisms that normally are nonpathogenic. This explains the identification of unusual bacteria
from the wounds of patients with diabetes.
Autonomic neuropathy produces chronic venous swelling. Motor peripheral neuropathy or
Charcot arthropathy can produce bony deformity, which, combined with the loss of protectivesensation, can result in skin ulceration from pressure or from shear forces. Associated factors are
a history of foot infection or ulceration and previous partial or whole-foot amputation.
Motor neuropathy leads to muscle weakness and intrinsic muscle atrophy in the hands and feet.
Patients with motor neuropathy can develop bunion, claw toe, and hammertoe deformities as a
result of muscle imbalance. They lose normal vascular tone and thermal regulation, often
developing severe venous swelling that can be managed only with compression hose. Severe
tissue swelling can lead to ulceration and infection. The patients develop dry, cracked skin as a
result of autonomic dysfunction, with the cracks allowing the entry of bacteria. Nail deformity or
pathologic proliferation may make the areas adjacent to the nails foci for skin breaks or for
infection.
Vascular disease
Ischemicperipheral vascular disease is the second risk factor for developing diabetic foot ulcer
and infection. This disorder used to be considered a small vessel disease, but current research
links the vascular pathology to the basement membrane of the arterial wall. The characteristics of
the disease are similar in persons who are diabetic and those who are not, except that its
distribution is somewhat more scattered and geographic in persons who are not diabetic, as
opposed to being progressive in a distal direction in persons who are diabetic.
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Immune deficiency
The third major risk factor is related to the immune deficiency seen in persons with diabetes.
Glycosylated immune proteins lose efficiency, and granulocytes do not perform adequately,
leaving these patients prone to infection with organisms that would not affect a healthy host.
Each of these potential abnormalities make the diabetic foot susceptible to abnormal mechanical
stresses that can lead to a break in the normal soft-tissue envelope. This can initiate a foot
infection that cannot be resolved easily.
Pathophysiology
Pressure over a bony prominence has often been cited as the cause for skin breakdown in patients
with diabetes. Skin breakdown occurs at far lesser loads when the pressure is applied by shear
forces. The accompanying loss of protective sensation prevents the patient from being warnedthat intolerable loads have been applied. This leads to blister formation and full-thickness skin
loss. The process is heightened in the presence of severe venous swelling, which further lowers
the injury threshold. Shoes become tight due to swelling, thus increasing the direct pressure and
shear forces applied to skin overlying the bony prominence. Thickened, hypertrophic nails
increase pressure on the soft tissues surrounding the nails. The common result is tissue failure and
ulcer formation.
Once the skin barrier is broken, wound healing can be impaired by abnormally functioning
WBCs. Moreover, patients often are malnourished. Many have a marginal vascular supply, withless ability to achieve resolution of infection and wound healing.
Presentation
Classification of diabetic foot ulcers
Most experts use some variant of the classification system developed by Wagner and most
currently modified by Brodsky.3,4
Table 1. Depth-Ischemia Classification of Diabetic Foot Lesions*3
Depth
ClassificationDefinition Treatment
0 At-risk foot, no ulceration Patient education, accommodative footwear,
regular clinical examination
1 Superficial ulceration, not
infected
Offloading with total contact cast (TCC),
walking brace, or special footwear
2 Deep ulceration exposing
tendons or joints
Surgical debridement, wound care, offloading,
culture-specific antibiotics
3 Extensive ulceration or
abscess
Debridement or partial amputation, offloading,
culture-specific antibiotics
Ischemia
Classification
A Not ischemic
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B Ischemia without gangrene Noninvasive vascular testing, vascular
consultation if symptomatic
C Partial (forefoot) gangrene Vascular consultation
D Complete foot gangrene Major extremity amputation, vascular
consultation
*Adapted from Brodsky JW: The diabetic foot. In: Coughlin MJ, Mann RA, eds. Surgery of the
Foot and Ankle. St Louis, Mo: Mosby; 1999: 911.
Indications
From a practical standpoint, vascular surgery consultation is warranted only when the patient is
symptomatic with ischemic pain or a nonhealing ulcer. Ischemic ulcers generally require
angioplasty or vascular bypass surgery to achieve wound healing. Neuropathic ulcers require
debridement of nonviable or infected tissue, combined with local wound care and offloading.
Grade 3 ulcers require debridement of infected or gangrenous tissue. Partial foot amputation,
more complex offloading or non weight bearing, and culture-specific parenteral antibiotictherapy are necessary. Grade 4 ulcers require partial or whole foot amputation.
Contraindications
The 1 or 2 elective issues in this topic are clearly indicated within the text. Most of the substance
of this chapter is nonsurgical. Failure to follow the guidelines discussed here leads to deep
infection and amputation.
Workup
Imaging Studies
Imaging can often be useful in determining the treatment of patients with diabetic foot lesions.
Soft-tissue pathology, such as abscesses and sinus tracts, can be better defined through
ultrasonography, computed tomography (CT) scanning, and magnetic resonance imaging (MRI).
The most common use of imaging is for the detection of bone pathology and the confirmation
of the development ofosteomyelitis. Plain radiographs may at times be useful in confirming bone
infection if it reveals changes beneath an ulcer, but it is most likely to be sufficient for diagnosis
when the infection is already well established and when the bones of the forefoot or hindfoot are
involved. Withosteomyelitis, radiographic changes will accurately reflect the destructive process
but will lag at least 2 weeks behind the progress of the infection.
Radionuclide scans have a limited role in diagnosis because inflammatory conditions may
enhance isotope uptake and diminish the specificity of the test. Leukocyte scans are more reliable
and can help to determine when an area of infection has subsided, but these tests still perform
poorly in the majority of evaluations. MRI has the highest diagnostic accuracy. When used by anexperienced radiologist, MRI can detect bone infection (characterized by an altered bone marrow
signal) with 90-100% sensitivity and specificity. Diagnosis can be complicated because changes
from acute Charcot arthropathy, fractures, and postoperative residues may be mistaken for
infection. Also, MRI findings can overestimate the extent of infection because of inflammatorychanges associated with surgery, fracture, neuroarthropathy, or septic arthritis.5
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Diagnostic Procedures
Qualitative and quantitative measures are used to assess the level of sensation. Qualitative
methods include light touch and pinprick sensation, 2-point discrimination, and proprioception.
These are often lowered in patients with sensory neuropathy, usually in a stocking-type pattern
below the knee. Quantitative methods offer more objective data. Most commonly, nylon
Semmes-Weinstein monofilaments of differing sizes are pressed into the skin perpendicularlyuntil they bend. The threshold of the patients sensation is the smallest filament that he/she can
feel. Protective sensation is assumed to be present if the patient can feel the 5.07 monofilament;
still, approximately 10% of patients with sensation at this level develop neuropathic joints orulcerations.
In addition, although a number of studies have utilized monofilaments for the assessment of
neuropathy, there are no substantive data that support any one standard method of application of
the monofilament.
Generally, testing is recommended at 8 to 10 anatomic sites, although a test of only 4 plantar sites
on the forefoot (the great toe and the base of the first through third metatarsals) can be used to
find 90% of patients with an insensate site.
The biothesiometer, an electrical device that delivers measurable stimulatory vibrations, has not
gained widespread use because of a lack of studies demonstrating its predictability and because
monofilaments are inexpensive and readily available. However, a prospective study of 103
patients suggested that the biothesiometer scored higher in sensitivity tests than did the 10 gmonofilament or its predecessor technology, the tuning fork.
Another case-control study, of 255 diabetic patients, found support for monofilament or
biothesiometer use. Foot ulceration was predicted with a specificity of 77% and a sensitivity of
100% based on either an abnormal Semmes-Weinstein monofilament perception or a vibration-
perception threshold of greater than 25 V.
The vascular examination will have the greatest effect on treatment choices. The qualitative
measurements include palpation of the pulses and determination of skin temperature, capillaryrefill, and hair and nail growth. Evidence of vascular disease is commonly gained through
palpating for the dorsalis pedis and posterior tibial pulses.
Qualitative methods focus on noninvasive measures of pressure, flow, and tissue oxygenation.
Doppler examination will yield pressure measurements at multiple levels of the leg, foot, and
ankle and depends on the compressibility of the vessels under study. The most common
measurement of peripheral vascular disease is the ankle-brachial index (ABI), the ratio of systolic
blood pressure in the ankle to that in the brachial artery. An ABI of 0.90 or less suggests the
presence of peripheral vascular disease. If the ABI is higher than 1.1, it should be considered
whether the measurement derives from a false elevation produced by medial arterial calcinosis.
Transcutaneous oxygen measurement requires expensive equipment, as well as a trained
technician and, thus, is not as widely used as a diagnostic tool. It is the most accurate method for
assessing local skin vascularity and healing potential. A transcutaneous oxygen tension of greater
than 30 mm Hg has been associated with a high likelihood that a wound will heal.
Treatment
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Medical Therapy
Preventive strategies
The major focus of current diabetic foot care is prevention. 12,13 Preventive strategies combine
patient education, prophylactic skin and nail care, and protective footwear. Foot-specific,
individualized patient education is the most important element of a comprehensive diabetic foot
program. Low-risk individuals must wear nonconstrictive shoes. Soft leather or athletic footwear
decreases the risk of tissue breakdown from direct pressure (see Image 2).
Depth-inlay, soft leather, laced shoe with a custom-made accommodative, pressure-
dissipating foot orthosis
Cushioned stockings are helpful, and white socks make identification of skin breakdown easier,
especially in individuals with impaired vision. Nails should be cut transversely to decrease the
risk of an ingrown toenail. Once a problem arises, the patient is instructed to seek medical
attention immediately. Often, the earliest sign of infection is slowly increasing blood sugars and
insulin requirement.
When applied to diabetic populations, the above strategies have been shown to markedly decrease
the rates of diabetic foot ulcer (DFU) and lower extremity amputation(LEA). Patient education
materials are available through the American Orthopaedic Foot and Ankle Society, theAmerican
Diabetes Association, the American Podiatric Medical Association, and the National Institutes of
Health (NIH) web site Feet Can Last a Lifetime.
When individuals progress to a higher degree of risk, they require accommodative footwear and
prophylactic skin and nail care. Depth-inlay, soft leather, Oxford-laced shoes with
accommodative pressure and custom-made shear-dissipating foot orthoses (insoles) have been
shown to appreciably decrease the development of DFUs. The complexity and individualized
nature of the shoes and custom-made foot orthoses vary with the magnitude of deformity and loss
of protective sensation. Calluses should be pared to decrease the incidence of shear-mediated
ulcer formation. Trained professionals should perform skin and nail care in these individuals.
Ulcer treatment
The first step in the treatment of a patient with diabetes who has a foot ulcer is medical
management of the systemic diabetes. Many individuals with diabetes are malnourished due to
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chronic renal disease or chronic infection. Many are also immunocompromised. Once the
systemic condition of the patient is optimized, specific attention can be directed to the foot
ulcer.14,15,16
Ulcers can be neuropathic or ischemic. Neuropathic ulcers are caused by pressure or by shear
forces. Once the ulcer is unroofed and the necrotic tissue is debrided, the soft-tissue base reveals
healthy granulation tissue. If the ulcer is unroofed and the tissue at the base is necrotic, the ulceris likely to be ischemic. A vascular surgeon should evaluate patients with ischemic ulcers to
determine if the limb can be salvaged. A risk-benefit analysis then can then be performed to
determine whether treatment should entail limb salvage, amputation, or a combination of both. Ifthe ulcer is neuropathic, noninvasive vascular testing is in order in the absence of palpable pedal
pulses.
From a practical standpoint, vascular surgery consultation is warranted only when the patient is
symptomatic with ischemic pain or a nonhealing ulcer. Ischemic ulcers generally require
angioplasty or vascular bypass surgery to achieve wound healing. Neuropathic ulcers require
debridement of nonviable or infected tissue, combined with local wound care and offloading.
Wet-to-dry wound care does not promote wound healing because dry wounds desiccate. This
allows potential wound-healing cells to die and opportunistic infection to propagate. Dry wounds
should be kept moist with saline-soaked dressings or hydrocolloid gels. Wounds that produce
massive quantities of exudative material should be treated with absorbent materials (calcium
alginate) and dressings while the wound is kept moist. Growth factor gels have been shown to
promote wound healing in wounds with reasonable wound-healing potential.17,18
Offloading distributes weight-bearing pressure over a larger surface area and provides an
interface to decrease shear forces. Elimination of weight bearing is generally not required. The
optimal offloading device is the total contact cast (TCC). 19,20This device acts to dissipate weight-
bearing and shearing loads by eliminating foot or ankle motion, using an interface material to
distribute pressure and shear forces. Venous swelling is lessened by the compression effect of the
cast. When the ulcer shows appreciable improvement, foot care can be simplified with
prefabricated walking braces that have a plantar weight-bearing surface lined with Plastazote or
other pressure-dissipating materials (see Image 3). When the swelling decreases or when ankleimmobilization is not necessary, healing shoes can be used (see Image 4).
Removable walking boot with a Plastazote-
lined weight-bearing surface
Healing shoe.
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The grade 0 foot has no ulcers but is at risk. Treatment involves foot-specific patient education
and appropriate footwear. Prefabricated, pressure-dissipating insoles are appropriate.
Occasionally, a bony prominence or deformity (eg, bunion, hammertoe) cannot be accommodated
by therapeutic footwear. In this situation, removal of the bony prominence (exostectomy) orcorrection of the deformity is advised to prevent ulceration. As ulcers increase in grade, they
require additional treatment.
o Grade 1 ulcers require debridement of nonviable or infected tissue, local wound care, and
offloading.
o Grade 2 ulcers require debridement, culture-specific antibiotics, local wound care, and
more extensive offloading techniques.
o Grade 3 ulcers require debridement of infected or gangrenous tissue. Partial foot
amputation, more complex offloading or nonweight-bearing strategies, and culture-
specific parenteral antibiotic therapy are necessary.
o Grade 4 ulcers require partial or whole foot amputation.
Following wound healing, patients should use offloading permanently. The plantigrade foot can
be managed with depth-inlay, soft leather, Oxford-laced shoes and custom-made accommodative
foot orthoses. When plantigrade alignment cannot be obtained, an ankle-foot orthosis or surgical
reconstruction or stabilization is required.
Persistent or recurrent ulceration
Ulcers that do not heal or that recur in appropriate footwear require careful evaluation. Heel
impact or increased forefoot loading can be lessened with a cushioned heel and/or rocker solemodification of the shoe. Consider surgery when accommodative methods are unsuccessful.Increased forefoot loading or ankle equinus (static or dynamic) can be treated with percutaneous
Achilles tendon lengthening, followed by immobilization in a below-knee walking cast for 4-6
weeks. Plastic surgery intervention with rotational flaps or free tissue transfer occasionally is
indicated. The key to success in these patients is patient education, accommodative pedorthic
footwear, and careful monitoring.
Prescription footwear
The Medicare Therapeutic Shoe Bill of 1993 provides financial support for 1 pair of appropriate
inlay-depth shoes and 3 pairs of custom-made foot orthoses yearly for individuals with diabetes.
Most insurance carriers have followed their lead with similar guidelines. They have realized thatpreventive strategies are cost-effective compared with amputation. The certified pedorthist is an
essential consultant in providing these devices. The bill requires that both the clinician treating
the diabetes and the orthopedic surgeon or podiatrist treating the foot sign the prescription.
Charcot foot
Charcot foot is a hypertrophic osteoarthropathy currently seen primarily in patients with diabetes
who have peripheral neuropathy. The etiology is neurotraumatic or neurovascular. The traumatic
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etiology implies fracture or stress fracture without protective sensation. The hypertropic response
results from the inherent motion applied to a nonimmobilized fracture. The vascular etiology
implies an abnormal vascular inflow producing bony resorption, bony weakening, and a similar
result. Eichenholtz stage 1 is the proliferative phase of the disease. The foot is very swollen, and
radiographs are negative for fracture or dislocation. Stage 2 is the period of periarticular fractureor dislocation. Stage 3 is the phase of consolidation or healing.
Treatment historically has been anecdotal, with only recent attempts at a scientific approach. 21
The foot with active disease is immobilized in a non-weight-bearing fashion in a total contact cast
(TCC) or other prefabricated device. When the process has consolidated, treatment has beenaccommodative, including with a specialized type of ankle-foot orthosis, the Charcot restraint
orthotic walker (CROW). Surgery is advised for bony infection, nonhealing ulcers, or a deformity
that cannot be accommodated with a custom orthosis. There has been a trend toward attempted
joint fusion in stages 2 and 3 to prevent deformity that would be difficult to accommodate with a
shoe-orthotic construct.
Surgical Therapy
Amputation
Any discussion of the diabetic foot requires introduction of the concept of function-preserving
amputation surgery.22Partial and whole foot amputations frequently are necessary as treatment for
infection or gangrene. The goal of treatment is the preservation of function, not just the
preservation of tissue. Amputation surgery should be the first step in the rehabilitation of the
patient. Because most of these individuals are ambulatory, surgical planning should be directed at
the creation of a load-bearing terminal end organ that can interface most easily with
accommodative footwear, a prosthesis, or a combination of both (ie, prosthosis). The principles
that direct construction of a residual limb for weight bearing with a prosthesis should be
employed when performing debridement or partial foot amputation.
The major value of partial foot amputation is the potential for the retention of plantar load-
bearing tissues, which are uniquely capable of tolerating the forces involved in weight bearing.23
The soft-tissue envelope should be capable of minimizing these forces. Avoid the use of split-
thickness skin grafts in load-bearing areas. Deformity should be avoided as much as possible.
Tendo-Achilles lengthening should be used to avoid equinus deformity and increased loading of
the residual forefoot in partial foot amputations. Retention of a deformed foot with exposed bony
prominence leads only to decreased walking ability and recurrent ulceration.
Complications
Failure to follow the above prevention and treatment guidelines leads to deep infection and
amputation.
Outcome and Prognosis
Individuals who develop foot ulcers have a significant health-related decrease in their quality of
life and consume a large quantity of health care resources. At 2 years following transtibial
amputation, 36% of these patients are known to have died, which means that preventive programsare extremely important. Preventive programs have been shown to markedly decrease the rates of
DFU and LEA in diabetic populations.
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