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Management of diabetic foot complications

Introduction

Diabetes creates a substantial burden on societies throughout the world, with foot disorders one of the most common complications. Patients with diabetes are at substantially increased risk of developing foot ulcers, particularly in the presence of neuropathy, foot trauma and foot deformity. Researchers have developed numerous classification systems for staging and describing the location of diabetic foot disease, which are useful for guiding management decisions. Foot ulceration is a common precursor to lower extremity amputation, and it is therefore important to ensure that there is a well-organized team employing a holistic approach, in which the ulcer is treated as a sign of multiorgan disease, to ensure the successful prevention and management of diabetic foot lesions. It is vitally important to always remember that the ultimate goal in the management of diabetic foot problems should be total wound healing and limb salvage. To aid in the prevention of foot disorders in patients with diabetes, preventative education may be helpful if the patient understands the advice and is empowered to help themselves. This collection of recent high-quality full-text articles from Springer Nature and other prominent publishers provides an overview of this important topic.

Contents

  1. Epidemiology
  2. Clinical features and diagnosis
  3. Management
  4. Organization and preventative care

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Epidemiology

Epidemiology and healthcare cost of diabetic foot problems

This chapter highlights the various factors associated with risk of lower extremity morbidity, and briefly discusses the cost effectiveness of prevention of such.

Summary
  • Lower extremity morbidity is a major contributor to the burden of diabetes on individuals and on healthcare systems.
  • The reported prevalence of diabetic peripheral neuropathy (DPN) ranges from 16% to 66%. Manifestations of DPN include autonomic neuropathy (often overlooked), reduced motor function, and sensory neuropathy (the most commonly recognized).
  • Peripheral vascular disease results in the inability of the dysvascular or ischemic limb to properly heal. Additionally, musculoskeletal deformity, which includes a hammertoe or bunion, and can arise due to motor neuropathy, predisposes to increased pressure and friction.
  • In addition to these factors, there are several modifiable risk factors associated with lower extremity disease, such as glycemic control (better control may be associated with reduced risk of lower extremity amputation).
  • A ‘perfect storm’ of risk factors for ulceration has been proposed by some researchers; one group found that the presence of at least two risk factors increased risk of ulceration between 35% and 78%, with a clinical triad of neuropathy, minor foot trauma and foot deformity present in more than 63% of those developing an ulcer.
  • Risk for amputation has been found to be greater among men than women in numerous studies, and studies have also identified racial and ethnic disparities in incidence of diabetic amputation. Lower socioeconomic status has been shown to carry a higher likelihood of amputation.
  • While a direct causal relationship has not been shown between amputation and mortality, a strong association has been demonstrated in several studies. Perioperative mortality following amputation ranges from 5.8% to 23% during the first 30 days.
  • It is generally agreed that prevention of lower extremity ulceration, infection and amputation is the most desirable approach, and is highly cost effective or cost saving.

Cook JJ, Simonson DC. In: The diabetic foot: Medical and surgical management. Edited by Veves A, Giurini JM, LoGerfo FW. Humana Press, 2012. doi: 10.1007/978-1-61779-791-0_2


Clinical features and diagnosis

Clinical examination and risk classification of the diabetic foot

This chapter outlines techniques for the examination of the diabetic foot, including a look at available classification systems.

Summary
  • Among patients with diabetes, foot ulceration is a common precursor to lower extremity amputation, providing an avenue for infection, and potentially causing progressive tissue necrosis and poor wound healing. Such ulceration is often associated with peripheral neuropathy and repetitive trauma.
  • For the successful prevention of foot complications, it is important to identify high-risk patients. Screening essentially involves four elements:
    • History of lower extremity disease
    • Sensory neuropathy
    • Peripheral arterial disease
    • Limited joint mobility or structural foot and ankle deformity.
  • Techniques and tools for the assessment of sensation, to screen for sensory neuropathy, include use of a tuning fork, the Semmes-Weinstein Monofilament, and vibration perception threshold testing.
  • The high-risk patient can also be identified by clinical assessment, using scoring systems such as the Modified Disability Score, which uses standard clinical tools to produce a disability score that has been proven to be predictive of diabetic foot complications.
  • When caring for diabetic foot ulceration, a clear classification system is necessary to ensure appropriate therapy, communicate risk and potentially predict outcome.
  • There are seven important questions to be asked when assessing a diabetic foot wound:
    • Where is the ulcer located?
    • How large is the ulcer?
    • What does the base look like?
    • What do the margins look like?
    • How deep is the ulceration? Are there underlying structures involved?
    • Is there infection?
    • Is there ischemia?
  • There have been several diabetic classification systems reported in the literature. These include the Wagner Ulcer Classification and the University of Texas Ulcer Classification.
  • The most common components of neuropathic ulceration risk can be identified using simple and readily available equipment in the primary care setting.

Lavery LA, Armstrong DG. In: The diabetic foot: Medical and surgical management. Edited by Veves A, Giurini JM, LoGerfo FW. Humana Press, 2012. doi: 10.1007/978-1-61779-791-0_4

Classification of diabetic foot disease

This paper discusses the various systems used for the classification of Charcot arthropathy and for the classification of ulceration.

Summary
  • Classification systems for diabetic Charcot arthropathy can be divided into temporal and descriptive (anatomic) types. The temporal classification system of Eichenholtz, while imperfect, is widely accepted, and has allowed for meaningful discussion on treatment options based on disease state.
  • The anatomic classification system of Cofield describes three patterns based on radiographic changes:
    • Metatarsophalangeal or phalangeal involvement
    • Tarsometatarsal joint destruction
    • Destruction through the head or neck of the talus, navicular and cuneiforms.
  • The anatomic classification system of Sammarco and Conti is based on patterns of bony destruction. Five anatomic patterns of Charcot midfoot involvement are described.
  • The anatomic classification of Brodsky classifies Charcot arthropathy according to the area of the foot with maximum bony destruction radiographically. It is the most widely quoted anatomic classification system for Charcot arthropathy.
  • The anatomic classification system of Schon established four types of midfoot arthropathy, and involves a clinical deformity severity stage based on the degree of collapse of the longitudinal arch of the foot; it was later modified to include a radiography severity scale.
  • The authors conclude that the anatomic classification systems of Schon et al. and Brodsky et al. appear to be most useful for guiding and discussing treatment. They propose the Eichenholtz temporal classification system should be used for staging, while either the Schon et al. or the Brodsky et al. anatomic classifications should be applied to describe the location of disease.
  • The most widely referenced classification system for diabetic foot ulcers, which is simple and easy to apply, is the Wagner and Meggitt classification – which uses six grades. Other classification systems of diabetic foot lesions include the depth-ischemia classification, the University of Texas classification, and the International Working Group on the Diabetic Foot classification.

Taylor R. In: The surgical management of the diabetic foot and ankle. Edited by Herscovici, Jr D. Springer International Publishing, 2016. doi: 10.1007/978-3-319-27623-6_4

Diabetic polyneuropathy

This chapter outlines the neuropathic syndromes that occur in diabetes mellitus, with a focus on diabetic peripheral neuropathy and autonomic neuropathy.

Summary
  • Diabetic neuropathy encompasses several neuropathy syndromes, the most common presentation of which is chronic distal symmetrical polyneuropathy, known frequently as diabetic peripheral neuropathy.
  • Diabetic peripheral neuropathy mainly presents as sensory loss, and is usually easily detected by simple clinical examination, with further assessment often necessary to determine severity.
  • Acute painful neuropathies are transient, and characterized by acute onset of pain in the lower limbs. There are two distinct types:
    • Acute painful neuropathy of poor glycemic control
    • Acute painful neuropathy of rapid glycemic control or insulin neuritis.
  • Other neuropathies include small fiber neuropathy, focal and multifocal neuropathies, proximal motor neuropathy, cranial mono-neuropathies, and thoraco-abdominal neuropathy.
  • There are several pressure palsies that also fall under the umbrella of diabetic polyneuropathy, such as carpal tunnel syndrome, and ulnar nerve and other isolated entrapments.
  • The pathogenesis of diabetic polyneuropathy remains unclear, but it is widely accepted that micro-vessel disease is important in this pathogenesis, and severe neural microvascular disease has been demonstrated in subjects with clinical diabetic neuropathy.
  • Autonomic neuropathy has a gradual onset and is slowly progressive. Intensive glycemic control is critical in preventing onset and slowing progression of diabetic autonomic neuropathy.
  • Diabetic peripheral neuropathy is painful in approximately half of all cases. The exact mechanisms of this pain remain to be fully elucidated, and its management poses a considerable clinical challenge. The most commonly prescribed first-line agents are pregabalin, duloxetine, gabapentin and amitriptyline. If pain is inadequately controlled opioids such as tramadol and oxycodone may be added.

Tesfaye S. In: The diabetic foot: Medical and surgical management. Edited by Veves A, Giurini JM, LoGerfo FW. Humana Press, 2012. doi: 10.1007/978-1-61779-791-0_3

Clinical features and diagnosis of peripheral arterial disease

This chapter discusses features of peripheral arterial disease in patients with diabetes, with a focus on patient evaluation and diagnostic techniques.

Summary
  • Peripheral arterial disease is characterized by two distinct pathological processes:
    • Nonocclusive microcirculatory impairment
    • Macroangiopathy manifesting as atherosclerotic lesions.
  • One of the most important steps to ensure salvage of the diabetic limb is assessment of the arterial circulation. This should start with taking a patient history and performing a physical exam, followed by the selective use of the vascular diagnostic laboratory.
  • Arterial insufficiency should be considered in any patient who presents with foot ulceration or gangrene, even if it has already been determined to be neuropathic, or due to an infected ulcer.
  • Pulse examination, including the status of the foot pulses, is the most important component of the physical exam, with ischemia always assumed to be present in the absence of a palpable pulse.
  • Non-invasive arterial testing for the diagnosis of peripheral arterial disease includes the following, all of which have significant limitations:
    • Doppler segmental pressures
    • Toe pressures
    • Doppler waveform analysis
    • Pulsed volume recordings
    • Duplex ultrasound
    • Transcutaneous oxygen tension and laser Doppler perfusion.
  • A thorough bedside evaluation with selective use of non-invasive vascular testing is usually sufficient for detecting arterial insufficiency in patients presenting with diabetic foot ulceration. If present, revascularization is indicated to save the limb. Only after determining that insufficiency is present is arteriography appropriate; it should not be considered a diagnostic tool.
  • Peripheral arterial disease is common in diabetes. Missing a diagnosis of arterial insufficiency can lead to ongoing wound problems and even limb loss. Awareness of the features and a high level of diagnostic skill help lead to improved outcome and limb salvage.

Akbari CM. In: The diabetic foot: Medical and surgical management. Edited by Veves A, Giurini JM, LoGerfo FW. Humana Press, 2012. doi: 10.1007/978-1-61779-791-0_5

The diabetic foot

This chapter reviews the various imaging techniques used in diabetic infectious arthropathies, highlighting ways for distinguishing these from neuropathic arthropathies.

Summary
  • An important difficulty faced by those involved in the management of diabetic patients is the identification of infections, and distinguishing these from neuropathic arthropathy.
  • There are several patterns of neuropathic arthropathy (Charcot joint) that can occur, including atrophic, hypertrophic and mixed. To aid in the interpretation of radiographic findings, progression of neuropathic arthropathy has been classified into three stages, plus a preradiographic stage, by Eichenholtz. While not commonly used clinically, this staging helps provide an understanding of progression of a Charcot joint.
  • In addition to radiography, other imaging techniques used in the investigation of neuropathic arthropathy include magnetic resonance imaging (MRI), computed tomography (CT), ultrasound and nuclear medicine.
  • Diabetic foot infections most commonly occur due to skin barrier breakdown. Imaging can be useful for assessing diabetic foot complications, identifying osteomyelitis or septic arthritis and differentiation from an isolated neuropathic joint. MRI plays a particularly important role here.
  • Again, several imaging modalities are useful in the investigation of diabetic foot infections, including radiography, used predominantly to reveal major structure abnormalities of the bones of the foot, MRI, ultrasound, CT, nuclear medicine and positron emission tomography.
  • MRI is the most appropriate means of identifying osteomyelitis in diabetic foot infections, and differentiating it from the reactive bone marrow edema that is seen in the neuropathic joint.

Legault KJ, O’Neill J. In: Essential imaging in rheumatology. Edited by O’Neill J. Springer-Verlag New York, 2015. doi: 10.1007/978-1-4939-1673-3_14


Management

Prevention and management of foot problems in diabetes: A summary guidance for daily practice 2015, based on the IWGDF guidance documents

This summary guidance describes the basic principles of the prevention and management of foot problems in patients with diabetes.

Summary
  • Foot problems are one of the most serious complications in diabetes mellitus, with foot lesions usually associated with the simultaneous presence of two or more risk factors, particularly diabetic peripheral neuropathy.
  • The five key elements for the prevention of foot problems are:
    • Identification of the at-risk foot
    • Regular inspection and examination of the at-risk foot
    • Education of patient, family and healthcare providers
    • Routinely wearing appropriate footwear
    • Treatment of pre-ulcerative signs.
  • The evaluation of a foot wound should be performed using a standardized and consistent strategy and must address the type, cause, site and depth, and signs of infection.
  • In most patients, foot ulcers will heal if treatment is based on the following principles:
    • Relief of pressure and protection of the ulcer
    • Restoration of skin perfusion
    • Treatment of infection
    • Metabolic control and treatment of comorbidity
    • Local wound care
    • Education provision for patients and relatives
    • Prevention of recurrence.
  • A well-organized team utilizing a holistic approach, in which the ulcer is a sign of multiorgan disease, is necessary for the successful prevention and management of diabetic foot lesions.
  • Ideally, a foot care program should incorporate the following:
    • Education – for patients, carers and healthcare staff
    • A system for detection of those at risk
    • Measures to reduce risk
    • Prompt and effective treatment
    • Auditing of all aspects of the service
    • An overall structure designed for chronic care.
  • There should be at least three levels of foot-care management:
    • Level 1 - general practitioner, podiatrist and diabetic nurse
    • Level 2 - diabetologist, surgeon (general, orthopedic or foot), vascular surgeon, endovascular interventionist, podiatrist and diabetic nurse, in collaboration with a shoe-maker, orthotist or prosthetist.
    • Level 3 - a level 2 foot center specialized in diabetic foot care, with multiple experts from several disciplines specialized in this area working together, acting as a tertiary reference center.

Schaper NC et al. Diabetes Metab Res Rev 2016; 32(Suppl 1): 7–15. doi: 10.1002/dmrr.2695

Nonoperative care and footwear for the diabetic foot and ankle patient

This chapter outlines nonoperative approaches to the prevention and treatment of diabetic foot and ankle lesions.

Summary
  • Typically, patients with diabetic foot lesions present with painless deformity, erythema, warmth and swelling. For evaluation and diagnosis, patient history is an important first step, followed by a physical examination.
  • Physical examination should include complete evaluation of the foot, assessing skin, nails, vascular status, musculoskeletal alignment and the presence/absence of protective sensation.
  • Diagnostic studies are the next step in patient evaluation, particularly when attempting to differentiate between Charcot arthropathy and musculoskeletal infections in the foot and ankle.
  • A 3-stage classification system (developed by Eichenholtz) shows the three stages through which Charcot arthropathy progresses:
    • Stage I – Development and fragmentation
    • Stage II – Coalescence
    • Stage III – Reconstruction and consolidation.
  • The location of Charcot arthropathy can be described using a four-region classification system:
    • Type 1 – tarsometatarsal region (in almost 60% of cases)
    • Type 2 – subtalar and transverse tarsal joints (up to 35% of cases)
    • Type 3 – ankle joint (approximately 9% of cases)
    • Type 4 – multiple joint involvement
    • Type 5 – forefoot only.
  • The goal of nonoperative foot care is to achieve a stable and plantigrade foot, avoid abnormal plantar pressures, prevent ulcers from occurring/recurring and allow the patient to ambulate.
  • Nonoperative care starts with routine skin and nail care, and appropriate footwear is very important. Prescription footwear for the diabetic foot and ankle include healing shoes, in-depth shoes, external shoe modifications, orthosis(es) or inserts and custom-made shoes. Proper footwear for diabetics should achieve the following:
    • Relieve areas of excessive pressure
    • Reduce shock and shear
    • Accommodate, stabilize and support deformities
    • Limit joint motion.
  • Various tools are used for ulcer care, from hydrocolloid-type dressings or platelet-derived wound healing factors right through to total contact casting, immobilization and Charcot resistant orthotic walker.

Karges DE. In: The surgical management of the diabetic foot and ankle. Edited by Herscovici, Jr D. Springer International Publishing, 2016. doi: 10.1007/978-3-319-27623-6_5

Management of diabetic foot ulcers

The various management options for diabetic foot ulcers are discussed here, with a focus on recent advances.

Summary
  • There are numerous treatment options available for diabetic foot ulcers, including the use of devices and adjuncts, such as pressure-relieving devices, which can be classified as nonremovable or removable. These devices are designed to support the lower leg, off-load affected areas, and to redistribute pressure across the foot.
  • Another adjunct option is negative-pressure therapy – a technology that is currently widely used in wound care, despite limited evidence supporting such use.
  • Hyperbaric oxygen has been suggested to have utility in the treatment of chronic wounds, but is limited by availability, and studies have failed to demonstrate clear benefit.
  • Surgical options for wound care include debridement, with options for vascular disease including percutaneous transluminal angioplasty. Non-vascular foot surgery, including debridement and joint resection, are often used in the treatment of osteomyelitis that has failed prolonged antibiotic therapy.
  • The choice of dressing for wounds is dependent upon factors such as severity, would position, stage of healing, need for control of microorganisms, exudate absorption, debridement, pain control and atraumatic dressing removal. Options include:
    • Low-adherent dressings
    • Semipermeable films
    • Foam dressings
    • Alginate dressings
    • Antimicrobial dressings
    • Hydrocolloids
    • Hydrogels.
  • Biological treatment options include:
    • Tissue engineering products
    • Protease-modulating dressings
    • Growth factors
    • Stem cells
    • Platelet-rich plasma.
  • Drug options include antibiotics, vasodilators, lipid-lowering medication, and agents for glycemic control.

Harries RL, Harding KG. Curr Geri Rep 2015; 4: 265–276. doi: 10.1007/s13670-015-0133-x

Pharmaceutical perspectives of impaired wound healing in diabetic foot ulcer

This paper provides a review of treatment options for diabetic foot ulcer, including a look at promising biological approaches.

Summary
  • Approximately 15% of patients with diabetes will develop diabetic foot ulcer once in their lifetime. The diabetic foot ulcer is a complex and chronic wound, often associated with damage to nerve tissue and peripheral vascular problems.
  • Factors to consider when determining treatment approach include physical condition of the patient, type of wound, and size of wound.
  • Exogenously applied biologically active compounds are the subject of significant research. These include growth factors, including epidermal growth factor (EGF), platelet-derived growth factor (PDGF), basic fibroblast growth factor (bFGF), and vascular endothelial growth factor (VEGF).
  • Other treatment approaches include:
    • Use of components of, or products designed to mimic, the extracellular matrix.
    • Short peptides and nucleic acids
    • Anti-inflammatory cytokines
    • Stem cell therapy
    • Conditioned medium
    • Amnion/chorion membrane.
  • Drug delivery systems are an important factor in the development of a therapeutic product, potentially able to carry pharmaceutical compounds to the wound healing area.
  • Limitations associated with current treatment include the heterogeneity of individuals and of wounds involved, hence clinical outcomes differ widely with the same treatments.
  • The current direction of research for pharmaceutical products in diabetes foot ulcer involves:
    • Application of multiple growth factors
    • Application of potential biological modules
    • Advanced delivery systems to protect the bioactive agent at the wound site
    • Modified/engineered proteins to improve stability and activity
    • Randomized controlled clinical trials to prevent bias
    • Longitudinal studies and post-marketing monitoring of pharmaceutical products.
  • There remains substantial unmet need for the treatment of diabetic foot ulcer. Critical factors for the successful development of novel products include product stability, cost, feasibility for industry scale-up, and patient compliance.

Lau H-C, Kim A. J Pharm Invest 2016; 46: 403–423. doi: 10.1007/s40005-016-0268-6

Endovascular revascularization: When and how

This chapter outlines treatment considerations for revascularization in the diabetic patient, highlighting the place of newer techniques and technologies.

Summary
  • Prior to considering revascularization in the diabetic patient, there are several factors that must be considered, including clinical findings, degree of tissue loss, degree of ischemia, patient age, life expectancy, comorbidities and the level and extent of arterial disease.
  • Medical therapy must be optimized prior to undergoing revascularization, including that for glycemic control, hypertension and dyslipidemia, with optimal wound care, infection treatment and good foot care also important, both before and after the procedure.
  • The two options for revascularization of the diabetic limb are endovascular treatment and surgical bypass, with angioplasty largely recommended for short-term revascularization, and bypass surgery recommended for a patient with reasonable life expectancy and suitable anatomy. Endovascular treatments have lower procedural morbidity than open repair.
  • Modern endovascular technologies and techniques allow complex arterial diseases to be treated successfully. The two main therapeutic options for endovascular therapy are balloon angioplasty or stent.
  • The main cause of endovascular failure is recurrent stenosis due to neointimal hyperplasia; this can be significantly reduced by use of drug-eluting balloons and drug-eluting stents. While such technologies are expensive, several studies have shown that the initial higher costs are offset by reduced reintervention rates.
  • Other less commonly used techniques for the treatment of peripheral arterial disease include atherectomy devices, laser and cryoablation.
  • Complications following endovascularization include hemorrhage at the access site, major medical complications and distal thromboembolism or vessel occlusion.

Wigham AJ, Uberoi R. In: Management of diabetic foot complications. Edited by Shearman C. Springer-Verlag London, 2015. doi: 10.1007/978-1-4471-4525-7_8

Surgical revascularization of the diabetic foot

This paper discusses surgical revascularization, with a focus on decision pathways for treatment approach, in the diabetic foot.

Summary
  • The main goal of revascularization in patients with diabetic foot is limb salvage, with restoration of limb function and quality of life. Revascularization is mainly indicated in the diabetic foot patient for critical limb ischemia causing pain at rest, and tissue loss with non-healing wounds or gangrene.
  • Early, accurate assessment of arterial limb perfusion is vital. The diagnosis of peripheral arterial disease can be confirmed clinically by bedside examination of the patient’s lower limb arterial pulses.
  • The first step following diagnosis is the pre-treatment work up – optimization of glycemic control, debridement of devitalized tissue and drainage of pus, initiation of broad-spectrum intravenous antibiotics and an anesthetic review.
  • The gold standard for revascularization in diabetic limb salvage is open surgical bypass to the distal tibial vessels or the pedal vessels. There are three choices of conduit for bypass, the patient’s own vein, synthetic man-made grafts and cadaveric veins.
  • Unfit patients who are not suitable candidates for surgical bypass should be considered for an endovascular approach.
  • Regular surveillance of a surgical bypass graft is necessary for early detection of hemodynamically significant graft-threatening stenosis to allow angioplasty to be performed and the graft to be saved.

Moxey PW, Chong PFS. In: Management of diabetic foot complications. Edited by Shearman C. Springer-Verlag London, 2015. doi: 10.1007/978-1-4471-4525-7_9

Amputation above the ankle: Achieving the best outcome for the patient

This paper examines various points of the care pathway for patients requiring major amputation for diabetic foot.

Summary
  • Potential indications for major amputation include:
    • Patients own limb no longer viable
    • Prosthetic limb is expected to improve quality of life
    • Uncontrolled infection
    • Uncontrolled ischemia pain that will not be improved by revascularization
    • Patient requests the procedure in preference to high-risk revascularization.
  • A patient should have a life expectancy of at least 2-3 months prior to undergoing such major surgery to ensure they gain benefit.
  • Many factors influence outcome after amputation, some of which can be optimized prior to surgery, with others providing realistic predictions of patient outcomes. These factors, which must be assessed prior to a decision regarding amputation, include:
    • Cognitive ability and motivation
    • Functional requirements
    • Indication for amputation (ischemia versus sepsis).
  • A decision regarding the level of amputation must take into consideration factors such as the patient’s expected level of function after surgery, their healing potential and general health factors. While below-knee amputation provides a better functional result, it may be associated with a higher risk of failure to heal.
  • Patients and their families must have realistic expectations for life following a major amputation. They must be provided with information that is clear and accurate, and uniform across sources.
  • There are several general factors associated with the surgery itself that can improve outcome, the most important of which is the experience of the team undertaking the operation. Three surgical approaches are:
    • Trans-tibial – can achieve a good result but requires good patient compliance
    • Knee disarticulation – provides better functioning, quality of life and potentially less phantom limb pain than transfemoral amputation
    • Trans-femoral – higher chance of healing but compromised mobility.
  • Post-operative management comprises several areas, including wound management, rehabilitation, care of the contra-lateral limb and pain management.

Storer N, Hulse M, Nordon IM, Baxter SJ. In: Management of diabetic foot complications. Edited by Shearman C. Springer-Verlag London, 2015. doi: 10.1007/978-1-4471-4525-7_10

Diabetic foot infections: An update in diagnosis and management

This paper discusses the occurrence of diabetic foot infections, with a focus on evaluation and treatment.

Summary
  • There are numerous risk factors for the development of a diabetic foot infection, with an ulcer almost a requirement. Loss of protective sensation and dry skin predispose to skin breakdown, and peripheral artery disease has been found to substantially increase the risk of a wound becoming infected.
  • Assessment of a diabetic foot infection involves assessment of the limb and the wound as well as the patient as a whole. Wounds usually require debridement, with diagnostic tests for severity including blood culture, wound culture, bone biopsy, laboratory tests, and imaging.
  • Treatment of diabetic foot infections aims to prevent infection spreading to deeper tissues such as the bone, which may evolve into a limb- or life-threatening condition.
  • General measures that should be undertaken for a patient with a diabetic foot infection include optimization of glycemic control and debridement of the ulcer in combination with offloading.
  • Patients with severe infection require hospitalization, whereas those with mild infections and most patients with moderate infections can be treated as outpatients.
  • Antimicrobial therapy should only be initiated for infected wounds. Almost all mild and moderate infections can be treated with oral antibiotics. The choice of an antimicrobial agent should be based on the results of microbial tests in combination with clinical evaluation.
  • Consideration of surgery should happen early in all patients with moderate or severe diabetic foot infections. Such intervention may range from debridement of necrotic tissue to major amputations.
  • Non-antibacterial treatment options for diabetic foot infections include the use of bioengineered skin equivalents, growth factors, granulocyte colony-stimulation factor, hyperbaric oxygen therapy or negative pressure wound therapy.
  • With appropriate treatment, 80–90% of non-limb-threatening infections and 50–60% of more severe infections resolve; rates of lower limb amputation may reach 50–60% in extensive infections and in medical centers with low experience.

Grigoropoulou P, Eleftheriadou I, Jude EB, Tentolouris N. Curr Diab Rep 2017;17:3. doi:10.1007/s11892-017-0831-1

Charcot arthropathy in the diabetic foot

In this chapter, the etiology and classification of Charcot arthropathy in the diabetic foot are discussed, along with diagnostic techniques and management options, both conservative and surgical.

Summary
  • Charcot foot is a non-infectious progressive condition characterized by joint dislocation, pathologic fractures, and severe destruction of the pedal architecture, associated with peripheral neuropathy.
  • Charcot foot usually occurs in the presence of dense peripheral neuropathy, in a person with normal circulation and a history of preceding trauma, which is often minor.
  • The most common classification system of Charcot arthropathy uses radiographic appearance combined with physiologic stages of the process.
  • Radiographically, osteoarthropathy looks like a severely destructive form of degenerative arthritis. X-rays are usually sufficient for diagnosis and to monitor disease activity, with computed tomography and magnetic resonance imaging rarely necessary.
  • Typically, the patient presenting with Charcot foot will have several characteristic clinical findings, and will have had a long duration of diabetes. Initial presentation usually involves the patient seeking attention for a markedly swollen foot that is difficult to fit in a shoe, with examination revealing bounding pulses through the edematous foot.
  • Diagnosis of acute Charcot arthropathy is helped greatly by plain radiographs with no further diagnostic imaging studies required in most cases.
  • Conservative management (immobilization and reduction of stress) is the mainstay of treatment. Off-loading/immobilizing devices for the management of Charcot feet include: wheelchair, crutches, walker, elastic bandage or jones dressing, Unna’s boot, total contact case, bivalved cast, posterior splint, fixed ankle walking boot, patellar tendon-bearing brace, Charcot restraining orthotic walker, and a surgical shoe with custom inlay.
  • Neuropathic arthropathy should not be considered as a primarily surgical disorder. The three keys to treatment should be prevention, then early recognition, followed by protection from further injury until all signs of reaction have subsided. Surgery should only be considered when conservative care attempts have failed. The primary indications for surgery are instability, gross deformity and progressive destruction despite immobilization.
  • Charcot foot is a serious limb-threatening complication of diabetes, attributed to pre-existing peripheral neuropathy, with some form of trauma.

Frykberg RG, Rogers LC. In: The diabetic foot: Medical and surgical management. Edited by Veves A, Giurini JM, LoGerfo FW. Humana Press, 2012. doi: 10.1007/978-1-61779-791-0_20


Organization and preventative care

Organization of the diabetic foot care team

This chapter addresses the questions of how does one set up a multidisciplinary team for the management of diabetic foot, and who should be involved.

Summary
  • Patients with diabetes frequently have a multitude of complicating issues, not only lower extremity complications, but also chronic renal disease, cardiac disease or gastrointestinal disturbances. A multidisciplinary medical team is therefore essential.
  • In the earliest wound care center, The Joslin-Deaconess Foot Center, diabetologists, podiatrists and vascular surgeons were included. This center allowed for management and coordination of care for diabetic foot ulcers, vascular disease and medical management of diabetes.
  • To provide comprehensive treatment, other key specialties must also be available, including plastic surgery, orthopedic surgery, infectious disease, physical therapy and prosthetists/orthotists.
  • Timely communication by all members of the patient management team is key to the success of diabetic foot disorder treatment. Such communication can be greatly facilitated by the creation of a dedicated unit in the hospital for patients with diabetic foot problems. There are several advantages of such an approach, including:
    • Patients being comanaged by the vascular surgical and podiatry teams are seen together, ensuring timely and direct communication
    • Physicians are consulted directly while on rounds, with patients seen immediately, diagnostic tests reviewed and ordered, and recommendations directly communicated, allowing for immediate formation and execution of a plan
    • Rounds can be conducted in a more efficient manner
    • Appropriately trained nursing staff, case managers and physical therapists can be assigned to deal with the specific requirements of diabetic patients with wounds.
  • Many of the same characteristics as those of a dedicated hospital unit are incorporated into outpatient wound care centers, which are often run in a multidisciplinary fashion, with specialists such as podiatrists, vascular surgeons, general surgeons and plastic surgeons.
  • The ultimate goal in the care of a patient with a diabetic foot problem should always be total wound healing and limb salvage, it is important to always keep this goal in mind.

Giurini JM, Pomposelli Jr FB. In: The diabetic foot: Medical and surgical management. Edited by Veves A, Giurini JM, LoGerfo FW. Humana Press, 2012. doi: 10.1007/978-1-61779-791-0_23

Foot care and the prevention of recurrent ulcers

In this chapter, the necessary standards of care for the prevention of recurrent ulcers are discussed.

Summary
  • The precursor to amputation is most often ulceration, which is often preventable. However, despite increasing awareness, the occurrence of amputations is increasing.
  • Some of the issues include those related to the provision of foot care. Currently, while an established pathway of care exists, this pathway is complicated and is beyond the resources of most multidisciplinary care teams.
  • Patients with diabetic foot ulcers are usually seen by general practitioners, district nurses, practice nurses and community podiatrists, with varying levels of expertise and often no specific training in diabetic foot complications.
  • Potential solutions to the problem of preventing foot ulceration include the development of realistic integrated pathways that are simple to follow.
  • Implementation of standardized care should take place, with all diabetic patients undergoing foot examination and being placed into appropriate risk classifications:
    • Low risk – normal sensation, palpable pulses
    • Increased risk – neuropathy or absent pulses
    • High risk – neuropathy or absent pulses plus deformity or skin changes or previous ulcer (within the previous 15 months)
    • Ulcerated foot/active foot disease.
  • Preventative education may be helpful if the patient understands the advice and is empowered to help themselves. They should be told their risk classification and given appropriate tailored information, including information on how to recognize a foot emergency and where to seek help.

King L. In: Management of diabetic foot complications. Edited by Shearman C. Springer-Verlag London, 2015. doi: 10.1007/978-1-4471-4525-7_14