Management of diabetic foot complications
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
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- 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.
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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
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- 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.
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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
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- 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.
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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
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- 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.
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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
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- 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.
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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
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- 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.
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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
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- 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.
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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
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- 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.
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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
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- 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.
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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