Review
The diabetic foot

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Abstract

Diabetic foot problems are responsible for nearly 50% of all diabetes-related hospital bed days. Approximately 10–15% of diabetic patients developed foot ulcers at some state in their life and 15% of all load in amputations are performed in patients with diabetes. There is a need to provide extensive education to both primary care physicians and the patients regarding the relationship between glucose control and complications encountered in the foot and ankle. The management of diabetic foot disease is focussed primarily on avoiding amputation of lower extremities and should be carried out through three main strategies; identification of the “at risk” foot, treatment of acutely diseased foot, and prevention of further problems. These are several obstacles in the management of DFI that include poor knowledge and awareness of diabetes and its complications, lack of appropriate podiatry services. These goals are possible only by the establishment of a dedicated team of podiatrist, endocrinologist, vascular surgeon and a pedorthist. The plastic surgeons, orthopaedic surgeons & diabetes teaching nurses/educator dedicated to foot care could be a part of the team. Identifying the patients with diabetes at risk for ulceration requires feet examination, including the vascular & neurological systems, skin conditions, and foot structure. Conservative management of foot problems has dramatically reduced the risk of amputation by simple procedures, such as appropriate foot wear, cleanliness, aggressive surgical debridement, regular wound dressing by simple wet-to-dry saline guage, and ulcer management.

Introduction

Diabetic foot problems account for more hospital admissions than any other long term complications of diabetes and are responsible for nearly 50% of all-diabetes-related hospital bed days. The diabetic foot is particularly at risk for complications because of its inability to tolerate stress. Diabetic foot ulcers (DFUs) are one of the most common and serious complications of diabetes and affects 15% of all diabetic patients and results in a high financial burden [1], [2]. About 50% of all lower limb amputations are performed in people with diabetes. Diabetes associated lower extremity complications are emerging as noteworthy public health concern in both developing and developed countries.

The lifetime risk to a person with diabetes for developing a foot ulcer could be as high as 25% [3] and the primary factors in the development of these lesions are vascular insufficiency and peripheral neuropathy. Approximately 20% of diabetic patients with foot ulcer will primarily have inadequate arterial blood flow, ∼50% will primarily have neuropathy, and approximately 80% will have both conditions [4], [5]. Neuropathy, peripheral vascular disease, and reduced resistance to infections are recognized risk factors leading to the development of DFUs, which have all the characteristics of a chronic wound.

Conservative management of foot problems has dramatically reduced the risk of amputation by simple routine procedures such as good foot wear, chiropody, cleanliness, aggressive surgical radical debridement, off-loading, and ulcer management. Even that most dramatic of diabetic foot problems, Charcot's arthropathy, no longer means an inevitable progressions to amputation. Diabetic foot problems are not only an important complication, but they are also a preventable complication, bit they are also a preventable complication.

Section snippets

Pathophysiology and risk factor

Minor trauma both physical and mechanical, leading to cutaneous ulceration is the precipitating event for diabetic foot problems. The impact of diabetes complications mediated through micro-macrovascular disease is nowhere better exemplified than by feet. The presence of neuropathy, vascular insufficiency and an altered response to infection makes the patient with diabetes unique to foot problems. Peripheral neuropathy, high mechanical pressure resulting from structural deformities in the

Peripheral neuropathy

A spectrum of peripheral neuropathy encounter in the lower extremity affects up to 60% with diabetes [10], [11], [12]. It is the most common cause of leg pain in patients with diabetes. The average endocrine practice with a mixed age-range of patients would expect a neuropathy prevalence of 33%. Neuropathy is more prevalent with increasing age and duration of diabetes. Sensory neuropathy is usually the precipitant of painful symptoms. Of 100 patients with sensory neuropathy, up to 50 may be

Peripheral arterial disease

Diabetes induced peripheral arterial disease affects both small and large vessels in extremities. Reduced blood supply mimics and exacerbates the changes brought about by neuropathy. The large vessels that deliver arterial blood to the foot are the posterior tibial artery, anterior tibial artery and the peroneal artery. With advancing diabetic disease, one or all of the arteries may be compromised. The incidence of PAD in patients with diabetes is at-least four times that of non-diabetic

Infections

The damage resulting from neuropathy, ischemia, or all three predisposes to foot infection. Infection may be bacterial (in association with ulcers) or fungal especially of toe nails. Infections are often undetected until limbs and sometimes life are threatened. The diabetic foot ulcers have an active and/or passive (biofilm) infections. Active infection includes the classic signs of ascending erythema, edema, purulence, increased drainage and malodour. Diabetic patients do not feel the

Soft tissue and bone deformity

Most of the skin injuries on the feet of diabetic patients with neuropathy occur in the forefoot, with equal distribution on plantar and dorsal surface and those on plantar are frequent at site of high pressure. The two important forces experienced by the foot during ambulation are direct sagittal force and transverse force (side to side or front to back). The sagittal plane force is experienced on the plantar aspect of the foot during heel strike and forefoot push off. These shear forces are

Prevention

Patient education is essential. Success in treatment and prevention of lower extremely diabetes related complications is only achieved with a motivated multidisciplinary approach where communication and collaborative efforts are at a high level with the goal of providing the right care to the right people at right time and in the right amount. Preventive strategies should include a multidisciplinary approach for both improved patient outcomes and short and long term cost effectiveness. A

Assessment

All patients with diabetes should receive a through foot examination at least once in six months/annually; those with diabetic foot related complaints should be evaluated more frequently. Patients are often unaware of serious foot problems because of the masking effect of neuropathy and lack of education of foot care. Peripheral neuropathy, peripheral vascular disease, and bony deformity set the stage for ulceration. Loss of protective sensation is a major component of nearly all diabetic foot

Wound evaluation

Wound evaluation (extent/size” and “depth/tissue loss items “in the PEDIS systems [26] includes the evaluation of the size and depth of the wound, both of which should be determined after debridement. The duration and size of the ulcer relates directly to healing potential. Full thickness or deep wound of longer than 2 months duration is 79% less likely to heal. A chronic ulcer is defined as wound that does not decrease in size by 50% in one month. Measurements (length × width × depth) of the wound

Charcot's arthropathy

The term Charcot foot refers to bone and joint destruction that occurs in the neuropathic foot (Fig. 3). It is important to have a high index of suspicion for Charcot osteoarthropathy. Classically Charcot joint disease presents an unexplained swelling and erythema of the foot. Although there is often a history of trauma prior to the development of the Charcot's joint, the trauma can be so insignificant that patients are unable to recall a specific injury, It is often believed that profound

Conclusions

Diabetes mellitus is global epidemic, and diabetic foot ulcer is one of the most serious and costly complications leading to severe economic and personal loss in the future. There is a need to provide extensive education to both primary care physicians and the patients regarding the relationship between glucose control and complications encountered in the foot and ankle. Peripheral neuropathy and peripheral vascular disease create an environment that will lead to ulceration and possible

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