Diabetic foot: Difference between revisions

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{{Diabetes mellitus }}
{{Diabetes mellitus }}
{{CMG}}; [[Afsaneh Morteza|Afsaneh Morteza, MD-MPH]] [mailto:afsaneh.morteza@gmail.com] '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]; {{CZ}}
{{CMG}}; [[Afsaneh Morteza|Afsaneh Morteza, MD-MPH]] [mailto:afsaneh.morteza@gmail.com] '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]; {{CZ}}
== Pathophysiology==
Diabetic foot is an umbrella term for foot problems in patients with [[diabetes mellitus]]. Due to [[artery|arterial]] abnormalities and [[diabetic neuropathy]] and delayed wound healing, [[infection]] or [[gangrene]] of the foot is relatively common. The key components of diabetic foot are [[neuropathy]], [[angiopathy]] and [[trauma]] <ref name="pmid12039404">{{cite journal| author=Assal JP, Mehnert H, Tritschler HJ, Sidorenko A, Keen H, Hellmut Mehnert Award Workshop Participants| title=On your feet! Workshop on the diabetic foot. | journal=J Diabetes Complications | year= 2002 | volume= 16 | issue= 2 | pages= 183-94 | pmid=12039404 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12039404  }} </ref>.                                                                                                                                         
===Neuropathy===
The most important cause of diabetic foot is [[neuropathy]]. This is present to some extent in more than half of the patients with diabetes older than 60 years old.  Peripheral neuropathy usually is profound at the point where it leads to the formation of a foot ulcer. What causes neuropathy and why it occurs is not fully known. It is most likely caused by a combination of factors such as; high blood glucose, [[reactive oxygen species]], vasculopathy, reduced oxygenation of the nerves, [[inflammation]], [[autoimmunity]] in diabetes, [[genetic]] factors, mechanical injury, [[smoking]] and [[alcohol abuse]].
Generalized symmetric distal polyneuropathy is the most common and widely recognized form of diabetic neuropathy leading to diabetic foot ulcer. It may be either sensory or motor, and involves small fibers, large fibers or both. The clinical manifestations are divided into the three types of sensory, motor and autonomic neuropathy. Motor neuropathy causes wasting of small muscles of the feet with hammer toes and weakness of hands and feet.
Sensory neuropathy causes:
*Impaired [[vibration]] perception and position sense
*Depressed tendon reflexes
*Dull, crushing or cramp-like pain in the bones of the feet,
*Sensory [[ataxia]]
*Shortening of the [[achilles tendon]]
*Abnormal thresholds for warm thermal perception
*Decreased neurovascular function
Autonomic neuropathy is the increased or decreased blood flow to the foot (hot foot) with an increased risk of [[charcot neuroarthropathy]], decreased sweating, dry skin, impaired vasomotion and blood flow. These lead to  cold feet which ultimately result into the loss of skin integrity, providing a vulnerable site for infection <ref name="pmid22529027">{{cite journal| author=Alexiadou K, Doupis J| title=Management of diabetic foot ulcers. | journal=Diabetes Ther | year= 2012 | volume= 3 | issue= 1 | pages= 4 | pmid=22529027 | doi=10.1007/s13300-012-0004-9 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22529027  }} </ref>.
===Angiopathy===
Micro and macrovascular complications are the leading cause of diabetic complications. [[Atherosclerosis]] occurs due to inflammation, which leads to the accumulation of foam cells. The vascular changes which are responsible for foot problems include stiff arteries due to calcification of the smooth muscle cells in the arterial wall (mediasclerosis). It is usually discovered by an impaired ankle brachial index ([[ABI]]). The resting ABI is the ratio of the blood pressure in the lower legs to the blood pressure in the arms. The ABI is calculated by dividing the [[systolic blood pressure]] at the ankle by the systolic blood pressures in the arm. It is a non-invasive method to assess the lower extremity arterial system and to detect the presence of arterial occlusion disease.  In severe cases, it leads to ischemic foot problems, which the only treatment is [[vascular surgery]]. Even in neuropathic foot ulcers, the non healing wounds are the result of impaired blood supply to the tissue. Decreasing the central blood pressure by antihypertensive drugs may be deleterious for these patients<ref name="pmid22529027">{{cite journal| author=Alexiadou K, Doupis J| title=Management of diabetic foot ulcers. | journal=Diabetes Ther | year= 2012 | volume= 3 | issue= 1 | pages= 4 | pmid=22529027 | doi=10.1007/s13300-012-0004-9 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22529027  }} </ref>. Microvascular complications cause skin damage, [[infection]] and impaired wound healing. Once a foot ulcer develops, peripheral vascular disease is the most important factor which may contribute to adverse outcomes.Vascular complications are like a positive feedback which worsen the skin and nerve damage in [[diabetes]] <ref name="pmid22623440">{{cite journal| author=Venermo M, Vikatmaa P, Terasaki H, Sugano N| title=Vascular laboratory for critical limb ischaemia. | journal=Scand J Surg | year= 2012 | volume= 101 | issue= 2 | pages= 86-93 | pmid=22623440 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22623440  }} </ref>
[[Image:Microcirculation image.png|500px|Neuropathy and angiopathy in the foot have a positive feedback on each other]]
===Trauma===
Trauma is frequently the trigger of foot [[ulcer]] as repetitive trauma and pressure to the area prevent healing. Excessive plantar pressure is related to limited joint mobility and to foot deformities (Charcot foot, hammer toe). Limited joint mobility and abnormal foot biomechanisms have been associated with an increased risk of ulceration. It could also be the result of poor vision and sensory neuropathy so that the patients does not feel the pain, nor do they see the ulcer. Loss of balance can also make patients more susceptible to falls. <ref name="pmid22529027">{{cite journal| author=Alexiadou K, Doupis J| title=Management of diabetic foot ulcers. | journal=Diabetes Ther | year= 2012 | volume= 3 | issue= 1 | pages= 4 | pmid=22529027 | doi=10.1007/s13300-012-0004-9 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22529027  }} </ref>.


==Epidemiology and Demographics==
==Epidemiology and Demographics==

Revision as of 17:28, 25 February 2013

For patient information, click here

Diabetic foot
Diabetic Foot Infection: Cellulitis and gangrene.
(Image courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Afsaneh Morteza, MD-MPH [2] Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [3]; Cafer Zorkun, M.D., Ph.D. [4]

Epidemiology and Demographics

Incidence

It has been reported that annually, about 1 to 4 percent of those with diabetes develop a foot ulcer; 10 to 15 percent of those with diabetes will have at least one foot ulcer during their lifetime[1]

Gender

In 1987, Borch-Johnsen et al. described a male preponderance for the development of severe microvascular complications [2]. Diabetic foot disease is not an exception to this rule. For unknown reasons , men have a higher risk of diabetic foot disease compared to women. Some possible explanations are a higher bioavailability of nitric oxide (NO) bioavailability and NO responsiveness and the protective role of estrogen in women [3]. However the beneficial effect of these factors are reversed by diabetes, irrespective of menopausal status.Nevertheless men still have a higher risk for having diabetic foot disease .

Complications

Patients with diabetic foot have an increased risk of all-cause mortality, especially cardiovascular disorders, compared with patients with diabetes without a history of diabetic foot ulcer.[4]

Diagnosis and Evaluation

A complete physical examination and patient history is the first step. it include dermatologic, vascular, neurologic and bone examination.

Dermatologic Examination

  • Visual inspection of the skin: peeling skin, maceration, fissuring between toes
  • Skin temperature: Should be warm at the tibia cold at distal toe .
  • Look for deformities, charcot foot, hammer toe, and heels.

Vascular Assessment

Pulses: Bilaterally, dorsalis pedis, posterior tibialis, popliteal and superficial femoral. ABI measurement:

  • Normal 1-1.3
  • Non compressible calcified >1.3
  • Stenosis <0.9
  • Advanced ischemia <0.4

Arterial oxygen supply could also be measured by transcutaneous oxymetery

Neuropathy Assessment

Symptoms including burning, pin, needles, at early stages

Using neuropathy symptoms score (NSS)[5] and neuropathy disability score (NDS),[6]. Almost half of the patients with diabetes have some level of neuropathy prior to diagnosis. the physician should assess;

Diabetic Foot Physical Examination

Inspection

  • Dilated veins
  • Scar, Sinuses
  • Shiny skin
  • Hair distribution
  • Areas of Pigmentation
  • Areas of discolouration
  • Varicose vein
  • Ulcers
  • Brittle or broken nail
  • Fungal infection

Palpation

  • Temperature (increase temperature- deep vein thrombosis, decrease temperature-ischemia)
  • Tenderness (squeeze calf muscle and achilles tendon for tenderness)
  • Pulsation- Dorsalis pedis
  • Capillary filling time
  • Ulcers in pressure areas like ball of great toe, base of fifth metatarsal, posterior aspect of heel

Motor Examination

  • Nutrition/Bulk
  • Tone
  • Power
  • Reflexes

Sensory

  • Vibration
  • Joint position sense

Video: Physical Examination Diabetes

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Video: Diabetic Foot Care

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Image: Diabetic Foot Ulcer

Diabetic foot ulcer


Treatment

Foot ulcers in diabetes require multidisciplinary assessment, usually by diabetes specialists and surgeons. Treatment consists of appropriate bandages, antibiotics (against staphylococcus, streptococcus and anaerobe strains), debridement and arterial revascularisation. It is often 500 mg to 1000 mg of flucloxacillin, 1 g of amoxicillin and also metronidazole to tackle the putrid smelling bacteria. Specialists are investigating the role of nitric oxide in diabetic wound healing. Nitric oxide is a powerful vasodilator, which helps to bring nutrients to the oxygen deficient wound beds. Specialists are using forms of light therapy such as LLLT to treat diabetic ulcers.

Prevention

Foot ulcers can be prevented by is by frequent physical examinations, good foot hygiene, diabetic socks and shoes, and by avoiding injury.

  • Foot-care education combined with increased surveillance can reduce the incidence of serious foot lesions [7].
  • Footwear; all major reviews recommend special footwear for patients with a prior ulcer or with foot deformities. One review added neuropathy as an indication for special footwear. The comparison of custom shoes versus well-chosen and well-fitted athletic shoes is not clear.

Clinical Trials

Clinical Evidence reviewed the topic and concluded "Individuals with significant foot deformities should be considered for referral and assessment for customized shoes that can accommodate the altered foot anatomy. In the absence of significant deformities, high quality well fitting non-prescription footwear seems to be a reasonable option" [8].

National Institute for Health and Clinical Excellence has reviewed the topic and concluded that for patients at "high risk of foot ulcers (neuropathy or absent pulses plus deformity or skin changes or previous ulcer" that "specialist footwear and insoles" should be provided [9]

A meta-analysis by the Cochrane Collaboration concluded that "there is very limited evidence of the effectiveness of therapeutic shoes" [10]. However, the meta-analysis was published before the major trial that is in the table below.

The major randomized controlled trial of specialized footwear show no benefit in patients with a prior foot ulceration (see table below).[11] A prior, smaller, non-randomized trial that showed benefit of custom foot wear in patients with a prior foot ulceration.[12]. In this trial, the number needed to treat was 4 patients.

Randomized controlled trials of interventions to prevent complications of diabetic foot.[11] [7] [13] [14]
Trial Patients Intervention Comparison Outcome Results Comment
Intervention Control
Litzelman[7]
1993		 395 patients
• general medicine practice		 Patient and provider education Usual care • Any foot lesion
• Serious foot lesions at one year		 Not reported • 11%
• 2.9%
• Insignificant
• Significant reduction
Lincoln[14]
2008		 172 patients
• Prior ulceration
• specialist clinic		 Targeted, one-to-one education Usual care Re-ulceration at
• 1 year
2 years		 • 30%
• 41%		 • 20%
• 41%		 • Insignificant
• Insignificant
McCabe[13]
1998		 2002 patients
• high-risk
• general diabetic clinic		 Screening and referral to foot-care clinic if they had prior ulcer, had low ankle–brachial index (<0.75), or had foot deformities Usual care • Ulceration within 2 years
• Amputation rates		 • 2%
• 0.1%		 4%
1.2%		 • Insignificant
• Significant
Reiber[11]
2002		 400 patients
• Prior ulceration
• Excluded severe deformity		 Therapeutic shoes Usual footwear Re-ulceration 15% 17% Insignificant difference

External Links

References

  1. ↑ Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR; et al. (2006). "Diabetic foot disorders. A clinical practice guideline (2006 revision)". J Foot Ankle Surg. 45 (5 Suppl): S1–66. doi:10.1016/S1067-2516(07)60001-5. PMID 17280936.
  2. ↑ Borch-Johnsen K, Nissen H, Salling N, Henriksen E, Kreiner S, Deckert T; et al. (1987). "The natural history of insulin-dependent diabetes in Denmark: 2. Long-term survival--who and why". Diabet Med. 4 (3): 211–6. PMID 2956021.
  3. ↑ Gladwin MT, Schechter AN, Ognibene FP, Coles WA, Reiter CD, Schenke WH; et al. (2003). "Divergent nitric oxide bioavailability in men and women with sickle cell disease". Circulation. 107 (2): 271–8. PMID 12538427.
  4. ↑ Brownrigg JR, Davey J, Holt PJ, Davis WA, Thompson MM, Ray KK; et al. (2012). "The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: a meta-analysis". Diabetologia. 55 (11): 2906–12. doi:10.1007/s00125-012-2673-3. PMID 22890823.
  5. ↑ Meijer JW, Smit AJ, Sonderen EV, Groothoff JW, Eisma WH, Links TP (2002). "Symptom scoring systems to diagnose distal polyneuropathy in diabetes: the Diabetic Neuropathy Symptom score". Diabet Med. 19 (11): 962–5. PMID 12421436.
  6. ↑ Daousi C, MacFarlane IA, Woodward A, Nurmikko TJ, Bundred PE, Benbow SJ (2004). "Chronic painful peripheral neuropathy in an urban community: a controlled comparison of people with and without diabetes". Diabet Med. 21 (9): 976–82. doi:10.1111/j.1464-5491.2004.01271.x. PMID 15317601.
  7. ↑ 7.0 7.1 7.2 Litzelman D, Slemenda C, Langefeld C, Hays L, Welch M, Bild D, Ford E, Vinicor F (1993). "Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial". Ann Intern Med. 119 (1): 36–41. PMID 8498761.
  8. ↑ Hunt D. "Foot ulcers and amputations in diabetes". Clin Evid: 455–62. PMID 16620415. Text " based on September 2005 search" ignored (help)
  9. ↑ "Scope: Management of type 2 diabetes: prevention and management of foot problems (update)" (PDF). Clinical Guidelines and Evidence Review for Type 2 Diabetes: Prevention and Management of Foot Problems. National Institute for Health and Clinical Excellence. 20 February 2003. Retrieved 2007-12-04.
  10. ↑ Spencer S. "Pressure relieving interventions for preventing and treating diabetic foot ulcers". Cochrane Database Syst Rev: CD002302. doi:10.1002/14651858.CD002302. PMID 10908550.
  11. ↑ 11.0 11.1 11.2 Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C; et al. (2002). "Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial". JAMA. 287 (19): 2552–8. PMID 12020336.
  12. ↑ Uccioli L, Faglia E, Monticone G, Favales F, Durola L, Aldeghi A, Quarantiello A, Calia P, Menzinger G (1995). "Manufactured shoes in the prevention of diabetic foot ulcers". Diabetes Care. 18 (10): 1376–8. PMID 8721941.
  13. ↑ 13.0 13.1 McCabe CJ, Stevenson RC, Dolan AM (1998). "Evaluation of a diabetic foot screening and protection programme". Diabet Med. 15 (1): 80–4. doi:10.1002/(SICI)1096-9136(199801)15:1<80::AID-DIA517>3.0.CO;2-K. PMID 9472868.
  14. ↑ 14.0 14.1 Lincoln NB, Radford KA, Game FL, Jeffcoate WJ (2008). "Education for secondary prevention of foot ulcers in people with diabetes: a randomised controlled trial". Diabetologia. 51 (11): 1954–61. doi:10.1007/s00125-008-1110-0. PMID 18758747.

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