Diabetic foot

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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)

Diabetic foot Microchapters
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Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Diabetic foot from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
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Echocardiography or Ultrasound
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Treatment
Medical Therapy
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Primary Prevention
Secondary Prevention
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Ongoing Trials at Clinical Trials.gov
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Diabetes mellitus Main page
Patient Information Type 1 Type 2
Overview
Classification Diabetes mellitus type 1 Diabetes mellitus type 2 Gestational diabetes
Differential Diagnosis
Complications
Screening
Diagnosis
Prevention

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

Gender

In 1987, Borch-Johnsen et al. described a male preponderance for the development of severe microvascular complications . 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 . 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.

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) and neuropathy disability score (NDS),. Almost half of the patients with diabetes have some level of neuropathy prior to diagnosis. the physician should assess;

• Muscle strength and tone
• Temperature
• Sensation
• Light touch
• Filament nerve conduction studies
• Quantitative sensory testing and autonomic testing.

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 .

• 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" .

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

A meta-analysis by the Cochrane Collaboration concluded that "there is very limited evidence of the effectiveness of therapeutic shoes" . 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). A prior, smaller, non-randomized trial that showed benefit of custom foot wear in patients with a prior foot ulceration.. In this trial, the number needed to treat was 4 patients.

Randomized controlled trials of interventions to prevent complications of diabetic foot.

Trial	Patients	Intervention	Comparison	Outcome	Results		Comment
					Intervention	Control
Litzelman 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 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 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 2002	400 patients • Prior ulceration • Excluded severe deformity	Therapeutic shoes	Usual footwear	Re-ulceration	15%	17%	Insignificant difference

External Links

• Diabetic Foot Research Page at the Center for Lower Extremity Ambulatory Research; for Professionals and Patients
• Imaging of the Diabetic Foot and Its Complications
• Assessing The Potential of Nitric Oxide in the Diabetic Foot
• Maggot Therapy Project