DIABETIC FOOT refers to the foot with any pathology which directly results from diabetes mellitus and includes infection, ulcers and/or deep tissue damage as well as neurological dysfunction and peripheral vascular disease. Diabetic foot syndrome belongs to the most serious complications of diabetes, especially when wounds occur, and its treatment requires a multidisciplinary approach.
DIABETES MELLITUS – a group of metabolic disorders which involve hyperglycemia resulting from disturbed insulin production or functioning or both.
Chronic diabetes can lead to serious complications:
- eyesight defects
- ischemic heart disease, cardiac infarction,
- renal disorders – diabetic neuropathy
- diabetic foot syndrome – disturbed vascularization and blood circulation can lead to ulcers and foot deformities and, consequently, to tissue necrosis and amputation.
Etiopathogenesis of diabetic foot syndrome:
- diabetic neuropathy
- mixed- neuropathic & ischemic (deep ischemia of lower limbs)
Diabetic foot syndrome affects:
- blood vessels,
Risk factors of amputation:
- Peripheral arterial disease
- Foot deformities (especially when mobility is limited)
- Callosity in the areas exposed to high pressure
- Previous ulcers and amputations ( as a result of diabetes complications)
- Vision problems
- Poor control of glycaemia
- Diabetes for more than 10 years
- feet injuries as a result of ill-fitting foot wear
- patient’s poor knowledge
- age over 40 years
- male gender
- poor foot care
Diabetic foot treatment and care require extensive diagnostics:
- Neuropathy symptoms, blood supply disturbances in lower limbs (Doppler ultrasound examination)
- Foot skin and nail processing by a specialist
- Long-term dressing application on the existing wounds
- Skin examination to assess: colour, thermal status, hair, perspiration, swelling and potential trophic changes
- Ulceration assessment: its location, depth, infection type (skin culture)
- Pulse evaluation in distinctive spots (dorsal artery of foot and posteriori tibial artery)
- Foot biomechanics assessment (deformities, joint mobility, foot shape especially after amputations)
- Sensation evaluation (touch, temperature, vibration and positioning)
- Autonomic system assessment (circulatory system responses: blood pressure variability, heart rate changes in deep breathing)
- Nerve conduction (febular, sural and median nerves)
- Heart rate measurements on: dorsal artery of foot, posteriori tibial artery, popliteal artery and femoral artery)
- Ankle-branchial index
- Doppler ultrasound examination
5. Radiological examination X-Ray, CT, NMR, bone scintigraphy.
6. Bacteriological examination: a swab culture from wound bed (ulcers, bone inflammation).
7. Analysis of pressure distribution on the feet.
8. Histopathologic examination –bone biopsy.
Photo gallery of cases:
Patient 1. – 64-year-old patient suffering from Diabetes Type 2.
Several-years’ changes on his left feet , ulceration on mid foot, under the big toe and the second toe pad as well as on the lateral foot part on both sides of the fistula. For many years the only treatment method involved a successive removal of the fibroma and wound courettage while the wound care focused mainly on sterile dressing and ointment application. The treatment was painful and tiresome and adversely affected the patient’s mental condition. Moreover, its poor results increased the sense of helplessness.
Staphylococcus aureus was identified in the obtained wound culture. The wounds were cleansed and long-term dressings were applied. The appropriate footwear was selected to release the pressure on the sore areas. Cornified skin was milled and callosity around the wounds was softened with urea-based keratin-dissolving agents. Ultrasound and X-ray examinations of the feet excluded any threatening changes.
The total treatment duration amounted to 14 months. However, the patient should be constantly monitored by podiatry and podology specialists owing to his diabetic neuropathy as he is at risk of wound opening. The patient was also advised to consult an angiologist to have Doppler ultrasound performed as a preventive action and to regularly check the glucose level and visit a diabetologist.
Patient 2. Type 2 diabetes patient (aged 48) after an amputation of the 4th toe of his left foot due to diabetic neuropathy complications.
A nail had stuck into the sole of the patient’s foot and caused swelling and reddening of 3rd toe. Previous interventions led to the amputation of the 4th toe. The patient came to our clinic with ulceration with necrotic fibrosis between the toes, profuse exudate, pain, reddening and swollen mid-foot and asked for immediate help.
The swab from the wound was collected to determine the bacteria so that oral antibiotic therapy could be implemented. CT was recommended to exclude any bone dislocation. The wound was decontaminated and the first stage of wound cleansing included the application of silver and absorption dressings. Pressure release pads were applied and appropriate footwear was recommended.
The second stage of treatment involved mill processing of cornified foot skin and oiling the skin with the agents for diabetic patients.
The total treatment and healing took 3 months. All that time the patient took good care of the wound immunisation and skin moisturising.
Patient 3. A patient suffering from insulin-dependent diabetes mellitus came to the clinic to treat the ulcer on the 2nd toe of his right foot and the resulting ulceration on the dorsal foot area.
High glucose level, improper diet and smoking added to the condition and led to a sudden swelling, pain and wounds.
Therefore, the wound treatment required glucose level stabilisation, strict diet and professional wound dressing.
The treatment took 4 weeks. Dietary restrictions and insulin injections required the control by the patient’s family.