DIABETIC FOOT BOOK
Editors: Veves, Aristidis, Giurini, John M., Guzman, Raul J. (Eds.) In the fourth edition of this gold-standard title, a distinguished panel of experts provides a thorough update of the significant improvements in our understanding of diabetic foot physiology and its clinical. This book provides a comprehensive guide for all healthcare professionals managing diabetic foot problems including general practitioners, nurses, podiatrists. Fully updated, now in full color, this latest edition of Levin and O'Neal's The Diabetic Foot continues the work's proud tradition of.
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Diabetic foot ulcers (DFU) are associated with significant impairment of quality of life, increased morbidity and mortality and are a huge drain on. Diabetes mellitus is associated with a series of macrovascular and microvascular changes that manifest in a wide range of complications. "This book is a must for any practitioner treating diabetic foot patients. With an array of authors from renowned institutions, this book has satisfactorily taken on.
Diabetic Foot Ulcer Care: Assessment and Management Imaging of the Diabetic Foot Noninvasive Vascular Testing: Modulating Wound Healing in Diabetes Footwear for Injury Prevention: Correlation with Risk Category Charcot Neuropathy of the Foot Surgical Aspects Surgical Pathology of the Foot and Clinicopathologic Correlations Plastic Surgical Reconstruction of the Diabetic Foot Charcot Neuropathy of the Foot: Rehabilitation of the Diabetic Amputee Section D: Team Approach Lower Limb Self-Management Education Role of the Wound Care Nurse Thus, patients with neuropathy frequently choose shoes that are too small.
Other simple examples of two risk factors working together in the pathway to ulceration are neuropathy and mechanical trauma common scenario is a neuropathic patient with a foreign body in the shoe , neuropathy and thermal trauma holidays are particularly dangerous and neuropathy and chemical trauma such as inappropriate use of over-the-counter chemical corn treatments which should never be used in patients with neuropathy.
In summary, whereas neuropathy was present in four out of five cases of new foot ulcers in the Reiber study 17 , as noted above, the combination of neuropathy and ischemia is becoming more common and in Western countries, and neuro-ischemic ulcers are the commonest type seen in in diabetic foot clinics.
DFUs are common, associated with much morbidity and even mortality but should be eminently preventable. It used to be believed that diabetic foot ulcers were difficult to heal: Despite increased knowledge of the pathogenesis and treatment of diabetic foot ulcers in recent years, it is still the third point, offloading the wound, that is poorly adhered to by health care professionals. That pain is a gift which is only realised when it is lost, as first described by Dr Paul Brand when studying leprosy However, before going into more detail on management, it is important to classify wounds appropriately in order to guide therapeutic management.
Accurate and concise ulcer description and classification systems are required to improve multidisciplinary collaboration and communication, as well as for aiding treatment choices. For many years, the Meggitt-Wagner grading system was regarded as the gold standard. One problem with this system is that the ischemic status of the wound is not included. Thus a number of new classification systems for diabetic foot wounds have been proposed and validated over the last 20 years. In a comparative prospective study across two Centres, one in the UK and one in the US, the University of Texas Classification System was shown to be superior to the Meggitt-Wagner system at predicting outcomes However, this study also showed that the traditional Meggitt-Wagner system was itself generally accurate in predicting outcomes.
View in own window. Clinical evaluation of the foot wound should include a detailed description of the site, size and depth of the wound. The neuropathic and vascular status of the wound should then be assessed for details see below. In general, neuropathic ulcers typically occur in the warm but insensate foot, often under pressure bearing areas, and are surrounded by callus.
In contrast, ischemic wounds tend to occur in the cool, poorly perfused foot and are often at lateral fifth metatarsal head regions or the medial first metatarsal head regions. In a predominantly ischemic wound, callus tissue is uncommon.
In a neuroischemic wound, the morphology will depend upon the predominance of each of these two pathologies. The correct identification of the degree of ischemia is of the utmost importance when evaluating a wound.
The Diabetic Foot
If the foot is cool with impalpable pulses then non-invasive Doppler ultrasound studies are indicated. Conventional methods of assessing tissue perfusion in the peripheral circulation may not be entirely reliable in patients with diabetes. For example, the Ankle Brachial Pressure Index, which is routinely used to screen for PVD in non-diabetic individuals, may well be falsely elevated in the patient with diabetes because of medial arterial calcification. Toe pressure indices may therefore be more reliable.
A detailed discussion of vascular procedures is outside the scope of this review, although any patient being considered for radiological or surgical procedures will require arteriography. Care must be taken in the use of certain dyes in patients with chronic renal disease. A detailed discussion of the assessment of foot perfusion in foot ulcer patients is provided in a recent review by Forsythe and Hinchliffe The correct diagnosis of infection in the diabetic foot wound is critical as it is often the combination of untreated infection and PVD that lead to amputation in the diabetic foot.
International Guidelines which were revised in still recommend that the diagnosis of infection requiring treatment is a clinical one. However, appropriate tissue specimens should be sent to the microbiological laboratory for culture and sensitivity. Superficial swabs are of little use: A high index of suspicion for the presence of osteomyelitis is essential when assessing the diabetic foot wound.
A recent systematic review concluded that the PTB test can accurately diagnose osteomyelitis in high-risk patients, and rule out osteomyelitis in low risk patients The plain radiograph remains the commonest first radiological investigation of an acutely presenting diabetic foot problem.
These latter studies are of limited availability and are expensive, and some carry a high radiation burden. They have their own sensitivity and specificity problems and may not be available in a timely manner. The plain radiographic findings could then be considered of high sensitivity and specificity, but with a two week lag, both for diagnosis and for response to treatment. Appropriate clinical information for the reporting radiologist must include that the patient is diabetic, whether an ulcer is present and if so, its precise anatomical location and whether it probes to bone.
The radiologist should be aware that most sites of acute osteomyelitis in the diabetic foot occur in the floor of an ulcer that probes to bone and that if the foot is neuropathic there may be acute fractures without a history of trauma or acute CN may be present.
Whilst periosteal reaction is an early feature of osteomyelitis, it is not commonly seen around the small bones of the foot, and if present, is most often seen around metatarsals, and may be due to fracture rather than osteomyelitis.
The hallmark plain radiographic feature of osteomyelitis in the diabetic foot is focal loss of bone density, almost invariably adjacent to the floor of an ulcer. Whilst sometimes described as bone destruction, it is initially bone de-mineralisation that causes this appearance, which can reverse on successful treatment, with radiographic re-appearance of the apparently destroyed bone Figure 3.
Obtaining the radiographic view most likely to demonstrate the bone in the floor of an ulcer is therefore an important consideration, often overlooked now that requests are electronic and radiographic views are selected from limited drop down menus.
For example, toe-tip ulcers and ulcers on the dorsum of the inter-phalangeal joints require lateral toe views - best obtained using dental radiographs if available; the inferior surfaces of metatarsal heads are best demonstrated on sesamoid views; the heel requires both lateral and axial views.
As a general rule, radiographs tangential to the bone surface at the site of suspected osteomyelitis are ideal, in addition to the standard radiographs of the region. A dedicated team of radiographers familiar with these requirements will improve the relevance and quality of the resultant radiographs.
Plain radiology remains an important investigation in the diagnosis and management of diabetic foot osteomyelitis, but it needs to be of high quality, with appropriate views, and regularly repeated to fulfil its potential. Acute presentation with an ulcer at the tip of the great toe, probing to bone. The terminal phalangeal tuft does show some irregularity left panel. C After 2 months of treatment there has been partial remineralisation of the bone but with an underlying pathological fracture right panel.
The principles of management of different types of foot ulcers will be discussed in brief in this section. The UT Wound Classification system will be used throughout.
High Risk Diabetic Foot: Treatment and Prevention
As noted above, neuropathic ulcers tend to occur under pressure areas, particularly at the plantar surface of the forefoot. Other recognized sites include the dorsal areas of the toes, particularly the distal inter-phalangeal joint if there is clawing of the toes.
In patients with marked deformities such as those caused by CN, ulcers may occur at other pressure points, particularly in the plantar mid-foot due to, for example, a dropped cuboid bone. Thus the management of a plantar neuropathic foot ulcer that is not infected is firstly sharp debridement of the ulcer down to bleeding healthy tissue with removal of all callus tissue over the wound and the edge, and secondly, the removal of pressure from the wound while the patient is walking.
Pain sensation normally protects wounds from further damage causing the non-neuropathic individual to limp.
Any patient with a plantar ulcer who walks into the clinic without limping must, by definition, have loss of pain sensation.
A neuropathic diabetic patient with a plantar ulcer will therefore walk on the ulcer as there is no warning symptom to inform him or her otherwise. Techniques for removing pressure include the use of casts either removable or irremovable , boots, half shoes, sandals and felted foam dressings. The total contact cast TCC is regarded as the gold standard.
Studies that randomize patients to an irremovable TCC, a removable cast Walker RCW or other offloading devices invariably confirm that healing is fastest in the irremovable device 7, Although RCWs and irremovable casts such as the TCC offload equally well in the gait laboratory, the irremovable device is always associated with more rapid healing in clinical practice.
The problem is that patients with neuropathic foot ulcers have lost the sensory cue that tells them not to walk on their active ulcer. Studies suggest that patients are compliant with wearing the offloading RCW during the day, but feel that home is safer and therefore tend to put slippers on, or even walk barefoot at home.
A subsequent trial has confirmed that if the RCW is rendered irremovable by wrapping with scotch cast for example, then the outcome is that there is no difference in healing rates between the TCC and the RCW rendered irremovable Most patients with simple neuropathic foot ulcers UT grades 1A, 2A, 1B, 2B generally heal in less than three months although of course this does vary with ulcer size.
There is no contraindication to casting neuropathic patients with mild foot infections UT grades 2A, 2B. It is recommended that after the wound is healed, offloading should continue for a further four weeks to enable the scar tissue to firm up.
Wound dressings are important to keep the ulcer clean, but the placement of a large dressing on a wound may lead the patient to a false sense of security by believing that dressing an ulcer is curative.
Nothing could be further from the truth in the neuropathic ulcer.
Levin and O'Neal's The Diabetic Foot with CD-ROM
Unfortunately, there is little evidence from randomized controlled trials RCTs that any dressing is superior to another. Indeed Jeffcoate and colleagues 33 randomized patients to one of three dressings and could find no difference in outcome according to dressing used: Thus, without an evidence-base, there is no indication to use some of the newer more expensive dressings. A neuro-ischemic ulcer is one occurring in a foot of a diabetic patient who has both a neuropathic deficit and impaired arterial inflow: Such patients warrant a full vascular investigation as described above, and referral to the vascular surgery team.
The principles of treatment are similar to those for neuropathic ulcers, and it has been confirmed that offloading can safely be used in non-infected neuro-ischemic ulcers under a weight-bearing area.
However, antibiotics should be used if there is any suspicion whatsoever of infection and casting only used with extreme caution in such cases With respect to the effectiveness of revascularization of the ulcerated foot in those with neuro-ischaemic lesions, results showed that major outcomes following endovascular or open bypass surgery were similar amongst studies Appropriate wound debridement and offloading together with antibiotics are important in the management of the infected neuropathic foot ulcer, although there are few data from randomized trials to guide the prescriber There is however no evidence that clinically non-infected neuropathic ulcers warrant treatment with antibiotics.
With respect to choice of antibiotic therapy, the reader is directed to the helpful Infectious Diseases Society of America Clinical Practice Guideline Commonly used broad-spectrum antibiotics include Clindamycin, Cephalexin, Ciprofloxacin and the Amoxycillin — Clavulanate potassium. Oral antibiotics usually suffice for mild infections, whereas more severe infections including cellulitis and osteomyelitis require intravenous antibiotic usage initially.
Care should also be taken to optimize glycemic control, as hyperglycemia impairs leucocyte function. The above statements on antibiotics refer to initial treatment: Finally, with respect to duration of antibiotics, there are no data available from randomized trials to help guide the practitioner.
Medical and Surgical Management
Antibiotics should be continued until clinical signs of infection have resolved, but there is no indication to continue antibiotics beyond this period of time and certainly no indication to continue until the wound has healed.
A recent review by Lipsky has identified the challenges facing us due to the increasing threat of multidrug-resistant pathogens Diagnosis of osteomyelitis has been discussed above both relating to the PTB test and also the use of plain radiographs. Although the treatment of osteomyelitis has traditionally been surgical, there is increasing evidence from case series and a RCT, that osteomyelitis localized to one or two bones, such as digits, may successfully be treated with antibiotics alone 38, A randomized trial from Spain showed that antibiotics alone were not inferior to localized surgery In recent years, many new adjunctive therapies, including skin substitutes, oxygen and other gases, products designed to correct abnormalities of wound biochemistry and cell biology associated with impaired wound healing, applications of cells, bioengineered skin and others, have been proposed to accelerate wound healing in the diabetic foot.
A recent internationally conducted systemic review concluded that there was little published evidence from appropriately designed clinical trials to justify the use of such newer therapies HBO has been promoted as an effective treatment in diabetic foot wounds over many years 9.
However, early RCTs have been criticized because of the small numbers of patients enrolled, and methodological and reporting inadequacies. A well designed and blinded RCT was conducted in Sweden some years ago suggesting the benefit of HBO in chronic neuro-ischemic infected foot ulcers with no possibility of revascularization More recently, there have been two negative studies including a large retrospective cohort trial 43 and a multi-center Canadian study that showed no benefits of HBO whatsoever in any patient group Thus, at present, the use of HBO in any diabetic foot wound has few data to support its efficacy.
A multi-centre trial is underway in the Netherlands which will be the largest trial ever performed for the use of HBO in diabetic foot ulcers; results should be available by late The application of NPWT is believed to accelerate healing through reducing edema, removal of exudate, increased perfusion, self-proliferation and the formation of granulation tissue RCTs have suggested efficacy in rates of wound healing and reduced amputations, with the application of NPWT in both post-surgical and non-surgical chronic non-healing ulcers 47, A recent systematic review confirmed that there was some evidence to support the use of NPWT in post-operative wounds Charcot neuroarthropathy, although uncommon, is a potentially devastating late complication of diabetic neuropathy Although the exact mechanisms resulting in the development of CN remain unclear, much progress has been made in our understanding of the etiopathogenesis of this disorder over the last decade.
CN occurs in a well-perfused foot with both somatic and autonomic neuropathy: A history of trauma may be present though may be missed because of the severe sensory loss. Although, in its pathogenesis, there are many unanswered questions, improved understanding in recent years of the role of inflammatory pathways might lead to new pharmacologic approaches in the acute phase of the condition. The outcomes in terms of management of CN have been generally poor because of ignorance that leads to delayed diagnosis.
Most important in the management of this condition is recognition of the acute Charcot foot. Any patient with known neuropathy who presents with a warm, swollen foot of unknown causation should be presumed to have acute CN until proven otherwise. Contrary to earlier reports, many patients may present with painful, difficult to describe symptoms in the affected foot despite significant neuropathy.
In its early stages, all investigations may be normal, including the foot x-ray.
The role of the radiologist in the diagnosis of acute and chronic CN is discussed in the next section. As with acute osteomyelitis see above , the initial radiographs in acute CN may appear almost normal, though it is common for soft tissue swelling to be present and radiographically visible, usually over the dorsum of the foot.
It is consequently imperative that both the clinician and the radiologist are aware of the possibility of this condition being present. The first more specific radiographic feature is bone demineralisation, usually subchondral or periarticular, around the joint s involved by the acute CN process in contrast to acute osteomyelitis, where it is related to the ulcer location. Focal peri-articular fractures may then develop Figure 4.
If CN is suspected, despite non-diagnostic initial radiographs, then the options are to treat as acute CN see below and perform serial radiographs at one to two week intervals until the diagnosis is confirmed or no longer clinically suspected, or treat similarly whilst arranging urgent radiological investigation with a more sensitive test whilst repeating the radiographs if the further tests are delayed.
If the MR scan shows no marrow signal abnormality in the foot, acute CN is unlikely. Buy this book Digital Version: CHF Order this title. In recent years, "diabetic foot" has become the common name given to chronic complications of diabetes mellitus in the lower limb. This book provides an up-to-date picture of the clinical scenario, the latest understanding of the mechanisms in regard to pathology, the current standards of therapy, and the organizational tasks that a modern approach to such a complex pathology warrants.
All contributors have delivered articles that are as informative and straight-to-the point as possible, including not only their own experience in the field, but also giving a wider picture to link each article to the other. The Diabetic Foot Syndrome is not only relevant to specialists, but also to all the caregivers involved in the management of the patients at risk for developing the pathology, those affected, and those who are at risk of recurrences.
Bibliographic Details.Plain radiographs can provide useful information in the presence of a diabetic foot ulcer when there is suspected soft tissue emphysema. Pedorthoic Care of the Diabetic Foot In a predominantly ischemic wound, callus tissue is uncommon. Mussa Open arterial reconstruction of the diabetic foot Joseph J.
As discussed above, a team approach is necessary to provide timely, appropriate care for these patients. Jones Preventing foot complications Lawrence A. Although ertapenem did not provide specific coverage for Pseudomonas or Enterococcus species, at the end of the therapy period the success rate for both groups of patients was similar.
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