An open diabetic foot ulcer may require debridement if necrotic or unhealthy tissue is present. The debridement of the wound will include the removal of the surrounding callus, which decreases the pressure points at the callused sites on the foot. Additionally, the removal of unhealthy tissue can aid in removing colonizing bacteria in the wound. It will also facilitate the collection of appropriate specimens for culture and permit examination for the involvement of deep tissues in the ulceration. Infection in a diabetic foot is limb threatening and at times life threatening, and therefore, must be treated aggressively.
Superficial infections should be treated with debridement, oral antibiotics, and regular dressings. Deep infections are considered when the signs of infection are combined with evidence of involvement of deeper tissue structures such as bones, tendons or muscles. Although superficial infections are usually caused by gram-positive bacteria, the deep foot infections are invariably polymicrobial and caused by gram-positive bacteria, gram-negative bacteria, and anaerobes.
All patients with deep infections should be hospitalized and started on broad-spectrum antibiotics. Surgical debridement should be carried out, which should include all the devitalized tissues, sloughed tendons, and infected bones. Multiple injections of insulin or continuous insulin infusion should be instituted to achieve metabolic control. The selection of wound dressings is also an important component of diabetic wound care management.
Atlas of the Diabetic Foot, 3rd Edition
Saline-soaked gauze dressings, for example, are inexpensive, well-tolerated, and contribute to an atraumatic, moist wound environment. Some of the newer dressings are — film dressing, foam dressing, non-adherent dressings, hydrogels, hydrocolloids, and alginates. The treating foot care team has to make an appropriate choice of dressing for a particular type of wound.
A number of adjunctive wound care treatments are under investigation and in practice for treating diabetic foot ulcers. The use of human skin equivalents has been shown to promote wound healing in diabetic ulcers via the action of cytokines and dermal matrix components that stimulate tissue growth and wound closure. It is spread over the wound and covered with non-adherent, saline-soaked gauze dressing.
The dressing is changed once or twice every day. It has to be realized that this gel therapy is effective only if other modalities such as recurrent surgical debridement of the ulcer and offloading are adhered to. Patients with evident peripheral ischemia need revascularization as adequate arterial blood supply is necessary to facilitate wound healing and resolve the underlying infection.
Surgical bypass is a common method of treatment for ischemic limbs, and favorable long-term results have been reported. Transluminal angioplasty of the iliac arteries in conjunction with a surgical bypass in the distal extremity may be implemented, and efficacy has been demonstrated in diabetic patients.
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Early detection of potential risk factors for ulceration can decrease the frequency of wound development. It is recommended that all patients with diabetes undergo a foot examination at least annually, to determine the predisposing conditions to ulceration. Patients should be educated regarding the importance of maintaining good glycemic control, wearing appropriate footwear, avoiding trauma, and performing frequent self-examinations.
Atlas of the Diabetic Foot, 3rd Edition
Primary prevention: Screening of high risk feet and proper advice on preventive footwear. Secondary prevention: Management of trivial foot lesions such as callus removal, treatment of nail pathologies, deroofing blisters, and so on. Tertiary prevention: Prompt referral to a specialist for advanced foot lesions. Significant limb salvage and prevention of amputation is achieved by training of primary care physicians and their paramedics in diabetic foot care.
The Step by Step Project of improving diabetic foot care was recently executed by the author under the auspices of the World Diabetes Foundation. Patient education and lifelong surveillance are essential to protect feet at risk from ulceration. Patients need to realize that high risk feet need to be used sparingly. The activity level should be as minimal as possible. Understanding the diabetic foot, proper examination of feet, investigations to classify the foot ulcers, and proper management techniques using a team approach, along with preventive steps, would go a long way in limb salvage and prevention of limb amputation in people with diabetes.
I acknowledge the contribution of Dr. Rutuja Sharma for assisting me in the preparation of the manuscript. Source of Support: Nil. Conflict of Interest: None declared. National Center for Biotechnology Information , U. Int J Diabetes Dev Ctries. Sharad P. Author information Article notes Copyright and License information Disclaimer. Corresopondence to: Dr. Dhantoli Park, Nagpur — , India. E-mail: ni. Received Jan 28; Accepted Mar 4. Keywords: Neuropathy, peripheral vascular disease, infected foot, deformed foot.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC. Introduction Diabetic foot is often quite a dreaded disability, with long stretches of hospitalization, and impossible, mounting expenses, with the ever dangling end result of an amputated limb.
Pathogenesis Diabetic foot ulcers result from the simultaneous actions of multiple contributing causes.
Neuropathy Neuropathy in diabetic patients is manifested in the motor, autonomic, and sensory components of the nervous system. Peripheral vascular disease Although atherosclerosis in patients with diabetes is similar to that seen in nondiabetics, it is generalized, occurs prematurely and progresses at an accelerated pace. Foot infection Infection in a diabetic foot is a limb threatening condition because the consequences of deep infection in a diabetic foot are more disastrous than elsewhere mainly because of certain anatomical peculiarities.
Osteomyelitis Osteomyelitis generally results from a contiguous spread of deep soft tissue infection through the cortex to the bone marrow. Classification Diabetic foot is classified into two major types. The Neuropathic Foot where neuropathy dominates The Neuroischemic Foot, where occlusive vascular disease is the main factor, although neuropathy is present. Open in a separate window.
Examination of feet Examination of the feet is an integral part of the physical examination of every patient, more so a diabetic patient. Management Diabetic foot should be managed using a multidisciplinary team approach. Dressing material The selection of wound dressings is also an important component of diabetic wound care management. A wide variety of new dressing materials have been developed. Revascularization Patients with evident peripheral ischemia need revascularization as adequate arterial blood supply is necessary to facilitate wound healing and resolve the underlying infection.
Prevention Early detection of potential risk factors for ulceration can decrease the frequency of wound development.
Prevention of diabetic foot includes: Primary prevention: Screening of high risk feet and proper advice on preventive footwear Secondary prevention: Management of trivial foot lesions such as callus removal, treatment of nail pathologies, deroofing blisters, and so on. Acknowledgments I acknowledge the contribution of Dr. References 1. Peripheral vascular disease and diabetes.
Diabetes in America. NIH Pub. Pendsey S. Diabetic Foot: A Clinical Atlas.
Jaypee Brothers Medical Publishers. Pathways to diabetic limb amputation: Basis for prevention. Diabetes Care. Pendsey S, Abbas ZG. The Step — by — step program for reducing diabetic foot problems: A model for the developing world.
Curr Diab Rep. Diabetic foot ulcers: Prevention, diagnosis and classification. Am Fam Physician. Kelkar P.
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