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1. Patients with diabetic foot may present as an emergency with sepsis (with or without ischemia), they may also present with tissue loss.
2. A prompt diagnosis, clear pathway, management plan as well as urgent surgical intervention will cutback complications and reduce the risk of amputation.
3. Multidisciplinary team approach is inevitable, as these conditions may be life threatening.
The global prevalence of Diabetes Mellitus is 5.1% and is constantly rising. It is anticipated to be 7.7% by 20301. It is calculated that 15% - 25% of Diabetic patients will suffer from diabetic foot infection and ulceration. Whilst 60–80% of them will eventually heal, 5–24% will end with amputation.
Pathogenesis of foot problems
Many factors contribute to the development of diabetic foot. The main factors are peripheral neuropathy and peripheral vascular disease.
More than 60% of foot ulcers are predominantly due to primary neuropathy. This neuropathy affects all components of the nervous system: sensory, motor fibers, and autonomic system.
Sensory neuropathy affects both type A myelin fibers which is responsible for proprioception and pressure sensation and type C sensory fibers which is responsible for pain.
Loss of the protective sensation increases the risk of foot ulceration. Skin damage following any minor trauma will lead to foot infection and abscess formation that eventually leads to ulceration.
Motor neuropathy leads to atrophy of the interosseous and lumbricales muscles that lead to claw deformity of the toes and foot arch. These deformities lead to areas of high pressure at the head of the metatarsal bones that may not be noticed by patients as they usually have sensory loss.
The autonomic neuropathy leads to altered blood flow regulation and diminished sweating which is responsible for dry skin and fissures, consequently patient’s feet will be prone to infection and ulcers.
Although diabetic patients have warm swollen feet, they have reduced capillary flow as result of the microangiopathy which causes arteriovenous shunts.
Atherosclerosis in diabetic patients affects the crural vessels rather than the proximal vessels. The compromised blood flow to the feet may result in an ischemic ulcer or gangrene.
Problems with diabetic foot can be serious, not only it can lead to limb loss but can also be life threatening.
Patients may present with symptoms and signs limited to the foot or with systemic problems.
A detailed patient history including history of any recent trauma or systemic disease such as renal or cardiovascular problems should be taken. The diagnosis is usually reached by a high clinical suspicion through the history and physical examination.
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Patients with diabetic foot problems may present with sepsis and/or tissue loss. They may have lower limb ischaemia or normal blood flow.
b. Clinical features
Patients with foot infection may complain of pain, swelling, discharge, offensive odour, etc., they may also have ulceration or tissue loss. In septic cases other systemic symptoms and signs of infection such as poorly controlled hyperglycaemia, nausea, vomiting, fever, etc. will exist.
A thorough lower limb examination is mandatory. The examination should include full vascular and neurological assessment as well as assessment of the foot anatomy for deformities. If dorsalis pedis and posterior tibial pulses are not palpable, Ankle brachial pressure index (ABPI) should be calculated using Doppler (normal 0.9-1.3). The ABPI might be high if the vessels are calcified and non compressible. Transcutaneous oximetry and toe pressure will be helpful in these circumstances.
Routine blood tests including full blood count, blood glucose level, C-reactive protein, erythrocyte sedimentation rate, electrolytes, renal function tests and blood culture are important as a base line and eventually in a further management plan.
There are many modalities used for imaging the diabetic foot. The aim of imaging is to detect early changes of oesteomylitis and infection. More than one imaging modality is often required to achieve accurate diagnosis and management of acute diabetic foot complications.
Although a plain X ray is useful in detection of any foreign body or gas in the soft tissue it has lower sensitivity (40_ 60%) and specificity rates (60_90%) in early detection of oesteomylitis.
Ultrasonography is useful in detection of any collection as it can differentiate between reactive collection and collection resulting in infection. It also plays an important role in guided aspiration procedures for culture and sensitivity7. Currently the magnetic resonance imaging is the modality of choice in detecting osteomyelitis (sensitivity and specificity >80%) in diabetic patients with foot swelling (12, 14, 15).
Duplex scanning of the arterial system of the lower limb will provide valuable information about the blood flow and patency of the vessels. Although angiography is the gold standard for investigating the ischaemia, it should be limited as it carries risk of contrast media nephropathy especially in diabetic patients. On the other hand, MR angiography is useful for assessing occlusive disease and will help in planning for further management of the lower limb ischaemia.
Multidisciplinary team approach is essential in management of septic patients due to diabetic foot infection and complications. The cornerstone principles of management of these patients are antibiotic treatment and surgical debridement or amputation in conjunction with medical stabilisation. If the patient has underlying lower limb ischaemia, management of the foot infection will take priority over any revascularisation procedure.
1) Antibiotic treatment
Although the choice of antibiotic treatment should be based on the culture and sensitivity results, early empirical wide spectrum parenteral antibiotic treatment is recommended. The antibiotic choice is usually based on severity of the infection and the expected pathogen15. Mild infection is often due to gram positive Staphylococci aureus bacteria only (26, 36, 37), on the contrary severe infection is usually caused by polymicrobial pathogens (mixed gram-positive, gram-negative and anaerobic bacteria) (25, 27, 28). Methicillin-resistant Staphylococcus aureus (MRSA) infection is isolated in 30% - 40% of patients. The presence of resistant bacteria species is associated with treatment failure and consequently the high risk of amputation.
2) Surgical Management
Surgical Management of Diabetic foot complications is dependent on the viability of the foot and leg. The aim of early debridement is to assess the extent of infection and bone destruction as well as the amount of bleeding from the wound edges (44_47). Drainage of any collection, opening all the infected tracks and excision of all non viable and slough tissues are crucial.
Intra-operative bone and deep tissue cultures should be sent for microbiology and histopathology. It is not uncommon that patients may require multiple surgical debridement to ensure satisfactory control of infection.
Trnasmetatarsal amputation is essential if there is extensive planter infection or forefoot gangrene. Below knee amputation may be feasible in patients with extensive bone destruction and infected non healing ulcers as a result of extensive neuroarthropathy Charcot foot.
Wound healing after surgical debridement is quite challenging. Numerous studies illustrated the value of negative-pressure wound therapy in assisting the wound healing of the diabetic foot (4_6). After wound stabilisation skin graft, flaps or reconstruction may also be required to achieve satisfactory functional lower limb (3_5).
In patients with ischaemia, prompt revascularisation is imperative to improve clinical outcome and limb salvage rate. Most Diabetic patients have co existing co-morbidities, therefore they are at high perioperative risk1,2.
The results of both vein bypass graft surgery and below knee angioplasty are comparable 1,5,8. Percutaneous transluminal angioplasty +/- stenting is currently the procedure of choice for treatment of any significant stenotic or occlusive atherosclerotic lesions. A hybrid procedure may be necessary to accomplish lower limb revascularisation (2, 55).
Aftercare and Prevention
Following complete wound healing and recovery from foot surgery, patients are likely to develop foot deformity. Appropriate footwear is essential to avoid high pressure areas and developing recurrence of foot ulceration and consequent complications. Patients should be reviewed on a regular basis by a multidisciplinary team to avoid risk of amputation.