Diabetic foot overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vishnu Vardhan Serla M.B.B.S. [2] Anahita Deylamsalehi, M.D.[3] Usama Talib, BSc, MD [4]
Overview
Type 2 diabetes and its complications are now considered as a growing health threat. It is the leading cause of blindness, end stage renal disease, coronary heart disease and foot ulceration which leads to amputations. In general, the incidence of nontraumatic lower extremity amputations has been reported to be at least 15 times greater in those with diabetes than with any other medical illness. Among patients with diabetes, the lifetime risk of having foot ulcer is 15%. Diabetic foot ulcers dramatically worsen the physical, psychological and social quality of life [1]. 1 in every 4 patients with diabetes develops complications. The pathogenesis of diabetics foot is due to two causes i.e. neuropathy and vasculopathy. Due to neuropathy the patient loses sensation whereas, vasculopathy causes poor blood supply to the foot region. Due to both these contributing factors, even a small trauma to the feet can give rise to ulcer or gangrene and may even require amputation. Thus, foot examination by a podiatrist or a doctor is recommended every year.
Historical Perspective
The discovery of the association between diabetes and foot ulceration and subsequent infection dates back to the 1850s. Significant breakthroughs in the management of diabetic foot wounds include the introduction of surgical debridement occurred in the early 1900s by Frederick Treves. He also introduced the critical role of footwear in diabetic foot ulcers. Furthermore the discovery of penicillin in 1928 by Alexander Fleming reduced the mortality rate of diabetic foot patients and their related complications significantly. Throughout the 20th century, advances in surgical limb revascularization and the advent of angioplasty drastically reduced the need for amputation. The latter method remained the mainstays of diabetic foot management, in the 2004 and 2012 Infectious Disease Society of America guidelines.
Classification
Diabetic foot is classified based on ulcer's features in order to assist with clinical decision-making regarding the need for oral or parenteral antibiotics, outpatient management, hospitalization, and surgical intervention. There are multiple methods of classification for diabetic foot. One of them that has been published by The Infectious Disease Society of America (IDSA) in their 2004 guideline and mainly has been focused on the extent of infection and inflammation of the ulcer. In addition another similar classification system has been released by The International Working Group on the Diabetic Foot (IWGDF) in 2012. The aforementioned systems were externally validated in a longitudinal study to assess prognostic value, which demonstrated increased risk for amputation among patients with infections classified as severe. Another widely accepted diabetic foot ulcer classification is Wagner ulcer classification system, which uses some ulcer's features such as depth, in addition to presence of osteomyelitis or gangrene.
Pathophysiology
Causes
Differentiating Diabetes foot other Diseases
Epidemiology and Demographics
The incidence of active diabetic foot ulcers is approximately 630 per 100,000 diabetic individuals world wide. According to an other estimate the incidence of diabetic foot ulcers is approximately 1500 per 100,000 individuals worldwide. The 5 year risk of mortality in diabetic patients with a foot ulcer is 2.5 times higher than diabetic individuals without a foot ulcer. Diabetic foot ulcer has a higher incidence in men.[2][3][4][5]
Risk Factors
Screening
Natural History, Complications and Prognosis
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. The complications of diabetic foot ulcers include infection, sepsis, osteomyelitis and death.[6][2]
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
Chest X Ray
CT
MRI
Echocardiography or Ultrasound
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Appropriate wound care is essential for the management of all diabetic foot ulcers. Uninfected diabetic ulcers do not require antibiotic therapy. For acutely infected wounds, empiric antibiotic with efficacy against Gram-positive cocci should be initiated after obtaining a post-debridement specimen for aerobic and anaerobic culture. Infections with antibiotic-resistant organisms and those that are chronic, previously treated, or severe usually require broader spectrum regimens.
Surgery
Primary Prevention
The primary prevention of diabetic foot ulcer includes control of blood sugar levels , pressure offloading, frequent physical examinations, good foot hygiene, diabetic socks and shoes, and by avoiding injury.
Secondary Prevention
The secondary prevention of diabetic foot ulcer includes pressure offloading, prevention of infection, treatment of infection, debridement and reconstruction of the damaged blood vessels, along with the use of primary preventive strategies.[2]
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
References
- ↑ Assal JP, Mehnert H, Tritschler HJ, Sidorenko A, Keen H, Hellmut Mehnert Award Workshop Participants (2002). "On your feet! Workshop on the diabetic foot". J Diabetes Complications. 16 (2): 183–94. PMID 12039404.
- ↑ 2.0 2.1 2.2 Armstrong DG, Boulton AJM, Bus SA (2017). "Diabetic Foot Ulcers and Their Recurrence". N Engl J Med. 376 (24): 2367–2375. doi:10.1056/NEJMra1615439. PMID 28614678.
- ↑ Abbott CA, Carrington AL, Ashe H, Bath S, Every LC, Griffiths J; et al. (2002). "The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort". Diabet Med. 19 (5): 377–84. PMID 12027925.
- ↑ Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y (2017). "Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis (†)". Ann Med. 49 (2): 106–116. doi:10.1080/07853890.2016.1231932. PMID 27585063.
- ↑ Boyko EJ, Ahroni JH, Cohen V, Nelson KM, Heagerty PJ (2006). "Prediction of diabetic foot ulcer occurrence using commonly available clinical information: the Seattle Diabetic Foot Study". Diabetes Care. 29 (6): 1202–7. doi:10.2337/dc05-2031. PMID 16731996.
- ↑ Brownrigg JR, Davey J, Holt PJ, Davis WA, Thompson MM, Ray KK; et al. (2012). "The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: a meta-analysis". Diabetologia. 55 (11): 2906–12. doi:10.1007/s00125-012-2673-3. PMID 22890823.