DIABETIC FOOT emedicine

Introduction Diabetic foot ulcers (DFUs) precede 85% of nontraumatic lower extremity amputations (LEAs). Approximately 3-4% of individuals with diabetes currently have foot ulcers or deep infections.

Semmes-Weinstein 5.07 (10 g) monofilament; the monofilament is applied to the high-risk areas on the plantar surface of the foot (ie, toe pulps, metatarsal heads, heel). Patients who cannot feel pressure from the monofilament have lost protective sensation and are at risk of developing a diabetic foot ulcer. Among persons with diabetes, 15% develop foot ulcers during their lifetime. Their risk of LEA increases by a factor of 8 once an ulcer develops. At 2 years following transtibial amputation, 36% of these patients are known to have died. Patient education Patients should be provided the following information regarding daily foot care 1 :

Wash feet every day with mild soap and warm water. Test the water temperature with your hand first. Don't soak your feet. When drying them, pat each foot with a towel and be careful between your toes. Use quality lotion to keep the skin of your feet soft and moist, but don't put any lotion between your toes. Trim your toenails straight across. Avoid cutting the corners. Use a nail file or emery board. If you find an ingrown toenail, see your doctor. Don't use antiseptic solutions, drugstore medications, heating pads, or sharp instruments on your feet. Don't put your feet on radiators or in front of the fireplace. Always keep your feet warm. Wear loose socks to bed. Don't get your feet wet in snow or rain. Wear warm socks and shoes in winter. Don't smoke or sit cross-legged. Both decrease blood supply to your feet. Never walk barefoot or in sandals or thongs. Choose and wear your shoes carefully. Buy new shoes late in the day when your feet are larger. Buy shoes that are comfortable without a "breaking in" period. Check how your shoe fits in width, length, back, bottom of heel, and sole. Avoid pointed-toe styles and high heels. Try to get shoes made with leather upper material and deep toe boxes. Wear

new shoes for only 2 hours or less at a time. Don't wear the same pair every day. Inspect the inside of each shoe before putting it on. Don't lace your shoes too tightly or loosely. Choose socks and stockings carefully. Wear clean, dry socks every day. Avoid socks with holes or wrinkles. Thin cotton socks are more absorbent for summer wear. Square-toe socks will not squeeze your toes. Avoid stockings with elastic tops.

Frequency Among persons with diabetes, 15% develop diabetic foot ulcers (DFUs) during their lifetimes. Currently, 3-4% of individuals with diabetes have deep infections or DFUs. Etiology Peripheral neuropathy Peripheral neuropathy affects sensory, motor, and autonomic pathways. Sensory neuropathy deprives the patient of early warning signs of pain or pressure from footwear, from inadequate soft-tissue padding, or from infection. This neuropathy appears in a stocking-glove distribution, with many patients complaining of burning or searing pain. 2 Optimal control of blood glucose levels decreases the incidence of most diabetes-associated organ system morbidity. The primary risk factor for the development of diabetic foot ulcers (DFUs) is loss of protective sensation, best measured by insensitivity to the Semmes-Weinstein 5.07 (10 g) monofilament (see Image 1). Abnormal white blood cell (WBC) function and the presence of peripheral vascular disease allow wounds to become contaminated and infected by organisms that normally are nonpathogenic. This explains the identification of unusual bacteria from the wounds of patients with diabetes. Autonomic neuropathy produces chronic venous swelling. Motor peripheral neuropathy or Charcot arthropathy can produce bony deformity, which, combined with the loss of protective sensation, can result in skin ulceration from pressure or from shear forces. Associated factors are a history of foot infection or ulceration and previous partial or whole-foot amputation. Motor neuropathy leads to muscle weakness and intrinsic muscle atrophy in the hands and feet. Patients with motor neuropathy can develop bunion, claw toe, and hammertoe deformities as a result of muscle imbalance. They lose normal vascular tone and thermal regulation, often developing severe venous swelling that can be managed only with compression hose. Severe tissue swelling can lead to ulceration and infection. The patients develop dry, cracked skin as a result of autonomic dysfunction, with the cracks allowing the entry of bacteria. Nail deformity or pathologic proliferation may make the areas adjacent to the nails foci for skin breaks or for infection. Vascular disease Ischemic peripheral vascular disease is the second risk factor for developing diabetic foot ulcer and infection. This disorder used to be considered a small vessel disease, but current research links the vascular pathology to the basement membrane of the arterial wall. The characteristics of the disease are similar in persons who are diabetic and those who are not, except that its distribution is somewhat more scattered and geographic in persons who are not diabetic, as opposed to being progressive in a distal direction in persons who are diabetic.

Immune deficiency The third major risk factor is related to the immune deficiency seen in persons with diabetes. Glycosylated immune proteins lose efficiency, and granulocytes do not perform adequately, leaving these patients prone to infection with organisms that would not affect a healthy host. Each of these potential abnormalities make the diabetic foot susceptible to abnormal mechanical stresses that can lead to a break in the normal soft-tissue envelope. This can initiate a foot infection that cannot be resolved easily. Pathophysiology Pressure over a bony prominence has often been cited as the cause for skin breakdown in patients with diabetes. Skin breakdown occurs at far lesser loads when the pressure is applied by shear forces. The accompanying loss of protective sensation prevents the patient from being warned that intolerable loads have been applied. This leads to blister formation and full-thickness skin loss. The process is heightened in the presence of severe venous swelling, which further lowers the injury threshold. Shoes become tight due to swelling, thus increasing the direct pressure and shear forces applied to skin overlying the bony prominence. Thickened, hypertrophic nails increase pressure on the soft tissues surrounding the nails. The common result is tissue failure and ulcer formation. Once the skin barrier is broken, wound healing can be impaired by abnormally functioning WBCs. Moreover, patients often are malnourished. Many have a marginal vascular supply, with less ability to achieve resolution of infection and wound healing. Presentation Classification of diabetic foot ulcers Most experts use some variant of the classification system developed by Wagner and most currently modified by Brodsky.3,4 Table 1. Depth-Ischemia Classification of Diabetic Foot Lesions* 3 Depth Classification 0 1 2 3 Ischemia Classification A Definition At-risk foot, no ulceration Treatment

Patient education, accommodative footwear, regular clinical examination Superficial ulceration, not Offloading with total contact cast (TCC), infected walking brace, or special footwear Deep ulceration exposing Surgical debridement, wound care, offloading, tendons or joints culture-specific antibiotics Extensive ulceration or Debridement or partial amputation, offloading, abscess culture-specific antibiotics

Not ischemic

B C D

Ischemia without gangrene Noninvasive vascular testing, consultation if symptomatic Partial (forefoot) gangrene Vascular consultation Complete foot gangrene Major extremity amputation, consultation

vascular

vascular

*Adapted from Brodsky JW: The diabetic foot. In: Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle. St Louis, Mo: Mosby; 1999: 911. Indications From a practical standpoint, vascular surgery consultation is warranted only when the patient is symptomatic with ischemic pain or a nonhealing ulcer. Ischemic ulcers generally require angioplasty or vascular bypass surgery to achieve wound healing. Neuropathic ulcers require debridement of nonviable or infected tissue, combined with local wound care and offloading. Grade 3 ulcers require debridement of infected or gangrenous tissue. Partial foot amputation, more complex offloading or non weight bearing, and culture-specific parenteral antibiotic therapy are necessary. Grade 4 ulcers require partial or whole foot amputation. Contraindications The 1 or 2 elective issues in this topic are clearly indicated within the text. Most of the substance of this chapter is nonsurgical. Failure to follow the guidelines discussed here leads to deep infection and amputation. Workup Imaging Studies Imaging can often be useful in determining the treatment of patients with diabetic foot lesions. Soft-tissue pathology, such as abscesses and sinus tracts, can be better defined through ultrasonography, computed tomography (CT) scanning, and magnetic resonance imaging (MRI). The most common use of imaging is for the detection of bone pathology and the confirmation of the development of osteomyelitis. Plain radiographs may at times be useful in confirming bone infection if it reveals changes beneath an ulcer, but it is most likely to be sufficient for diagnosis when the infection is already well established and when the bones of the forefoot or hindfoot are involved. With osteomyelitis, radiographic changes will accurately reflect the destructive process but will lag at least 2 weeks behind the progress of the infection. Radionuclide scans have a limited role in diagnosis because inflammatory conditions may enhance isotope uptake and diminish the specificity of the test. Leukocyte scans are more reliable and can help to determine when an area of infection has subsided, but these tests still perform poorly in the majority of evaluations. MRI has the highest diagnostic accuracy. When used by an experienced radiologist, MRI can detect bone infection (characterized by an altered bone marrow signal) with 90-100% sensitivity and specificity. Diagnosis can be complicated because changes from acute Charcot arthropathy, fractures, and postoperative residues may be mistaken for infection. Also, MRI findings can overestimate the extent of infection because of inflammatory changes associated with surgery, fracture, neuroarthropathy, or septic arthritis. 5

Diagnostic Procedures Qualitative and quantitative measures are used to assess the level of sensation. Qualitative methods include light touch and pinprick sensation, 2-point discrimination, and proprioception. These are often lowered in patients with sensory neuropathy, usually in a stocking-type pattern below the knee. Quantitative methods offer more objective data. Most commonly, nylon Semmes-Weinstein monofilaments of differing sizes are pressed into the skin perpendicularly until they bend. The threshold of the patients sensation is the smallest filament that he/she can feel. Protective sensation is assumed to be present if the patient can feel the 5.07 monofilament; still, approximately 10% of patients with sensation at this level develop neuropathic joints or ulcerations. In addition, although a number of studies have utilized monofilaments for the assessment of neuropathy, there are no substantive data that support any one standard method of application of the monofilament. Generally, testing is recommended at 8 to 10 anatomic sites, although a test of only 4 plantar sites on the forefoot (the great toe and the base of the first through third metatarsals) can be used to find 90% of patients with an insensate site. The biothesiometer, an electrical device that delivers measurable stimulatory vibrations, has not gained widespread use because of a lack of studies demonstrating its predictability and because monofilaments are inexpensive and readily available. However, a prospective study of 103 patients suggested that the biothesiometer scored higher in sensitivity tests than did the 10 g monofilament or its predecessor technology, the tuning fork. Another case-control study, of 255 diabetic patients, found support for monofilament or biothesiometer use. Foot ulceration was predicted with a specificity of 77% and a sensitivity of 100% based on either an abnormal Semmes-Weinstein monofilament perception or a vibrationperception threshold of greater than 25 V. The vascular examination will have the greatest effect on treatment choices. The qualitative measurements include palpation of the pulses and determination of skin temperature, capillary refill, and hair and nail growth. Evidence of vascular disease is commonly gained through palpating for the dorsalis pedis and posterior tibial pulses. Qualitative methods focus on noninvasive measures of pressure, flow, and tissue oxygenation. Doppler examination will yield pressure measurements at multiple levels of the leg, foot, and ankle and depends on the compressibility of the vessels under study. The most common measurement of peripheral vascular disease is the ankle-brachial index (ABI), the ratio of systolic blood pressure in the ankle to that in the brachial artery. An ABI of 0.90 or less suggests the presence of peripheral vascular disease. If the ABI is higher than 1.1, it should be considered whether the measurement derives from a false elevation produced by medial arterial calcinosis. Transcutaneous oxygen measurement requires expensive equipment, as well as a trained technician and, thus, is not as widely used as a diagnostic tool. It is the most accurate method for assessing local skin vascularity and healing potential. A transcutaneous oxygen tension of greater than 30 mm Hg has been associated with a high likelihood that a wound will heal. Treatment

Medical Therapy Preventive strategies The major focus of current diabetic foot care is prevention. 12,13 Preventive strategies combine patient education, prophylactic skin and nail care, and protective footwear. Foot-specific, individualized patient education is the most important element of a comprehensive diabetic foot program. Low-risk individuals must wear nonconstrictive shoes. Soft leather or athletic footwear decreases the risk of tissue breakdown from direct pressure (see Image 2).

Depth-inlay, soft leather, laced shoe with a custom-made accommodative, pressuredissipating foot orthosis Cushioned stockings are helpful, and white socks make identification of skin breakdown easier, especially in individuals with impaired vision. Nails should be cut transversely to decrease the risk of an ingrown toenail. Once a problem arises, the patient is instructed to seek medical attention immediately. Often, the earliest sign of infection is slowly increasing blood sugars and insulin requirement. When applied to diabetic populations, the above strategies have been shown to markedly decrease the rates of diabetic foot ulcer (DFU) and lower extremity amputation (LEA). Patient education materials are available through the American Orthopaedic Foot and Ankle Society, the American Diabetes Association, the American Podiatric Medical Association, and the National Institutes of Health (NIH) web site Feet Can Last a Lifetime. When individuals progress to a higher degree of risk, they require accommodative footwear and prophylactic skin and nail care. Depth-inlay, soft leather, Oxford-laced shoes with accommodative pressure and custom-made shear-dissipating foot orthoses (insoles) have been shown to appreciably decrease the development of DFUs. The complexity and individualized nature of the shoes and custom-made foot orthoses vary with the magnitude of deformity and loss of protective sensation. Calluses should be pared to decrease the incidence of shear-mediated ulcer formation. Trained professionals should perform skin and nail care in these individuals. Ulcer treatment The first step in the treatment of a patient with diabetes who has a foot ulcer is medical management of the systemic diabetes. Many individuals with diabetes are malnourished due to

chronic renal disease or chronic infection. Many are also immunocompromised. Once the systemic condition of the patient is optimized, specific attention can be directed to the foot ulcer.14,15,16 Ulcers can be neuropathic or ischemic. Neuropathic ulcers are caused by pressure or by shear forces. Once the ulcer is unroofed and the necrotic tissue is debrided, the soft-tissue base reveals healthy granulation tissue. If the ulcer is unroofed and the tissue at the base is necrotic, the ulcer is likely to be ischemic. A vascular surgeon should evaluate patients with ischemic ulcers to determine if the limb can be salvaged. A risk-benefit analysis then can then be performed to determine whether treatment should entail limb salvage, amputation, or a combination of both. If the ulcer is neuropathic, noninvasive vascular testing is in order in the absence of palpable pedal pulses. From a practical standpoint, vascular surgery consultation is warranted only when the patient is symptomatic with ischemic pain or a nonhealing ulcer. Ischemic ulcers generally require angioplasty or vascular bypass surgery to achieve wound healing. Neuropathic ulcers require debridement of nonviable or infected tissue, combined with local wound care and offloading. Wet-to-dry wound care does not promote wound healing because dry wounds desiccate. This allows potential wound-healing cells to die and opportunistic infection to propagate. Dry wounds should be kept moist with saline-soaked dressings or hydrocolloid gels. Wounds that produce massive quantities of exudative material should be treated with absorbent materials (calcium alginate) and dressings while the wound is kept moist. Growth factor gels have been shown to promote wound healing in wounds with reasonable wound-healing potential. 17,18 Offloading distributes weight-bearing pressure over a larger surface area and provides an interface to decrease shear forces. Elimination of weight bearing is generally not required. The optimal offloading device is the total contact cast (TCC). 19,20 This device acts to dissipate weightbearing and shearing loads by eliminating foot or ankle motion, using an interface material to distribute pressure and shear forces. Venous swelling is lessened by the compression effect of the cast. When the ulcer shows appreciable improvement, foot care can be simplified with prefabricated walking braces that have a plantar weight-bearing surface lined with Plastazote or other pressure-dissipating materials (see Image 3). When the swelling decreases or when ankle immobilization is not necessary, healing shoes can be used (see Image 4).

Removable walking boot with a Plastazotelined weight-bearing surface

Healing shoe.

The grade 0 foot has no ulcers but is at risk. Treatment involves foot-specific patient education and appropriate footwear. Prefabricated, pressure-dissipating insoles are appropriate. Occasionally, a bony prominence or deformity (eg, bunion, hammertoe) cannot be accommodated by therapeutic footwear. In this situation, removal of the bony prominence (exostectomy) or correction of the deformity is advised to prevent ulceration. As ulcers increase in grade, they require additional treatment. o o o Grade 1 ulcers require debridement of nonviable or infected tissue, local wound care, and offloading. Grade 2 ulcers require debridement, culture-specific antibiotics, local wound care, and more extensive offloading techniques. Grade 3 ulcers require debridement of infected or gangrenous tissue. Partial foot amputation, more complex offloading or nonweight-bearing strategies, and culturespecific parenteral antibiotic therapy are necessary. o Grade 4 ulcers require partial or whole foot amputation.

Following wound healing, patients should use offloading permanently. The plantigrade foot can be managed with depth-inlay, soft leather, Oxford-laced shoes and custom-made accommodative foot orthoses. When plantigrade alignment cannot be obtained, an ankle-foot orthosis or surgical reconstruction or stabilization is required. Persistent or recurrent ulceration Ulcers that do not heal or that recur in appropriate footwear require careful evaluation. Heel impact or increased forefoot loading can be lessened with a cushioned heel and/or rocker sole modification of the shoe. Consider surgery when accommodative methods are unsuccessful. Increased forefoot loading or ankle equinus (static or dynamic) can be treated with percutaneous Achilles tendon lengthening, followed by immobilization in a below-knee walking cast for 4-6 weeks. Plastic surgery intervention with rotational flaps or free tissue transfer occasionally is indicated. The key to success in these patients is patient education, accommodative pedorthic footwear, and careful monitoring. Prescription footwear The Medicare Therapeutic Shoe Bill of 1993 provides financial support for 1 pair of appropriate inlay-depth shoes and 3 pairs of custom-made foot orthoses yearly for individuals with diabetes. Most insurance carriers have followed their lead with similar guidelines. They have realized that preventive strategies are cost-effective compared with amputation. The certified pedorthist is an essential consultant in providing these devices. The bill requires that both the clinician treating the diabetes and the orthopedic surgeon or podiatrist treating the foot sign the prescription. Charcot foot Charcot foot is a hypertrophic osteoarthropathy currently seen primarily in patients with diabetes who have peripheral neuropathy. The etiology is neurotraumatic or neurovascular. The traumatic

etiology implies fracture or stress fracture without protective sensation. The hypertropic response results from the inherent motion applied to a nonimmobilized fracture. The vascular etiology implies an abnormal vascular inflow producing bony resorption, bony weakening, and a similar result. Eichenholtz stage 1 is the proliferative phase of the disease. The foot is very swollen, and radiographs are negative for fracture or dislocation. Stage 2 is the period of periarticular fracture or dislocation. Stage 3 is the phase of consolidation or healing. Treatment historically has been anecdotal, with only recent attempts at a scientific approach. 21 The foot with active disease is immobilized in a non-weight-bearing fashion in a total contact cast (TCC) or other prefabricated device. When the process has consolidated, treatment has been accommodative, including with a specialized type of ankle-foot orthosis, the Charcot restraint orthotic walker (CROW). Surgery is advised for bony infection, nonhealing ulcers, or a deformity that cannot be accommodated with a custom orthosis. There has been a trend toward attempted joint fusion in stages 2 and 3 to prevent deformity that would be difficult to accommodate with a shoe-orthotic construct. Surgical Therapy Amputation Any discussion of the diabetic foot requires introduction of the concept of function-preserving amputation surgery.22 Partial and whole foot amputations frequently are necessary as treatment for infection or gangrene. The goal of treatment is the preservation of function, not just the preservation of tissue. Amputation surgery should be the first step in the rehabilitation of the patient. Because most of these individuals are ambulatory, surgical planning should be directed at the creation of a load-bearing terminal end organ that can interface most easily with accommodative footwear, a prosthesis, or a combination of both (ie, prosthosis). The principles that direct construction of a residual limb for weight bearing with a prosthesis should be employed when performing debridement or partial foot amputation. The major value of partial foot amputation is the potential for the retention of plantar loadbearing tissues, which are uniquely capable of tolerating the forces involved in weight bearing. 23 The soft-tissue envelope should be capable of minimizing these forces. Avoid the use of splitthickness skin grafts in load-bearing areas. Deformity should be avoided as much as possible. Tendo-Achilles lengthening should be used to avoid equinus deformity and increased loading of the residual forefoot in partial foot amputations. Retention of a deformed foot with exposed bony prominence leads only to decreased walking ability and recurrent ulceration. Complications Failure to follow the above prevention and treatment guidelines leads to deep infection and amputation. Outcome and Prognosis Individuals who develop foot ulcers have a significant health-related decrease in their quality of life and consume a large quantity of health care resources. At 2 years following transtibial amputation, 36% of these patients are known to have died, which means that preventive programs are extremely important. Preventive programs have been shown to markedly decrease the rates of DFU and LEA in diabetic populations.