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International Journal of Surgery xxx (2015) 1e4

Contents lists available at ScienceDirect

International Journal of Surgery

journal homepage: www.journal-surgery.net

Review

The diabetic foot management e Recent advance

Q5

Prabhu Dayal Sinwar

New PG Hostel Room No 28, Sardar Patel Medical College Bikaner, Rajasthan, India

h i g h l i g h t s

Q1

 Diabetic neuropathy and peripheral vascular disease are the main etiological factors in foot ulceration.
 Wagner's classication is one of the most widely used and universally accepted grading systems for DFU, consisting of six simplistic wound grades used
to assess ulcer depth.
 Assessment of peripheral neuropathy and evaluation of peripheral arterial status are the two important investigations in a diabetic foot.
 Management of diabetic neuropathic ulcer by appropriate and timely removal of callus, control of infection and reduction of weight bearing forces.
 Management of diabetic ischaemic foot are medical management, surgical management and percutaneous transluminal angioplasty of stenosed and
occluded lower extremity arteries.

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 13 October 2014
Received in revised form
22 January 2015
Accepted 26 January 2015
Available online xxx

Diabetic ulceration of the foot represents a major global medical, social and economic problem. It is the
commonest major end-point of diabetic complications. Diabetic neuropathy and peripheral vascular
disease are the main etiological factors in foot ulceration and may act alone, together, or in combination
with other factors such as microvascular disease, biomechanical abnormalities, limited joint mobility and
increased susceptibility to infection. In the diabetic foot, distal sensory polyneuropathy is seen most
commonly. The advent of insulin overcame the acute problems of ketoacidosis and infection, but could
not prevent the vascular and neurological complications. Management of diabetic neuropathic ulcer by
appropriate and timely removal of callus, control of infection and reduction of weight bearing forces.
Management of diabetic ischaemic foot are medical management, surgical management and percutaneous transluminal angioplasty of stenosed and occluded lower extremity arteries. Foot ulceration in
persons with diabetes is the most frequent precursor to amputation.
2015 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.

Keywords:
Diabetic foot
Neuropathy
Atherosclerosis
Neuropathic ulcer
Angioplasty
Amputation

Q2

1. Introduction
Diabetic ulceration of the foot represents a major global medical,
social and economic problem. It is the commonest major end-point
of diabetic complications. Diabetic neuropathy and peripheral
vascular disease are the main etiological factors in foot ulceration
and may act alone, together, or in combination with other factors
such as microvascular disease, biomechanical abnormalities,
limited joint mobility and increased susceptibility to infection.
Ulceration rarely results from a single pathology. It is the
interaction of contributory causes which leads to the breakdown of
the foot at risk [1]. The neuropathic foot, for example, does not
spontaneously ulcerate. It is the combination of insensitivity and

either extrinsic factors e.g. walking barefoot and stepping on a

sharp object, or simply wearing ill-tted shoes, or intrinsic factors
such as diminished sensation and the development of a callosity
which progresses to an ulcer on walking. Neuropathy is the most
signicant pathology in the pathway to ulceration [2].
Diabetic foot disease is an important problem confronting the
diabetologists, internists and surgeons [3]. The advent of insulin
overcame the acute problems of ketoacidosis and infection, but
could not prevent the vascular and neurological complications. Foot
is the most vulnerable part in a diabetic. It is exposed to frequent
trauma and requires a sensitive sensory protection, which is often
lacking in a diabetic. The foot, being farthest away from the central
nervous system and hemodynamically disadvantageously placed,
becomes the common site of complicated lesions. Foot ulceration in
persons with diabetes is the most frequent precursor to amputation
[4,5]. Overall, patients with diabetes are more likely to have an

E-mail address: prabhusinwar@gmail.com.

http://dx.doi.org/10.1016/j.ijsu.2015.01.023
1743-9191/ 2015 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.

Please cite this article in press as: P.D. Sinwar, The diabetic foot management e Recent advance, International Journal of Surgery (2015), http://
dx.doi.org/10.1016/j.ijsu.2015.01.023

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P.D. Sinwar / International Journal of Surgery xxx (2015) 1e4

amputation than patients without diabetes [6].

2. Etiopathogenesis
In a large prospective study by Lavery et al. [7], signicant independent risk factors for DFI included wounds that penetrated to
bone, wounds with a long duration, recurrent wounds, wounds
with a traumatic aetiology and the presence of PAD.
Although the etiopathogenesis of diabetic foot disease is
multifactorial, three main factors, namely neuropathy, ischaemia
and infection lead to tissue necrosis and ulcer formation [8]. Other
factors are foot biomechanics and weight bearing, peripheral vessel
calcications, trauma, (possibly) diabetic autonomic neuropathy
and microangiopathy and diabetic skeletal disease.
2.1. Neuropathy in diabetic foot
In the diabetic foot, distal sensory polyneuropathy is seen most
commonly. However, motor and autonomic bres may also be
involved and combined neuropathies frequently occur. The development of a neuropathy is linked to poor glycaemic control over
many years and it increases in frequency with both age and the
duration of diabetes.
Multiple factors such as blood glucose concentration, blood
lipids, structure of myelin sheath and its permeability, axonal ow
and micro and macroangiopathy of the peripheral nerves
contribute to the production of diabetic neuropathy [9]. Longitudinal data from the Rochester Study [10] supported the contention
that the duration and severity of exposure to hyperglycemia
inuenced the severity of the neuropathy. Current research on
diabetic neuropathy is focused on oxidative stress, advanced
glycation-end products, protein kinase C and the polyol pathway
[11].
2.2. Blood ow in diabetic neuropathic foot
Recent studies have shown that the blood ow is increased in
diabetic foot. The latter is due to the arterio-venous shunting and
dilated and stiff peripheral arteries [12]. The pulsatility index which
is inversely proportional to the quantity of the blood ow is
markedly reduced in diabetic foot. The normal Doppler ow
pattern is triphasic: a forward ow in systole followed by a reverse
ow and a further short forward ow in diastole. In diabetics there
is an increased forward ow with the absence of reverse ow.
2.3. Skeletal changes in diabetic foot
Due to increased blood ow to the lower limb there in enhanced
blood supply to the bones of the diabetic foot.
2.4. Stiffening of arterial wall
The medial wall calcication in the peripheral vessels in the
lower limb raises ankle brachial systolic pressure and shortens
transit times of pulse wave. In Charcot's diabetic neuroarthropathy
vascular calcication is found in about 90% [13].
Ward et al. have shown that rapid increase in ow of blood
bypasses small vessels and the capillary nutrient circulation and
results in a relative distal ischaemia [14].
The enhanced blood ow, vasodilatation and arteriovenous
shunting, all arising out of sympathetic denervation leads to
abnormal venous pooling and oedema. Atherosclerosis of the large
vessels of the leg in a diabetic is often multisegmental, distal and
bilateral.
Diabetic angiopathy is reported to be the most frequent cause of

morbidity and mortality in diabetic patients [15]. Macroangiopathy

manifests as a diffuse multisegmental involvement typically
involving the infrapopliteal vessels, and is also associated with
compromised collateral circulation.
Parving and Resmusen have demonstrated functional abnormality in the form of leakage of albumin from the capillaries to the
interstitium; however an occlusive microvascular disease in the
diabetic foot has not been clearly demonstrated [16].
The presence of neuropathy makes the feet insensitive and the
diabetic patient is often not aware of even a severe mechanical
trauma and gross infection.
3. Presentation
Patients present with a variety of complaints ranging from local
to systemic signs of infections. Local signs of infection may include
pain/tenderness, erythema, oedema, purulent drainage and newonset malodor. Systemic signs of infection include anorexia,
nausea, vomiting, fever, chills, night sweats, change in mental
status and a recent worsening of glycaemic control.
Wagner's classication is one of the most widely used and
universally accepted grading systems for DFU, consisting of six
simplistic wound grades used to assess ulcer depth (grades 0e5)
[17]. This classication is limited by the inability to recognize
ischaemia and infection as independent risk factors in all classication grades [18] (Table 1).
Q3
A more recently proposed and popularized DFU classication is
the University of Texas Health Science Center San Antonio (UT)
classication system [18]. This system incorporates a matrix
structure of four grades of wound depth with subgroups to denote
the presence of infection, ischaemia or both (Table 2).
Wounds with frank purulence and/or two or more local signs of
inammation such as warmth, erythema, lymphangitis, lymphadenopathy, oedema, pain and loss of function may be classied as
infected.
Lower extremity vascular insufciency is made by a combination of one or more clinical signs or symptoms of claudication, restpain, absent pulses, dependent rubor, atrophic integument,
absence of pedal hair or pallor on elevation. From the practical
point of view the diabetic foot can be divided into two major types:
(1) Ischaemic diabetic foot and (2) Non Ischaemic neuropathic
diabetic foot [8].
4. Investigations
Assessment of peripheral neuropathy and evaluation of peripheral arterial status are the two important investigations in a
diabetic foot.
Accurate sensory testing in diabetic neuropathy is of paramount
importance in the diagnosis, objective quantication and monitoring natural evolution or effects of therapy. These involve testing
for (1) Vibration perception Threshold (VPT) {assessed by a Biothesiometer}, (2) Thermal Discrimination Threshold (TDT)
{assessed by using 1. Marstock stimulator 2. Automated thermal

Table 1
Wagner classication system.
Grade

Wound depth

0
1
2
3
4
5

Pre-ulcerative area without open lesion

Supercial ulcer (partial/full thickness)
Ulcer deep to tendon, capsule, bone
Stage 2 with abscess, osteomyelitis or joint sepsis
Localized gangrene
Global foot gangrene

Please cite this article in press as: P.D. Sinwar, The diabetic foot management e Recent advance, International Journal of Surgery (2015), http://
dx.doi.org/10.1016/j.ijsu.2015.01.023

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Table 2
The University of Texas Health Science Center San Antonio (UT) classication
system.

A
B
C
D

No open lesion
With infection
Ischaemic
Infection/
Ischaemia

Supercial wound
With infection
Ischaemic
Infection/
Ischemia

Tendon/Capsule
With infection
Ischaemic
Infection/
Ischemia

Bone/Joint
With infection
Ischaemic
Infection/
Ischemia

line agent for the treatment of painful neuropathy [32]. Duloxetine is an inhibitor of the re-uptake of 5-hydroxytryptamine and
norepinephrine and has recently been approved by the Food and
Drug Administration for the treatment of neuropathic pain.
5.3. Management of diabetic ischaemic foot

5. Treatment

1. Medical Management. 2. Surgical Management. 3. Percutaneous Transluminal Angioplasty of stenosed and occluded lower
extremity arteries.
Medical management: It is indicated when ulcer is small, recent
and also in those patients unt for reconstructive surgery.
Surgical management: This comprises of arterial reconstruction,
sympathectomy and amputation.
Arterial reconstruction e Indications for reconstructive surgery
are intractable rest pain and claudication, nonhealing ulcers even
after good medical management.
Lumbar sympathectomy e For relief of ischaemic rest pain this
has an important role to play.
Percutaneous transluminal angioplasty: Angioplasty is particularly useful in high risk patients where surgery is contraindicated.
The lesions most amenable for angioplasty include stenoses less
4 cm long and occlusions shorter than 10 cm.

5.1. Management of diabetic neuropathic ulcer

6. Dressing

The three cardinal principles of management are [8]: 1. Appropriate and timely removal of callus. 2. Control of infection. 3.
Reduction of weight bearing forces.
Delbridge and Lequesne et al. [23] have shown that the formation of callus is central to the development of neuropathic ulcer in a
diabetic.
After removing the callus a bacterial swab may be taken from
the oor of the ulcer and appropriate antibiotic instituted. Dressing
materials can include natural, modied and synthetic polymers, as
well as their mixtures or combinations, processed in the form of
lms, foams, hydrocolloids and hydrogels. Moreover, wound
dressings may be employed as medicated systems, through the
delivery of healing enhancers and therapeutic substances (drugs,
growth factors, peptides, stem cells and/or other bioactive
substances).
The most important aspect of promoting healing is to remove
weight bearing force from the site of ulcer and ensure a redistribution of the shearing forces [24]. A recent systematic review by
Patton et al. [25] demonstrated that insoles may prevent diabetic
foot ulceration, but most of the evidence is poor and inconclusive.
The current state of the art in insole design primarily addresses
vertical forces with the aim of reducing foot pressures [26e28]. 1.
Special foots. 2. Polyethylene foam insoles (Plastozole). 3. Micro cell
rubber insole (Tovey's insole) [29]. 4. Cork cradle shoe. 5. Special
windows cut out in the shoes to accommodate the deformed foot. 6.
Total contact plast cast with minimum padding [29].

Wound dressing material can be of various categories like antimicrobials, silver impregnated dressings, enzymatic debridement,
negative pressure device, advanced wound dressing, skin substitute, growth factors and biologic wound product, hyperbaric oxygen etc.

threshold tester [19e21]}.

Although angiography and visualisation of the vascular tree is
taken as the gold standard for evaluation of peripheral arterial
disease, currently, non-invasive vascular laboratory has assumed an
important role in the evaluation of peripheral ischemia and the
diabetic foot [22].
The various tests used consist of: 1. Doppler ultrasound (for
estimation of ankle brachial ratio). 2. Photo-plethysmography. 3.
Transcutaneous oximetry. 4. Laser doppler owmetry. 5. Television
microscopy.

5.2. Tricyclic drugs

Several randomised clinical trials have supported the use of
these agents in the management of neuropathic pain. Selective
serotonin-re-uptake inhibitors e These inhibit presynaptic reuptake of serotonin. Studies suggest that treatment with paroxetine [30], but not uoxetine [31], is associated with considerable
relief from pain. Similarly, citalopram was conrmed to be efcacious in relieving neuropathic pain, but was less effective than
imipramine [32]. Anticonvulsants e These have been used in the
management of neuropathic pain for many years [33,34]. Gabapentin is an adjuvant anticonvulsant which is emerging as a rst-

6.1. Sugar management

The importance of choosing one type of long acting insulin,
becoming familiar with it and sticking with it is recommended. In
view of recent information from the UGDP study, oral agents should
be employed with more caution. Emphasis on foot care is stressed
[35].
In our institution we experience good results of diabetic foot
management with proper sugar level management, proper wound
care in form of daily dressing and debridement of slough, skin
grafting for large chronic red granulating tissue wound.
7. Conclusion
Diabetic sensorimotor polyneuropathy is common (20%e30% of
diabetics). Multiple factors such as blood glucose concentration,
blood lipids, structure of myelin sheath and its permeability, axonal
ow and micro and macroangiopathy of the peripheral nerves
contribute to the production of diabetic neuropathy. Half of patients with diabetic sensorimotor polyneuropathy are asymptomatic. It cannot be diagnosed by history alone. It is essential to
examine the feet carefully and regularly. The presence of unilateral
heat and swelling in a neuropathic diabetic patient should be
presumed to be due to acute Charcot neuropathy until proven
otherwise.
Ethical approval
Its review study based on the previous research work.
Funding
None.

Please cite this article in press as: P.D. Sinwar, The diabetic foot management e Recent advance, International Journal of Surgery (2015), http://
dx.doi.org/10.1016/j.ijsu.2015.01.023

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Author contribution
All work done by the corresponding author.

[15]
[16]

Conicts of interest
[17]

None.
[18]

Guarantor
Prabhu Dayal Sinwar.
Acknowledgement
No source of funding present.

[19]

[20]

[21]

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dx.doi.org/10.1016/j.ijsu.2015.01.023

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89
90
91
92
93
94
95
96