Management
of the Diabetic Foot
Grunfeld (1991), in a review of diabetic foot management,
noted that “Much of what is written in textbooks about diabetic
foot ulcers is the result of the personal clinical experience of
talented clinicians and teachers who feel strongly about their views.
Yet, one group may state dogmatically that a procedure is contraindicated
and dangerous, while another views it as the treatment of choice.”
Five cornerstone of management of the diabetic foot
(International
Consensus on the Diabetic Foot)
* Regular inspection and examination
* Identification of the foot at risk
* Education of patient, family and healthcare providers
* Appropriate foot wear
* Treatment of non-ulcerative pathology
* Components of care to achieve reduction in amputation
National
Diabetes Strategy, (Australia):
* Regular foot examination by trained health professionals
* Foot care education tailored to individuals
* Risk factor reduction
* Specialist treatment of active foot problems
* Ongoing preventative care for individuals who have experienced
a problem or are at risk of developing a problem
Framework
for management:
(International
Consensus on the Diabetic Foot)
* Improve circulation (non-invasive vascular testing; PTA; vascular
surgery)
* Remove oedema
* Pain control (analgesic agents; support)
* Treat infection (antibiotics – oral, parenteral; culture;
biopsy; x-ray; CT; Bone-scan; MRI)
* Improve metabolic control
* Non-weightbearing (protective/therapeutic shoes; insoles/orthoses;
contact casting/scotch cast boot; crutches; wheel chair)
*
Topical treatment (debridement; dressings; topical agents; skin
grafting)
* Foot surgery (incision/drainage; corrective surgery; amputation)
* General condition (cardiovascular treatment; microangiopathy;
malnutrition; smoking)
* Setting (patient/staff education; compliance; support/follow up;
multidisciplinary)
Evidence
that it works
Edmond et al (1986)
Larsen et al (1995)
Weaver et al (1994)
Armstrong et al (1998)
Classification systems to guide management
* Several available/in use
* Lack prospective studies regarding outcomes
* Based on consensus
The
UTHSC Classification:
Category 0: No Pathology
* Patient diagnosed with diabetes mellitus
* Protective sensation intact
* Ankle brachial index >0.80 and toe systolic >45 mmHg
* Foot deformity may be present
* No history of ulceration
Possible treatment for category 0
* Two to three visits a year to assess neurovascular status and
foci of stress
* Possible shoe accommodations
* Patient education
Category
1: Neuropathy, no deformity
* Protective sensation absent
* ABI >0.80 and toe systolic >45mmHg
* No history of ulceration
* No history of Charcot’s
* No foot deformity
Possible treatment for category 1
* Same as category 0 plus
* Possible therapeutic footwear
* Quarterly visits to assess shoe gear and monitor for signs of
irritation
Category 2: Neuropathy with Deformity
* Protective sensation absent
* ABI >0.80 and toe systolic >45mmHg
* No history of neuropathic ulceration
* No history of Charcot’s joint
* Foot deformity present(focus of stress)
Possible treatment for category 2
*Same as category 1 plus:
* Pedorthic/orthotist consultation for possible molded/extra depth
shoe accommodation
* Possible prophylactic surgery to alleviate focus of stress
Category 3: History of pathology
* Protective sensation absent
* Ankle brachial index >0.80 and toe systolic pressure >45mmHg
* History of neuropathic ulceration
* History of Charcot’s joint
* Foot deformity present (focus of stress)
Possible treatment for category 3
* Same a category 2 plus:
* Pedorthic/orthotist consultation for molded/extra depth shoe accommodation
* Possible prophylactic surgery to alleviate focus of stress
* More frequent visits may be indicated for monitoring
Category 4A: Neuropathic Wound
* Protective sensation absent
* ABI >0.80 and toe systolic >45mmHg
* Foot deformity normally present
* Non-infected neuropathic ulceration
* No acute Charcot’s joint present
Possible treatment for category 4A:
* Pressure reduction program
* Wound care program instituted
Category 4B: Acute Charcot’s Joint:
* Protective sensation absent
* ABI >0.80 and toe systolic >45mmHg
* Non-infected neuropathic ulceration may be present
* Charcot’s joint
Possible treatment for category 4B:
* Pressure reduction program instituted
* Thermometric and radiographic monitoring
* If ulcer is present treat as for category 4A
Category 5: The Infected Diabetic Foot
* Protective sensation may or may not be present
* Infected wound
* Charcot’s joint may be present
Possible treatment for category 5:
* Debridement of infected, necrotic tissue and/or bone, as indicated
* Possible hospitalisation, antibiotic regimen
* Medical management
Category 6: The Ischaemic Limb
* Protective sensation may or may not be present
* ABI <0.80 or toe systolic <45mmHg or pedal transcutaneous
oxygen tension <40mmHg
* Ulceration may be present
Possible treatment for category 6:
* Vascular consult, possible vascular revascularisation
* If infection is present, treatment same as category 5
Wound Management Principles:
* Establishing optimum local conditions to allow healing
by secondary intention to proceed in a smooth and uninterrupted
manner
* Reduction or control of the local and systemic factors which have
caused or predisposed to the development or prolongation of reduced
tissue viability
* Education of the patient or carer to the many ancillary factors
that predispose the patient to ongoing ulceration and the ways of
avoiding or controlling these
* Continuous monitoring, regular review and treatment of areas of
previous or potential ulceration
* Close liaison with other members of the hospital and primary health
care teams
Management
of infection:
* Describe lesion (cellulitis, ulcer, etc) and any drainage
* Enumerate presence/absence of inflammation
* Define whether infection is present and attempt to determine probable
cause
* Examine soft tissue for evidence of crepitus, abscess and sinus
tracts
* Investigate any skin breaks with sterile metal probe to see if
bone can be reached
* Measure the wound (length, width, depth)
* Palpate and record pedal pulse, use Doppler if necessary
* Evaluate neurological status
* Cleanse and debride wound; remove any foreign material and eschar
* Culture cleansed wound
* Order plain radiographs of the infected foot in most cases
* Antibiotic regimes vary
* Hospitalisation for ulceration (if indicated)
Hyperbaric oxygen:
* Being used more in non-healing wounds
* Elevates tissue oxygen levels
Footwear:
* Can both harm and protect the foot
Objectives of providing footwear for the diabetic foot:
* To relieve areas of excessive plantar pressure
* To reduce shock
* To reduce shear
* To accommodate deformities
* To stabilise and support deformities
* To limit motion of joints
Off
-loading
Cliché:
“Its not what you put on a wound that matters, its what
you take off”
Methods
for off loading:
* Bed rest
* Wheelchair
* Hosiery
* Accommodative padding
* Foot orthoses
* Footwear
* Total contact casts
* Walkers
* Ambulatory boots
Total
contact casts:
* Could be considered ‘gold standard’
* Crucial to its success is the close conformity between the foot
and leg of the plaster (outer layers may be fibreglass)
* Minimal or no cast padding is used
Mechanisms
of action of TCC’s:
* Redistribution of plantar pressure
* Reduction of oedema
* Limits stress on granulating tissue
* Reduces cadence and stride length
* Eliminates propulsive phase of gait
* ‘funnel’ shape of leg takes weights
* Protection from trauma
* Compliance
Contraindication
for TCC’s
* Inexperience in application
* Infected would
* Ulcer must be wider than deeper
* Non-compliance
* Claustrophobic
* Skin conditions
* Low ABI
Variations in TCC:
* Bivalved
* Cavity for wound inspection
Ambulatory
boot/Scotch cast boots:
Advantages:
* Distribution of plantar foot pressure
* Custom made
* Rigid and lightweight
* Removable for redressings, bathing etc
* Patients remains ambulatory
Disadvantages
* Unaesthetic and bulky
* Cost
* Expertise for applications
*Compliance
Surgical management:
* Incision and drainage
* Debridement
* Amputation
* Plastic surgery
* Vascular
* Prophylactic surgery
Indications
for amputation:
Minor amputations:
* As part of open debridement
* Chronic neuropathic ulcer – if too much tissue loss to save
digit
* Ischaemia – after infection is controlled and limb is revascularised
Major amputations:
* Extensive tissue loss
* Unreconstructable ischaemia
* Failed revascularisation
* Charcot’s of ankle with instability
Online
resources:
ePodiatry's
links to resources on management
of the diabetic foot and patient information on diabetes
foot care
Therapeutic
Footwear for the Neuropathic Foot: An algorithm - full text
from Diabetes Care
Preventing
diabetic foot problems - full text article ffrom Postgraduate
Medicine
Application
of a total contact cast - from diabeticfoot.net
Diabetic
foot care algorithm |
