Diabetic foot

A diabetic foot is any pathology that results directly from peripheral arterial disease (PAD) and/or sensory neuropathy affecting the feet in diabetes mellitus; it is a long-term (or "chronic") complication of diabetes mellitus.[1][2] Presence of several characteristic diabetic foot pathologies such as infection, diabetic foot ulcer and neuropathic osteoarthropathy is called diabetic foot syndrome. The resulting bone deformity is known as Charcot foot.

Diabetic foot
Other namesDiabetic foot syndrome
Neuropathic diabetic foot ulcer
SpecialtyInfectious disease, endocrinology, surgery

Due to advanced peripheral nerve dysfunction associated with diabetes (diabetic neuropathy), patients' feet have a dryness of the skin and a reduced ability to feel pain (nociception). Hence, minor injuries may remain undiscovered and subsequently progress to a full-thickness diabetic foot ulcer. Moreover, foot surgery is well tolerated without anaesthesia.[3] The feet's insensivity to pain can easily be established by 512 mN quantitative pinprick stimulation.[4]

In diabetes, peripheral nerve dysfunction can be combined with peripheral artery disease (PAD) causing poor blood circulation to the extremities (diabetic angiopathy).[5] Around half of the patients with a diabetic foot ulcer have co-existing PAD.[6] Vitamin D deficiency has been recently found to be associated with diabetic foot infections and increased risk of amputations and deaths.[7] Research estimates that the lifetime incidence of foot ulcers within the diabetic community is around 15% and may become as high as 25%.[8] Where wounds take a long time to heal, infection may set in, spreading to bones and joints, and lower limb amputation may be necessary. Foot infection is the most common cause of non-traumatic amputation in people with diabetes.[9]

Prevention

Prevention of diabetic foot may include optimising metabolic control via the regulation of blood glucose levels; identification and screening of people at high risk for diabetic foot ulceration, especially those with advanced painless neuropathy; and patient education in order to promote foot self-examination and foot care knowledge. Patients would be taught routinely to inspect their feet for hyperkeratosis, fungal infection, skin lesions and foot deformities. Control of footwear is also important as repeated trauma from tight shoes can be a triggering factor,[10] especially where peripheral neuropathy is present. Evidence is limited that low-quality patient education courses have a long-term preventative impact.[11]

A recent work critically evaluated the existing foot screening guidelines, with a view to examining their completeness in terms of advancement in clinical practice, improvements in technology, and changes in socio-cultural structure. This work clearly highlighted that limitations of currently available guidelines and lack of evidence on which the guidelines are based are responsible for the current gaps between guidelines, standard clinical practice, and development of complications. For the development of standard recommendations and everyday clinical practice, it will be necessary to pay more attention to both the limitations of guidelines and the underlying evidence.[12]

According to a 2011 meta-analysis, "Of all methods proposed to prevent diabetic foot ulcers, only foot temperature-guided avoidance therapy was found beneficial in RCTs".[13]

Prediction

Monitoring a person's feet can help in predicting the likelihood of developing ulcers. A common method for this is using a special thermometer to look for spots on the foot that have higher temperature which indicate the possibility of an ulcer developing.[14] At the same time there is no strong scientific evidence supporting the effectiveness of at-home foot temperature monitoring.[15]

The current guideline in the United Kingdom recommends collecting 8-10 pieces of information for predicting the development of foot ulcers.[16] A simpler method proposed by researchers provides a more detailed risk score based on three pieces of information (insensitivity, foot pulse, previous history of ulcers or amputation). This method is not meant to replace people regularly checking their own feet but complement it.[14][17]

Treatment

Treatment of diabetic foot ulceration can be challenging and prolonged; it may include orthopaedic appliances, surgery and antimicrobial drugs and topical dressings.[11]

Most diabetic foot infections (DFIs) require treatment with systemic antibiotics. The choice of the initial antibiotic treatment depends on several factors such as the severity of the infection, whether the patient has received another antibiotic treatment for it, and whether the infection has been caused by a micro-organism that is known to be resistant to usual antibiotics (e.g. MRSA). The objective of antibiotic therapy is to stop the infection and ensure it does not spread.[18]

It is unclear whether any particular antibiotic is better than any other for curing infection or avoiding amputation. One trial suggested that ertapenem with or without vancomycin is more effective than tigecycline for resolving DFIs. It is also generally unclear whether different antibiotics are associated with more or fewer adverse effects.[9]

It is recommended however that the antibiotics used for treatment of diabetic foot ulcers should be used after deep tissue culture of the wound. Tissue culture and not pus swab culture should be done. Antibiotics should be used at correct doses in order to prevent the emergence of drug resistance. It is unclear if local antibiotics improve outcomes after surgery.[19]

References
  1. Hefni, Abd Al-Hamead; Ibrahim, Al-Metwally R; Attia, Khaled M.; Moawad, Mahmoud M.; El-ramah, Ayman F.; Shahin, Mohamed M.; Al-Molla, Mahmoud; Abd Al-Satar, Lotfi. "Bacteriological study of diabetic foot infection in Egypt". Journal of the Arab Society for Medical Research. 8 (1): 26–32. S2CID 85976195.
  2. Boulton in Diabetes, 30;36 2002
  3. Sophie Arts , Laura Kerselaers , Johan De Neve , Johan Vanlauwe , Stef Cornelis, Dimitri Aerden. (2022). "Foot Surgery without Anesthesia in Diabetic Patients with Sensory Neuropathy: A Short Series". Foot & Ankle Surgery. Retrieved 2022-01-18.{{cite web}}: CS1 maint: multiple names: authors list (link)
  4. Ernst-Adolf Chantelau (2020-01-16). "A Novel Diagnostic Test for End-Stage Sensory Failure Associated With Diabetic Foot Ulceration: Proof-of-Principle Study". Journal of Diabetes Science and Technology. 15 (3): 622–629. doi:10.1177/1932296819900256. ISSN 1932-2968. PMC 8111226. PMID 31948277.
  5. Formosa, C., Cassar, K., Gatt, A., Mizzi, A., Mizzi, S., Camileri, K.P., Azzopardi, C., DeRaffaele, C., Falzon, O., Cristina, S. and Chockalingam, N., 2013. Hidden dangers revealed by misdiagnosed peripheral arterial disease using ABPI measurement. Diabetes research and clinical practice, 102(2), pp.112-116.https://doi.org/10.1016/j.diabres.2013.10.006
  6. International Working Group on the Diabetic Foot (2015). "Guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes". Retrieved 23 November 2015.
  7. Darlington, C., Kumar, S., Jagdish, S., Sridhar, M. Evaluation of Serum Vitamin D Levels in Diabetic Foot Infections: A Cross-Sectional Study in a Tertiary Care Center in South India. Iranian Journal of Medical Sciences, 2019; 44(6): 474-482. doi: 10.30476/ijms.2018.44951
  8. Singh, N. (2005). "Preventing Foot Ulcers in Patients With Diabetes". JAMA. 293 (2): 217–28. doi:10.1001/jama.293.2.217. PMID 15644549.
  9. Selva Olid A, Solà I, Barajas-Nava LA, Gianneo OD, Bonfill Cosp X, Lipsky BA (4 September 2015). "Systemic antibiotics for treating diabetic foot infections". Cochrane Database of Systematic Reviews. 2015 (9): CD009061. doi:10.1002/14651858.CD009061.pub2. PMC 8504988. PMID 26337865.
  10. Stiegler, H (2004). "Das diabetische Fußsyndrom". Herz. 29 (1): 104–15. doi:10.1007/s00059-004-2534-z. PMID 14968346. S2CID 39360504.
  11. Dorresteijn JAN, Kriegsman DMW, Assendelft WJJ, Valk GD (2014). "Patient education for preventing diabetic foot ulceration". Cochrane Database of Systematic Reviews (12): CD001488. doi:10.1002/14651858.CD001488.pub5. hdl:2066/108980. PMC 7057029. PMID 25514250.
  12. Formosa, C., Gatt, A. and Chockalingam, N., 2016. A critical evaluation of existing diabetic foot screening guidelines. The review of diabetic studies: RDS, 13(2-3), p.158. https://dx.doi.org/10.1900%2FRDS.2016.13.158
  13. Arad Y, Fonseca V, Peters A, Vinik A (2011). "Beyond the Monofilament for the Insensate Diabetic Foot: A systematic review of randomized trials to prevent the occurrence of plantar foot ulcers in patients with diabetes". Diabetes Care. 34 (4): 1041–6. doi:10.2337/dc10-1666. PMC 3064020. PMID 21447666.
  14. "Simple tool identifies the people with diabetes most likely to develop foot ulcers". NIHR Evidence. National Institute for Health and Care Research. 2022-06-21. doi:10.3310/nihrevidence_51316. S2CID 251787297.
  15. Golledge, Jonathan; Fernando, Malindu E; Alahakoon, Chanika; Lazzarini, Peter A.; aan de Stegge, Wouter B.; van Netten, Jaap J.; Bus, Sicco A. (23 May 2022). "Efficacy of at home monitoring of foot temperature for risk reduction of diabetes‐related foot ulcer: A meta‐analysis". Diabetes/Metabolism Research and Reviews. 38 (6): e3549. doi:10.1002/dmrr.3549. ISSN 1520-7552. PMID 35605998. S2CID 251981184.
  16. "Diabetic foot problems: prevention and management". National Institute for Health and Care Excellence (NICE). Retrieved 2022-09-06.
  17. Chappell, Francesca M; Crawford, Fay; Horne, Margaret; Leese, Graham P; Martin, Angela; Weller, David; Boulton, Andrew J M; Abbott, Caroline; Monteiro-Soares, Matilde; Veves, Aristidis; Riley, Richard D (25 May 2021). "Development and validation of a clinical prediction rule for development of diabetic foot ulceration: an analysis of data from five cohort studies". BMJ Open Diabetes Research & Care. 9 (1): e002150. doi:10.1136/bmjdrc-2021-002150. ISSN 2052-4897. PMC 8154962. PMID 34035053.
  18. Bader MS. "Diabetic Foot Infection". American Family Physician. Retrieved 8 October 2020.
  19. Marson, BA; Deshmukh, SR; Grindlay, DJC; Ollivere, BJ; Scammell, BE (November 2018). "A systematic review of local antibiotic devices used to improve wound healing following the surgical management of foot infections in diabetics". The Bone & Joint Journal. 100-B (11): 1409–1415. doi:10.1302/0301-620X.100B11.BJJ-2018-0720. PMID 30418057. S2CID 53280854.
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