- The incidence of diabetes mellitus DM is
- Patients with DM have a 12-25% lifetime risk of
developing a foot ulcer.
- Foot ulcers have become a major and increasing
public health problem.
- The related morbidities, impairment of life quality
of patients together with the implied costs for their
management have attracted the attention of health
- Fortunately, most of foot problems in patients
with DM can be prevented with careful foot
- If complications do occur, daily attention will
ensure that they are detected before they
- It may take time and effort to build good
foot care habits, but self-care is essential.
- In fact, when it comes to foot care, the
patient is a vital member of the medical team.
- According to the Centers for Disease Control and
Prevention, 7.8% of the United States population had DM in
2007, which equals almost 24 million persons.
- In 2007, DM and its complications cost the US $174
billion; $116 billion in direct costs and $58.3 billion in
indirect costs such as disability and loss of productivity.
- Peripheral vascular and neurologic complications that
are closely linked to foot ulceration, account for 31% and
24% of the expenses respectively.
- Every year, 82,000 limb amputations are
performed in patients with DM in US.
- The majority of these amputations are
performed in the elderly.
- Amputations resulting from DM may be
due to multiple etiologies including foot
ulcers, ischemia and heel ulcers.
- Although amputation may become necessary in
certain cases of ischemia or infection, ablative
surgery is rarely necessary for treatment of
neuropathic ulceration and is to be avoided.
- Decreased limb length correlates with increased
energy expenditure for ambulation.
- Amputation in a diabetic patient is associated with
a 50-66% incidence of contralateral amputation
within 5 years.
PREVENTING FOOT PROBLEMS IN DIABETICS
- Controlling blood sugar levels
- Quit smoking
- Avoid activities that can injure the feet
- Use care when trimming the nails
- Wash and check the feet daily
- Choose socks and shoes carefully
- Ask for foot exams
GRADE 0 LESIONS
— Counseling regarding preventive foot
care should be given to any patient
whose feet are at risk for ulcer
development, particularly patients with
GRADE 1 AND 2 LESIONS
— Extensive debridement, good local wound care,
relief of pressure on the ulcer, and control of
infection (when present) are believed to be
important components of therapy for grade 1 and 2
- Method of debridement
May be mechanical, chemical and/or biological.
- Local wound care:
After debridement, ulcers should be kept clean and
moist but free of excess fluids. Moisture accelerates tissue
Dressings should be selected based upon wound
characteristics, such as the extent of exudate, desiccation,
or necrotic tissue.
Assessment for peripheral artery disease
- Clinically, by asking about H/O symptoms
suggesting LL ischemia and looking for its physical
signs and by ABI measurement.
- Doppler US as a non-invasive test to assess LL
- MRI angiography or arteriography if indicated in
Assessment for osteomyelitis
- Clinically, osteomyelitis is likely to be present if bone can be seen at
the floor of a deep ulcer, or if it can be easily detected by probing the
ulcer with a sterile, blunt stainless steel probe.
- Radiologic tests
Radiologic tests may be useful if the diagnosis of osteomyelitis remains
uncertain including bone scan.
- Bone biopsy C/S
If clinical and radiographic assessments fail to provide a diagnosis, then
bone biopsy can be considered.
Debridement and local wound care
As described before
Parenteral antibiotic therapy based upon the culture results has
traditionally been given for four to six weeks in patients with
osteomyelitis. The optimal regimen and when to transition to
oral therapy are dependent upon the clinical features of each
— Mechanical off-loading relieves pressure on
the ulcer and enhances healing.
— Revascularization plays an important role in the
management of diabetic foot ulcers in patients
with documented peripheral artery disease (to
avoid the need for amputation)
— Patients with these more advanced lesions require
urgent hospital admission and surgical management. The
following advanced therapies may be used in addition to the
previous management lines. However, amputation may
sometimes be required.
Negative pressure wound therapy
Negative pressure wound therapy (NPWT), also called
vacuum-assisted closure (VAC), involves the application of
controlled subatmospheric pressure to the surface of the
wound. NPWT enhances wound healing by increasing
wound perfusion, reducing edema, reducing the local
bacterial burden and increasing the formation of granulation
Hyperbaric oxygen therapy (HBOT)
— Hyperbaric oxygen therapy, as a component of diabetic ulcer
management, may be associated with improved healing but the
indications for hyperbaric oxygen in the treatment of nonhealing
diabetic foot ulcers remain uncertain.
— Use of honey, larva (muggets) and herbs have been reported with
— Human skin equivalents have been studied in diabetic patients with
noninfected, nonischemic chronic plantar ulcers .
— A platelet-derived growth factor gel preparation (becaplermin) is
approved by the US Food and Drug Administration as an adjuvant
therapy for diabetic foot ulcers . It promotes cellular proliferation and
angiogenesis and thereby improves wound healing.
Summary and recommendations
- Diabetic foot complications are common and serious.
- They represent a major impact on patients’ health. In addition,
they can affect adversely both patients and the society
economically and socially.
- Fortunately, most of these complications can be prevented by
controlling the blood sugar level and daily foot care.
- Health education programs for the patients, relatives and the
whole society are mandatory to improve the prognosis. In these
programs all authorities should share including heath care centers,
cultural centers, mosques and media.
Summary and recommendations (cont.)
- Screening of high risk groups is essential to detect the
- Management of diabetic foot complications needs a specialized
center with general, vascular, plastic, orthopedic surgery facilities
together with podiatrist, dietirian and internists and
endocrinologists to achieve a favorable outcome.
- The earlier the diagnosis and management the better the
- Encourage the medical research activities that may lead to
development of new diagnostic and management tools for better