Clinica Vascular Zurbano, Varices, Tratamientos Laser, Masaje Linfatico, Cirugia Vascular, Tratamiento del Linfedema, Tratamiento Aneurisma

What is the diabetic foot?, What are the tail of the diabetic foot? "Symptoms? Treatment? All information on the diabetic foot.

What is it?

It can be defined as a syndrome that affects people with diabetes mellitus and the most common clinical manifestation is an ulcer. It is estimated that approximately 15% of diabetics develop an ulcer in their lower limbs over the disease.

The definition accepted by the Spanish Society of Angiology and vascular Surgery is "an underlying neuropathic etho-pathogen disorder and induced by a prolonged hyperglycemia, in which co-exist with or without ischemia, and after triggering traumatic, produces injury and/or foot ulceration”.

What are the causes of diabetic foot?

Several factors affecting this syndrome: peripheral neuropathy, peripheral vascular disease and immune-pathy.

Peripheral neuropathy is a major cause of diabetic foot, it affects the sensory nerves (alteration of peripheral sensitivity to painful stimuli) and motor (muscle atrophy of the foot that leads to foot deformity, hammer toes, claw toes, hallux valgus ...). One must add the autonomic neuropathy that causes dysfunction of sweating and consequently leads to dry skin, hyperkeratosis (calluses) and cracks in the foot.

Peripheral vascular disease in diabetic micro-angiopathy manifesting as characterized by atherosclerotic lesions in different arterial regions. The arteries of the lower extremities most commonly affected are the femoral and tibial. Another feature in diabetic patients is the significant calcification that occurs in the arterial media layer. These calcifications are not obstructive but if changes occur in the determination of the ankle / brachial index, these have to be taken into account.

Diabetic micro-angiopathy has been long considered a determining factor in diabetic foot ischemia but recent studies have shown that obstructive but not functional. It is a factor which can promote infection but is not decisive in the affected limb ischemia.

The immune-pathy that diabetic patients suffer refers to the alteration of leukocyte function as a result of hyperglycemia and therefore favors the infection of ulcerative lesions.

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What is Charcot foot or Charcot neuropathic arthron-pathy of Charcot?

It is a joint disease (involvement of joints) due to chronic degenerative loss of sensation in diabetic patients. The minor trauma that is subjected to the foot joints go unnoticed by the patient and will lead to a serious distortion and a loss of function of the affected foot.

What are screening and testing needed to assess the disease?

We must make an inspection of the skin, nails and bones is which  any bone deformities is observed, thickened nails, subcutaneous fat atrophy, loss of hair on the back of the feet and pressure points with hyperkeratosis or presence from injury colitis.

The vascular examination begins with the observation of skin temperature and pulse palpation in both lower limbs of the patient. The echo-Doppler blood for the determination of ankle-brachial index (T / B) is a noninvasive test to determine the possible degree of calcification and arterial insufficiency.

With the Semmes-Weinstein monofilament the sensitivity to light pressure is explored. It is a simple instrument with a nylon filament which puts pressure on various points of the foot and sees if the patient feels or not any contact. At points where the sensation is not perceived is where there is risk of injury of having lost protective sensation.

The exploration of vibratory sensation, which is the last to be affected, it is made with a Rydel-Seiff graduated diapason.

According to data collected in the scan the extent of disease and the risk of developing ulcerative injuries can be determined.

There are several classifications based on the extent and depth of the ulcerated lesion, like the Wagner-Merritt. More comprehensive classifications have been developed from this one where the presence of aggravating factors such as ischemia and infection are shown, as the classification of the University of Texas. To understand the risk of developing an ulcer the most appropriate is the International Working Group on the Diabetic Food.

Classification of the University of Texas

Classification of the International Working Group on the Diabetic Foot

What triggers the diabetic foot ulcers and how are they?

The onset of the injury occurs because of a traumatism either intrinsic (due to osteoarticular disorders of the foot or the limitation of joint movement) or extrinsic (physical, chemical or thermal). Such trauma cannot be perceived by the patient, for example the gall of a shoe, and consequently delay the implementation of treatment.

The type of ulcer that will develop depends on the predominant causative factor:

- Neuropathic ulcer: it is located in areas of pressure or friction as bony prominences in the foot, finger pads, heel, and dorsal area joints. They are oval or rounded edges usually hyperkeratotic and granulated bed, except it presents gangrene. This is usually a painless injury, unless it is complicated by infection.

- Ulcer disease: are injuries with gangrene bed or necrotic, painful and surrounding skin is normal. If bleeding does not appear debriding or greatly diminished. They are located in the fingertips, heel and side of the first and fifth metatarsal.

When can it be said that there is infection?

The appearance of pus and two or more signs of inflammation (heat, redness, swelling and induration, and pain) are indicative of infection. If there is crackling, fetid, hemorrhagic bullae, skin discoloration or purplish areas it is a necrotizing infection.

Signs and symptoms of systemic involvement may not appear in these types of patients: fever, uncontrolled metabolic, chills, tachycardia, leukocytosis and elevated ESR.

Simple radiographic examination is important for the assessment of bone infection (osteitis or osteomyelitis). If the test is negative radiological and doubts of bone infection persist it should be ruled out with MRI or CT.

What is the treatment of diabetic foot ulcers?

• Metabolic control. After making the diagnosis of the etiology of the injury by physical examination and necessary tests, it is essential to control diabetes to successfully complete the treatment.

• Treatment of vascular disorders: is performed by conventional surgical procedures (such as bypass, endarterectomy or amputation) or endovascular surgery (Percutaneous trans luminal angioplasty, arterial stent). Sometimes conservative procedures are used as heparinization and local treatment with urokinase.
• Infection control. Infection is a major complication of diabetic foot ulcers due to metabolic and vascular alterations; therefore it may require systemic therapy with antibiotics. If signs of infection, an empirical antibiotic therapy is performed and thereafter, according to culture results and antibiotic, treatment is adjusted. In the case of complication of infection with abscesses, cellulitis, necrotizing soft tissue infections and osteomyelitis, surgical debridement is necessary and drainage. It consists of cleaning of necrotic tissue and slough and placement of drains (Penrose).
• Proper discharge of the area through orthosis and splints. Increasing pressure on one area of the foot is sometimes the source of the ulcer and / or hinders epithelialization and therefore is a transcendental aspect to their healing. You can use temporary discharge elements, i.e. during the healing of the injury; these are felt adhesives, footwear discharge silicones podiatry use, splints, prefabricated and custom splints.

The final discharge elements are those that help prevent ulcers and bone deformities characteristic of the diabetic foot (plantar orthosis and therapeutic footwear).

• Local treatment of wounds. The treatment applied to the injuries varies according to the stage where it is (Wagner classification-Merrit) but only by following these steps:

LOCAL TREATMENT OF ULCERS

• Clean the wound. It is done with a saline solution thereby facilitating the mechanical drag of the necrotic debris. Only when the wound has signs of infection an antiseptic should be used iodine (povidone, chlorhexidine 0.5%). Then the wound should be dried without performing friction on the bed.

• Debridement. It is imperative in the debridement of the labrum Hyperkeratotic, slough, necrotic and fibrotic tissue from the wound layer, because it favors the growth of bacteria and hinders epithelialization.
  • There are different ways to perform the debridement:
    • Surgical Debridement: using scissors or scalpel.
    • Enzymatic debridement: the product most used is the collagenase that is applied to the wound layer and covered with slightly moistened gauze.
    • Autolytic Debridement: it is provided by products such as hydrogels, hydrocolloids, alginates, and transparent film. They are based on maintaining a moist environment under the dressing that helps to Debridement and granulation tissue formation. It is the method of choice in case of ischemic wounds with a component and bone exposure.

• Control of exudate. The liquid that generates the wound layer is essential for the proper healing of the ulcer, but both the defect and the excess of exudate can be harmful. Dressings that help maintain the proper level of humidity are the alginate or hydrocolloid hydro fiber bandage.
• Prevention and treatment of infection. All wounds of slow evolution are contaminated and the bacterial load to prevent infection can be controlled with the use of silver bandages and carbon activated. These have no side effects or develop resistance as with antibiotics. On the first signs of infection it is indicated the use of silver sulfadiazine topical antibiotics and nitrofurazone are both lethal to Gram + and Gram -.
• Encourage healing and re-epithelialization. When the ulcer is in phase of granulation its ideal dressing is one that maintains a moist environment and protects proper wound infections. The most prominent are hydrocolloid bandages, hydro polymers, the silicone and collagen.

How can ulcers be prevented of appearing?

First we must act on the risk factors that contribute to the disease:

- Hyperglycemia.

- Smoking

- Hypertension

- Dyslipidemia

Below are the necessary foot care to reduce the number of injuries and their severity.

1. Daily foot inspection to detect bullous injuries, bleeding, interdigital maceration. Use a mirror to inspect the sole and heel.
2. Before proceeding to fit the shoe, hand inspected to detect its internal projections, ridges or seams for foreign bodies, which must be eliminated.
3. The shoes should always be deep and wide. When there is no bone deformity, use soft templates to distribute the pressure and if there is deformity, a rigid template to distribute and reduce abnormal pressures.
4. Change socks and shoes twice a day.
5. Never walk barefoot. Use large footwear in places like the beach or pool.
6. Never use hot water bottles or heating pads to warm them.
7. Never use the resection of ingrown toenails or calluses. Visit a podiatrist.
8. Do not rush the cutting of nails, but do it gently and file them straight.
9. Wash your feet with soap and water during five minutes. Produce a good rinse and thorough drying, especially between the toes.
10. Before using hot water on the hygiene of the feet, measure the temperature with your elbow.
11. Apply moisturizer after bathing.
12. Notify your nurse or family doctor onset of swelling, redness or ulceration even if it is painless.

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