Foot Care

Abstract

Key Messages•Foot problems are a major cause of morbidity and mortality in people with diabetes and contribute to increased healthcare costs.•The management of foot ulceration in people with diabetes requires an interdisciplinary approach that addresses glycemic control, infection, offloading of high-pressure areas, lower-extremity vascular status and local wound care.•Antibiotic therapy is not generally required for neuropathic foot ulcerations that show no evidence of infection. •Foot problems are a major cause of morbidity and mortality in people with diabetes and contribute to increased healthcare costs.•The management of foot ulceration in people with diabetes requires an interdisciplinary approach that addresses glycemic control, infection, offloading of high-pressure areas, lower-extremity vascular status and local wound care.•Antibiotic therapy is not generally required for neuropathic foot ulcerations that show no evidence of infection. Foot complications are a major cause of morbidity and mortality in persons with diabetes and contribute to increased healthcare utilization and costs (1Boulton A.J. Armstrong D.G. Albert S.F. et al.American Diabetes AssociationAmerican Association of Clinical EndocrinologistsComprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists.Diabetes Care. 2008; 31: 1679-1685Crossref PubMed Scopus (46) Google Scholar, 2Davis W.A. Norman P.E. Bruce D.G. Davis T.M. Predictors, consequences and costs of diabetes-related lower extremity amputations complicating type 2 diabetes: the Freemantle Diabetes Study.Diabetologia. 2006; 49: 2634-2641Crossref PubMed Scopus (126) Google Scholar, 3O'Brien J.A. Patrick A.R. Caro J.J. Cost of managing complications resulting from type 2 diabetes mellitus in Canada.BMC Health Serv Res. 2003; 3: 7Crossref PubMed Scopus (17) Google Scholar). In populations with diabetes, individuals with peripheral neuropathy and peripheral arterial disease (PAD) are predisposed to foot ulceration and infection, which ultimately may lead to lower-extremity amputation (4Reiber G.E. Vileikyte L. Boyko E.J. et al.Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings.Diabetes Care. 1999; 22: 157-162Crossref PubMed Scopus (793) Google Scholar, 5Crawford F. Inkster M. Kleijnen J. Fahey T. Predicting foot ulcers in patients with diabetes: a systematic review and meta-analysis.QJM. 2007; 100: 65-86Crossref PubMed Scopus (133) Google Scholar, 6Faglia E. Clerici G. Gabrielli L. et al.Long-term prognosis of diabetic patients with critical limb ischemia: a population-based cohort study.Diabetes Care. 2009; 35: 822-827Crossref Scopus (168) Google Scholar). Although amputation rates for people with diabetes have decreased in the past decade, they remain exceedingly high compared to nondiabetic populations (7Fosse S. Hartemann-Heurtier A. Jacqueminet S. et al.Incidence and characteristics of lower limb amputations in people with diabetes.Diabet Med. 2009; 26: 391-396Crossref PubMed Scopus (96) Google Scholar, 8Ikonen T.S. Sund R. Venermo M. Winell K. Fewer major amputations among individuals with diabetes in Finland in 1997-2007: a population-based study.Diabetes Care. 2010; 33: 2598-2603Crossref PubMed Scopus (75) Google Scholar). Therefore, it is essential that every effort possible be made to prevent foot problems, and, if they do occur, that early and aggressive treatment be undertaken. Characteristics that have been shown to confer a risk of foot ulceration in persons with diabetes include peripheral neuropathy, previous ulceration or amputation, structural deformity, limited joint mobility, PAD, microvascular complications, high glycated hemoglobin (A1C) levels and onychomycosis (9Boyko E.J. Ahroni J.H. Stensel V. et al.A prospective study of risk factors for diabetic foot ulcer. The Seattle Diabetic Foot Study.Diabetes Care. 1999; 22: 1036-1042Crossref PubMed Scopus (500) Google Scholar, 10Fernando D.J. Masson E.A. Veves A. et al.Relationship of limited joint mobility to abnormal foot pressures and diabetic foot ulceration.Diabetes Care. 1991; 14: 8-11Crossref PubMed Scopus (294) Google Scholar, 11Boyko E.J. Nelson K.M. Ahroni J.H. et al.Prediction of diabetic foot ulcer occurrence using commonly available clinical information.Diabetes Care. 2006; 29: 1202Crossref PubMed Scopus (265) Google Scholar). Loss of sensation over the distal plantar surface to the 10-g Semmes Weinstein monofilament is a significant and independent predictor of future foot ulceration and the possibility of lower-extremity amputation (12Feng Y. Schlösser F.J. Bauer E. Sumpio B.E. The Semmes Weinstein monofilament examination is a significant predictor of the risk of foot ulceration and amputation in patients with diabetes mellitus.J Vasc Surg. 2011; 53: 220-226Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar). In those persons with diabetes with foot ulcers, a number of wound classification systems have been developed to provide objective assessment of severity. Of these, the University of Texas Diabetic Wound Classification System has been validated as a predictor of serious outcomes in patients with diabetes with foot ulcers (Table 1) (13Armstrong D.G. Lavery L.A. Harkless L.B. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation.Diabetes Care. 1998; 21: 855-859Crossref PubMed Scopus (795) Google Scholar, 14Oyibo S.O. Jude E.B. Tarawneh I. et al.A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems.Diabetes Care. 2001; 24: 84-88Crossref PubMed Scopus (413) Google Scholar).Table 1University of Texas Diabetic Wound Classification System 13Armstrong D.G. Lavery L.A. Harkless L.B. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation.Diabetes Care. 1998; 21: 855-859Crossref PubMed Scopus (795) Google Scholar Open table in a new tab In persons with diabetes with underlying ischemia, the distribution of PAD is greater in the arterial tree below the knee than is seen in those without diabetes (15Jude E.B. Oyibo S.O. Chalmers N. Boulton A.J. Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome.Diabetes Care. 2001; 24: 1433-1437Crossref PubMed Scopus (555) Google Scholar). Noninvasive assessments for PAD in diabetes include the use of the ankle-brachial blood pressure index (ABI), determination of systolic toe pressure by photoplethysmography (PPG) (PPG assesses the intensity of light reflected from the skin surface and the red cells below, which is indicative of arterial pulse flow in the arterioles of the respective area), transcutaneous oximetry (tcPO2) and Doppler arterial flow studies (16Kalani M. Brismar K. Fagrell B. et al.Transcutaneous oxygen tension and toe blood pressure as predictors for outcome of diabetic foot ulcers.Diabetes Care. 1999; 22: 147-151Crossref PubMed Scopus (213) Google Scholar, 17Faglia E. Caravaggi C. Marchetti R. et al.SCAR (SCreening for ARteriopathy) Study GroupScreening for peripheral arterial disease by means of the ankle-brachial index in newly diagnosed type 2 diabetic patients.Diabet Med. 2005; 22: 1310-1314Crossref PubMed Scopus (59) Google Scholar). Although the ABI is a readily available and easy-to-perform technique, it may underestimate the degree of peripheral arterial obstruction in some individuals with diabetes partly due to medial arterial wall calcification in lower-extremity arteries (18Aerden D. Massaad D. von Kemp K. et al.The ankle-brachial index and the diabetic foot: a troublesome marriage.Ann Vasc Surg. 2011; 25: 770-777Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar). Measurement of systolic toe pressure by PPG may be more accurate in determining the presence of arterial disease in this population (19Williams D.T. Harding K.G. Price P. An evaluation of the efficacy of methods used in screening for lower-limb arterial disease in diabetes.Diabetes Care. 2005; 28: 2206-2210Crossref PubMed Scopus (191) Google Scholar). For those persons in whom lower-limb ischemia is suspected, intra-arterial digital subtraction contrast arteriography has provided the most definitive assessment of PAD but may precipitate renal failure in individuals with higher degrees of renal insufficiency. Advanced magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) do not require arterial access and, therefore, have gained popularity as reliable alternatives to iodinated contrast studies due to their less invasive approaches (20Brillet P.Y. Vayssairat M. Tassart M. et al.Gadolinium-enhanced MR angiography as first-line preoperative imaging in high-risk patients with lower limb ischemia.J Vasc Interv Radiol. 2003; 14: 1139-1145Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 21Lapeyre M. Kobeiter H. Desgranges P. et al.Assessment of critical limb ischemia in patients with diabetes: comparison of MR angiography and digital subtraction angiography.AJR Am J Roentgenol. 2005; 185: 1641-1650Crossref PubMed Scopus (78) Google Scholar, 22Met R. Bipat S. Legemate D.A. et al.Diagnostic performance of computed tomography angiography in peripheral arterial disease: a systematic review and meta-analysis.JAMA. 2009; 301: 415-424Crossref PubMed Scopus (234) Google Scholar). However, caution is still necessary with MRA and CTA in persons with renal dysfunction. The injection of intravenous radiocontrast dye also must be used in CTA; therefore, caution should be exercised (as with the use of intra-arterial iodinated contrast) in persons with renal insufficiency so as to avoid precipitating acute renal failure. Gadolinium-based contrast agents used in MRA have been associated with the development of nephrogenic systemic fibrosis in individuals with poor renal function (23Pedersen M. Safety update on the possible causal relationship between gadolinium-containing MRI agents and nephrogenic systemic fibrosis.J Magn Reson Imaging. 2007; 25: 881-883Crossref PubMed Scopus (35) Google Scholar, 24Centers for Disease Control and Prevention (CDC) Nephrogenic fibrosing dermopathy associated with exposure to gadolinium-containing contrast agents–St. Louis, Missouri, 2002-2006.MMWR Morb Mortal Wkly Rep. 2007; 56: 137-141PubMed Google Scholar). The foot examination should include the assessment of skin temperature since increased warmth is the first indicator of inflammation in an insensate foot and also may be the first sign of acute Charcot neuroarthropathy resulting from the loss of protective sensation in the foot (25Lavery L.A. Higgins K.R. Lanctot D.R. et al.Preventing diabetic foot ulcer recurrence in high-risk patients: use of temperature monitoring as a self-assessment tool.Diabetes Care. 2007; 30: 14-20Crossref PubMed Scopus (281) Google Scholar, 26Armstrong D.G. Lavery L.A. Monitoring healing of acute Charcot's arthropathy with infrared dermal thermometry.J Rehabil Res Dev. 1997; 34: 317-321PubMed Google Scholar, 27Yu G.V. Hudson J.R. Evaluation and treatment of stage 0 Charcot's neuroarthropathy of the foot and ankle.J Am Podiatr Med Assoc. 2002; 92: 210-220Crossref PubMed Scopus (63) Google Scholar). In addition, an acute Charcot foot may be associated with erythema and swelling, with overall clinical characteristics very similar to cellulitis (28Frykberg R.G. Zgonis T. Armstrong D.G. et al.American College of Foot and Ankle SurgeonsDiabetic foot disorders. A clinical practical guideline (2006 revision).J Foot Ankle Surg. 2006; 45: S1-S66Abstract Full Text Full Text PDF PubMed Scopus (562) Google Scholar, 29Ledermann H.P. Morrison W.B. Differential diagnosis of pedal osteomyelitis and diabetic neuroarthropathy: MR imaging.Semin Musculoskelet Radiol. 2005; 9: 272-283Crossref PubMed Scopus (66) Google Scholar). The clinical and radiological differentiation between an acute Charcot foot and a foot infection can be very challenging (30Embil J.M. Trepman E. A case of diabetic Charcot arthropathy of the foot and ankle.Nat Rev Endocrinol. 2009; 5: 577-581Crossref PubMed Scopus (8) Google Scholar). Plain radiographs have low sensitivity and specificity in differentiating osteomyelitis from Charcot changes. Magnetic resonance imaging (MRI) of the foot may help clarify this differential diagnosis, although no single radiological investigation to date has proven to be completely definitive (31Ahmadi M.E. Morrison W.B. Carrino J.A. et al.Neuropathic arthropathy of the foot with and without superimposed osteomyelitis: MR imaging characteristics.Radiology. 2006; 238: 622-631Crossref PubMed Scopus (93) Google Scholar). The prevention of amputations has involved the use of various preventative measures, including regular foot examination and evaluation of amputation risk, regular callus debridement, patient education, professionally fitted therapeutic footwear to reduce plantar pressure and accommodate foot deformities, and early detection and treatment of diabetic foot ulcers (32Apelqvist J. Bakker K. van Houtum W.H. Schaper N.C. International Working Group on the Diabetic Foot (IWGDF) Editorial BoardPractical guidelines on the management and prevention of the diabetic foot: based upon the International Consensus on the Diabetic Foot (2007).Diabetes Metab Res Rev. 2008; 24: S181-S187Crossref PubMed Scopus (269) Google Scholar). Many of the studies conducted to assess interventions designed to reduce the occurrence of and heal diabetic foot ulcers have, unfortunately, suffered from methodological problems, thereby reducing the quality of the evidence to support their use (33Arad Y. Fonseca V. Peters A. Vinik A. Beyond the monofilament for the insensate diabetic foot.Diabetes Care. 2011; 34: 1041-1046Crossref PubMed Scopus (47) Google Scholar, 34Bus S.A. Valk G.D. van Deursen R.W. et al.The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review.Diabetes Metab Res Rev. 2008; 24: S162-S180Crossref PubMed Scopus (179) Google Scholar). Generally, the management of foot ulceration should address glycemic control, pressure relief/offloading, infection, lower-extremity vascular status and local wound care (35Margolis D.J. Kantor J. Berlin J.A. Healing of diabetic neuropathic foot ulcers receiving standard treatment. A metaanalysis.Diabetes Care. 1999; 22: 692-695Crossref PubMed Scopus (330) Google Scholar). This is best achieved with an interdisciplinary approach (36Dargis V. Pantelejeva O. Jonushaite A. et al.Benefits of a multidisciplinary approach in the management of recurrent diabetic foot ulceration in Lithuania: a prospective study.Diabetes Care. 1999; 22: 1428-1431Crossref PubMed Scopus (181) Google Scholar, 37Aydin K. Isildak M. Karakaya J. Gürlek A. Change in amputation predictors in diabetic foot disease: effect of multidisciplinary approach.Endocrine. 2010; 38: 87-92Crossref PubMed Scopus (37) Google Scholar). Specific recommendations about dressing types cannot be made as there is insufficient evidence to support the use of one variety versus another; however, the concepts that are generally accepted as the essentials of good wound care include the provision of an optimal wound environment, pressure offloading from the ulcer site and, in nonischemic wounds, regular debridement of nonviable tissue (38Steed D.L. Donohoe D. Webster M.W. Lindsley L. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group.J Am Coll Surg. 1996; 183: 61-64PubMed Google Scholar, 39Edwards J. Stapley S. Debridement of diabetic foot ulcers.Cochrane Database Syst Rev. 2010; 1: CD003556PubMed Google Scholar). In general, wound dressings that maintain a moist wound environment should be selected. There are insufficient data to support the use of specific dressing types or antimicrobial dressings in the routine management of diabetic foot wounds (40Vermeulen H. Ubbink D. Goossens A. et al.Dressings and topical agents for surgical wounds healing by secondary intention.Cochrane Database Syst Rev. 2004; 2: CD003554PubMed Google Scholar, 41Vermeulen H. van Hattem J.M. Storm-Versloot M.N. Ubbink D.T. Topical silver for treating infected wounds.Cochrane Database Syst Rev. 2007; 1: CD005486PubMed Google Scholar, 42Bergin S.M. Wraight P. Silver based wound dressings and topical agents for treating diabetic foot ulcers.Cochrane Database Syst Rev. 2006; 1: CD005082PubMed Google Scholar, 43Canadian Agency for Drugs and Technologies in Health. Silver Dressings for the Treatment of Patients with Infected Wounds: A Review of Clinical and Cost-Effectiveness. July 7, 2010. Available at: http://www.cadth.ca/media/pdf/l0193_silver_dressings_htis-2.pdf. Accessed March 1, 2013.Google Scholar, 44Storm-Versloot M.N. Vos C.G. Ubbink D.T. Vermeulen H. Topical silver for preventing wound infection.Cochrane Database Syst Rev. 2010; 3: CD006478PubMed Google Scholar, 45Hinchliffe R.J. Valk G.D. Apelqvist J. et al.A systematic review of the effectiveness of interventions to enhance the healing of chronic ulcers of the foot in diabetes.Diabetes Metab Res Rev. 2008; 24: S119-S144Crossref PubMed Scopus (184) Google Scholar, 46Hilton J.R. Williams D.T. Beuker B. et al.Wound dressings in diabetic foot disease.Clin Infect Dis. 2004; 39: S100-S103Crossref PubMed Scopus (128) Google Scholar, 47Nelson E.A. O'Meara S. Golder S. et al.Systematic review of antimicrobial treatments for diabetic foot ulcers.Diabet Med. 2006; 23: 348-359Crossref PubMed Scopus (96) Google Scholar, 48O'Meara S.M. Cullum N.A. Majid M. Sheldon T.A. Systematic review of antimicrobial agents used for chronic wounds.Br J Surg. 2001; 88: 4-21Crossref PubMed Scopus (178) Google Scholar). There is also insufficient evidence to make any recommendation about the role of negative pressure wound therapy (NPWT) in the routine management of neuropathic wounds. There is, however, some evidence to support NPWT as a postoperative intervention after extensive debridement (49Armstrong D.G. Lavery L.A. Diabetic Foot Study ConsortiumNegative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial.Lancet. 2005; 366 (12): 1704-1710Abstract Full Text Full Text PDF PubMed Scopus (722) Google Scholar, 50Ubbink D.T. Westerbos S.J. Evans D. et al.Topical negative pressure for treating chronic wounds.Cochrane Database Syst Rev. 2008; 3: CD001898PubMed Google Scholar, 51Canadian Agency for Drugs and Technologies in Health. Negative Pressure Therapy for Patients Infected Wounds: A Review of the Clinical and Cost Effectiveness Evidence and Recommendations for Use. July 14, 2010. Available at: http://www.cadth.ca/media/pdf/l0194_negative_pressure_therapy_htis-2.pdf. Accessed March 1, 2013.Google Scholar, 52Gregor S. Maegele M. Sauerland S. et al.Negative pressure wound therapy: a vacuum of evidence?.Arch Surg. 2008; 143: 189-196Crossref PubMed Scopus (161) Google Scholar). Other adjunctive measures for wound healing, such as topical growth factors and dermal substitutes, have been studied in diabetic foot ulcer management, but these studies have been limited in sample size, duration and follow-up. These therapies may be considered if other conventional options already have been explored (53Buchberger B. Follmann M. Freyer D. et al.The importance of growth factors for the treatment of chronic wounds in the case of diabetic foot ulcers.GMS Health Technol Assess. 2010; 6 (Doc12)doi:10.3205/hta000090PubMed Google Scholar). Pressure offloading may be achieved with temporary footwear until the ulcer heals and the character of the foot stabilizes. Removable and irremovable cast walkers and total contact casting have demonstrated efficacy as pressure-reducing devices in plantar surface ulcers (54Armstrong D.G. Lavery L.A. Wu S. et al.Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds: a randomized controlled trial.Diabetes Care. 2005; 28: 551-554Crossref PubMed Scopus (209) Google Scholar, 55Armstrong D.G. Nguyen H.C. Lavery L.A. et al.Off-loading the diabetic foot wound: a randomized clinical trial.Diabetes Care. 2001; 24: 1019-1022Crossref PubMed Scopus (448) Google Scholar, 56Katz I.A. Harlan A. Miranda-Palma B. et al.A randomized trial of two irremovable off-loading devices in the management of plantar neuropathic diabetic foot ulcers.Diabetes Care. 2005; 28: 555-559Crossref PubMed Scopus (179) Google Scholar). Although very effective in healing noninfected, nonischemic plantar surface neuropathic ulcers, total contact casting requires careful individual selection and personnel trained specifically in its application due to its potential for complications (57Nabuurs-Franssen M.H. Sleegers R. Huijberts M.S. et al.Total contact casting of the diabetic foot in daily practice: a prospective follow-up study.Diabetes Care. 2005; 28: 243-247Crossref PubMed Scopus (112) Google Scholar). Where bony foot deformities prevent the fitting of appropriate footwear and/or offloading of pressure-related ulcers, consultation with a surgeon skilled in foot surgery may be considered to address the deformity (58Singh N. Armstrong D.G. Lipsky B.A. Preventing foot ulcers in patients with diabetes.JAMA. 2005; 293: 217-228Crossref PubMed Scopus (1999) Google Scholar, 59Blume P.A. Paragas L.K. Sumpio B.E. et al.Single-stage surgical treatment of noninfected diabetic foot ulcers.Plast Reconstr Surg. 2002; 109: 601-609Crossref PubMed Scopus (61) Google Scholar, 60Sayner L.R. Rosenblum B.I. Giurini J.M. Elective surgery of the diabetic foot.Clin Podiatr Med Surg. 2003; 20: 783-792Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar). Treatment of the acute Charcot foot requires immobilization of the foot, typically for several months, in a total contact cast or removable walker device until excessive foot temperatures return to normal (61Molines L. Darmon P. Raccah D. Charcot's foot: newest findings on its pathophysiology, diagnosis and treatment.Diabetes Metab. 2010; 36: 251-255Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar). Although bisphosphonate therapy has been considered for the management of Charcot arthropathy, further studies are necessary to fully evaluate the use of these agents and other medical therapies in the routine treatment of Charcot arthropathy (62Trepman E. Nihal A. Pinzur M.S. Current topics review: Charcot neuroarthropathy of the foot and ankle.Foot Ankle Int. 2005; 26: 46-63Crossref PubMed Scopus (138) Google Scholar, 63Jude E.B. Selby P.L. Burgess J. et al.Bisphosphonates in the treatment of Charcot neuroarthropathy: a double-blind randomised controlled trial.Diabetologia. 2001; 44: 2032-2037Crossref PubMed Scopus (211) Google Scholar, 64Pitocco D. Ruotolo V. Caputo S. et al.Six-month treatment with alendronate in acute Charcot neuroarthropathy: a randomized controlled trial.Diabetes Care. 2005; 28: 1214-1215Crossref PubMed Scopus (119) Google Scholar). Infection may complicate foot ulcers and may progress rapidly to become limb and/or life threatening (65Lavery L.A. Armstrong D.G. Wunderlich R.P. et al.Risk factors for foot infections in individuals with diabetes.Diabetes Care. 2006; 29: 1288-1293Crossref PubMed Scopus (473) Google Scholar). When infections first begin, the most frequently encountered pathogens include Staphylococcus aureus, Streptococcus pyogenes (group A streptococcus) and Streptococcus agalactiae (group B streptococcus). With time and the presence of devitalized tissue, gram-negative and anaerobic pathogens also can play a role in the process, leading to polymicrobial infections (66Lipsky B.A. Berendt A.R. Cornia P.B. et al.2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections.Clin Infect Dis. 2012; 54: e132-e173Crossref PubMed Scopus (1087) Google Scholar, 67Rao N. Lipsky B.A. Optimizing antimicrobial therapy in diabetic foot infections.Drugs. 2007; 67: 195-214Crossref PubMed Scopus (60) Google Scholar). Specimens for culture from the surface of wounds, as opposed to deeper tissues obtained by debridement, are unreliable in determining the bacterial pathogens involved (68Perry C.R. Pearson R.L. Miller G.A. Accuracy of cultures of material from swabbing of the superficial aspect of the wound and needle biopsy in the preoperative assessment of osteomyelitis.J Bone Joint Surg Am. 1991; 73: 745-749PubMed Google Scholar, 69Senneville E. Melliez H. Beltrand E. et al.Culture of percutaneous bone biopsy specimens for diagnosis of diabetic foot osteomyelitis: concordance with ulcer swab cultures.Clin Infect Dis. 2006; 42: 57-62Crossref PubMed Scopus (227) Google Scholar, 70Slater R.A. Lazarovitch T. Boldur I. et al.Swab cultures accurately identify bacterial pathogens in diabetic foot wounds not involving bone.Diabet Med. 2004; 21: 705-709Crossref PubMed Scopus (114) Google Scholar). Initial antibiotic therapy is typically empiric and may be broad spectrum, with subsequent antibiotic selection tailored to the sensitivity results of cultured specimens. With the exception of only a small number of antimicrobial agents that do have a specific indication for the treatment of diabetic foot infections, the majority of the agents available for use are selected for their antibacterial spectrum (66Lipsky B.A. Berendt A.R. Cornia P.B. et al.2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections.Clin Infect Dis. 2012; 54: e132-e173Crossref PubMed Scopus (1087) Google Scholar, 71Embil J.M. Trepman E. Diabetic infection.in: Gray J. Therapeutic Choices. 6th ed. Canadian Pharmacists Association, Ottawa, Ontario, Canada2011Google Scholar). Table 2 summarizes the different antimicrobial choices for the empiric management of foot infections in persons with diabetes. Uncontrolled diabetes can result in immunopathy with a blunted cellular response to infection. Up to 50% of patients with diabetes who have a significant limb infection may not have systemic signs of fever or leukocytosis at presentation (72Eneroth M. Apelqvist J. Stenström A. Clinical characteristics and outcome in 223 diabetic patients with deep foot infections.Foot Ankle Int. 1997; 18: 716-722Crossref PubMed Scopus (176) Google Scholar). Deep infections require prompt surgical debridement in addition to appropriate antibiotic therapy (73Tan J.S. Friedman N.M. Hazelton-Miller C. et al.Can aggressive treatment of diabetic foot infections reduce the need for above-ankle amputation?.Clin Infect Dis. 1996; 23: 286-291Crossref PubMed Scopus (177) Google Scholar). Granulocyte colony-stimulating factors have been used as adjunctive therapy in infected diabetic wounds and, in some studies, were found to reduce the need for surgical intervention. Data are limited and caution is advised in interpreting these findings (74Cruciani M. Lipsky B.A. Mengoli C. de Lalla F. Granulocyte-colony stimulating factors as adjunctive therapy for diabetic foot infections.Cochrane Database Syst Rev. 2009; 3: CD006810PubMed Google Scholar).Table 2Empiric antimicrobial therapy for infection in the diabetic foot∗Modified and used with permission from Embil JM, Trepman E. Diabetic foot infections. In: Principles and Practice of Hospital Medicine. Editors: Sylvia C. McKean, John J. Ross, Daniel D. Dressler, Daniel J. Brotman, Jeffrey S. Ginsberg. Printed in China: McGraw-Hill; 2012.MRSA, methicillin-resistant Staphylococcus aureus; TMP-SMX, trimethoprim-sulfamethoxazole. Open table in a new tab MRSA, methicillin-resistant Staphylococcus aureus; TMP-SMX, trimethoprim-sulfamethoxazole. In medically suitable individuals with PAD, distal limb revascularization has potential benefit in long-term limb salvage. Certain subpopulations with diabetes on insulin therapy have poorer outcomes after revascularization than those on oral anithyperglycemic therapy, perhaps reflecting a greater association of comorbidities (75Pomposelli F.B. Kansal N. Hamdan A.D. et al.A decade of experience with dorsalis pedis artery bypass: analysis of outcome in more than 1000 cases.J Vasc Surg. 2003; 37: 307-315Abstract Full Text PDF PubMed Scopus (320) Google Scholar, 76Dosluoglu H.H. Lall P. Nader N.D. et al.Insulin use is associated with poor limb salvage and survival in diabetic patients with chronic limb ischemia.J Vasc Surg. 2010; 51: 1178-1189Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar). Endovascular techniques with angioplasty and stenting in infrainguinal arteries are also effective in limb salvage, although the long-term results are inferior in the population with diabetes compared to those without diabetes (77Abularrage C.J. Conrad M.F. Hackney L.A. et al.Long-term outcomes of diabetic patients undergoing endovascular infrainguinal interventions.J Vasc Surg. 2010; 52: 314-322Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 78Dick F. Diehm N. Galimanis A. et al.Surgical or endovascular revascularization in patients with critical limb ischemia: influence of diabetes mellitus on clinical outcome.J Vasc Surg. 2007; 45: 751-761Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar). Hyperbaric oxygen therapy (HBOT) is not considered part of the routine management of persons with neuropathic/neuroischemic foot ulcerations with or without underlying infection. In carefully selected persons with nonhealing foot ulcerations for whom all possible interventions have been attempted, HBOT may be considered as an adjunctive therapy (79Löndahl M. Katzman P. Nilsson A. Hammarlund C. Hyperbaric oxygen therapy facilitates healing of chronic foot ulcers in patients with diabetes.Diabetes Care. 2010; 33: 998-1003Crossref PubMed Scopus (285) Google Scholar, 80Löndahl M. Fagher K. Katzman P. What is the role of hyperbaric oxygen in the management of diabetic foot disease?.Curr Diabetes Rep. 2011; 11: 285-293Crossref PubMed Scopus (24) Google Scholar, 81Räkel A. Huot C. Ekoé J.M. Canadian Diabetes Association Technical Review: the diabetic foot and hyperbaric oxygen therapy.Can J Diabetes. 2006; 30: 411-421Abstract Full Text Full Text PDF Google Scholar). Currently, evidence-based criteria for the selection of persons with diabetes who have foot problems and who may benefit from HBOT do not exist.Recommendations1.In people with diabetes, foot examinations by healthcare providers should be an integral component of diabetes management to identify persons at risk for ulceration and lower-extremity amputation [Grade C, Level 3 (5Crawford F. Inkster M. Kleijnen J. Fahey T. Predicting foot ulcers in patients with diabetes: a systematic review and meta-analysis.QJM. 2007; 100: 65-86Crossref PubMed Scopus (133) Google Scholar, 12Feng Y. Schlösser F.J. Bauer E. Sumpio B.E. The Semmes Weinstein monofilament examination is a significant predictor of the risk of foot ulceration and amputation in patients with diabetes mellitus.J Vasc Surg. 2011; 53: 220-226Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar)] and should be performed at least annually and at more frequent intervals in those at high risk [Grade D, Level 4 (1Boulton A.J. Armstrong D.G. Albert S.F. et al.American Diabetes AssociationAmerican Association of Clinical EndocrinologistsComprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists.Diabetes Care. 2008; 31: 1679-1685Crossref PubMed Scopus (46) Google Scholar)]. Assessment by healthcare providers should include the assessment of skin changes, structural abnormalities (e.g. range of motion of ankles and toe joints, callus pattern, bony deformities), skin temperature, evaluation for neuropathy and PAD, ulcerations and evidence of infection [Grade D, Level 4 (1Boulton A.J. Armstrong D.G. Albert S.F. et al.American Diabetes AssociationAmerican Association of Clinical EndocrinologistsComprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists.Diabetes Care. 2008; 31: 1679-1685Crossref PubMed Scopus (46) Google Scholar)].2.People at high risk of foot ulceration and amputation should receive foot care education (including counselling to avoid foot trauma), professionally fitted footwear and early referrals to a healthcare professional trained in foot care management if foot complications occur [Grade C, Level 3 (33Arad Y. Fonseca V. Peters A. Vinik A. Beyond the monofilament for the insensate diabetic foot.Diabetes Care. 2011; 34: 1041-1046Crossref PubMed Scopus (47) Google Scholar, 82Valk G.D. Kriegsman D.M. Assendelft W.J. Patient education for preventing diabetic foot ulceration: a systematic review.Endocrinol Metab Clin North Am. 2002; 31: 633-658Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar, 83McCabe C.J. Stevenson R.C. Dolan A.M. Evaluation of a diabetic foot screening and protection programme.Diabet Med. 1998; 15: 80-84Crossref PubMed Scopus (189) Google Scholar)].3.Individuals who develop a foot ulcer should be managed by a multidisciplinary healthcare team with expertise in the management of foot ulcers to prevent recurrent foot ulcers and amputation [Grade C, Level 3 (36Dargis V. Pantelejeva O. Jonushaite A. et al.Benefits of a multidisciplinary approach in the management of recurrent diabetic foot ulceration in Lithuania: a prospective study.Diabetes Care. 1999; 22: 1428-1431Crossref PubMed Scopus (181) Google Scholar)].4.There is currently insufficient evidence to recommend any specific dressing type for diabetic foot ulcers [Grade C, Level 3 (40Vermeulen H. Ubbink D. Goossens A. et al.Dressings and topical agents for surgical wounds healing by secondary intention.Cochrane Database Syst Rev. 2004; 2: CD003554PubMed Google Scholar)]. General principles of wound management involve the provision of a moist wound environment, debridement of nonviable tissue (nonischemic wounds) and offloading of pressure areas [Grade B, Level 3 (38Steed D.L. Donohoe D. Webster M.W. Lindsley L. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group.J Am Coll Surg. 1996; 183: 61-64PubMed Google Scholar)].5.Evidence is currently lacking to support the routine use of adjunctive wound-healing therapies, such as topical growth factors, granulocyte colony-stimulating factors, dermal substitutes or HBOT in diabetic foot ulcers, but they may be considered in nonhealing, nonischemic wounds when all other options have been exhausted [Grade D, Level 4 (53Buchberger B. Follmann M. Freyer D. et al.The importance of growth factors for the treatment of chronic wounds in the case of diabetic foot ulcers.GMS Health Technol Assess. 2010; 6 (Doc12)doi:10.3205/hta000090PubMed Google Scholar, 74Cruciani M. Lipsky B.A. Mengoli C. de Lalla F. Granulocyte-colony stimulating factors as adjunctive therapy for diabetic foot infections.Cochrane Database Syst Rev. 2009; 3: CD006810PubMed Google Scholar, 80Löndahl M. Fagher K. Katzman P. What is the role of hyperbaric oxygen in the management of diabetic foot disease?.Curr Diabetes Rep. 2011; 11: 285-293Crossref PubMed Scopus (24) Google Scholar)].Abbreviations:HBOT, hyperbaric oxygen therapy; PAD, peripheral arterial disease. 1.In people with diabetes, foot examinations by healthcare providers should be an integral component of diabetes management to identify persons at risk for ulceration and lower-extremity amputation [Grade C, Level 3 (5Crawford F. Inkster M. Kleijnen J. Fahey T. Predicting foot ulcers in patients with diabetes: a systematic review and meta-analysis.QJM. 2007; 100: 65-86Crossref PubMed Scopus (133) Google Scholar, 12Feng Y. Schlösser F.J. Bauer E. Sumpio B.E. The Semmes Weinstein monofilament examination is a significant predictor of the risk of foot ulceration and amputation in patients with diabetes mellitus.J Vasc Surg. 2011; 53: 220-226Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar)] and should be performed at least annually and at more frequent intervals in those at high risk [Grade D, Level 4 (1Boulton A.J. Armstrong D.G. Albert S.F. et al.American Diabetes AssociationAmerican Association of Clinical EndocrinologistsComprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists.Diabetes Care. 2008; 31: 1679-1685Crossref PubMed Scopus (46) Google Scholar)]. Assessment by healthcare providers should include the assessment of skin changes, structural abnormalities (e.g. range of motion of ankles and toe joints, callus pattern, bony deformities), skin temperature, evaluation for neuropathy and PAD, ulcerations and evidence of infection [Grade D, Level 4 (1Boulton A.J. Armstrong D.G. Albert S.F. et al.American Diabetes AssociationAmerican Association of Clinical EndocrinologistsComprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists.Diabetes Care. 2008; 31: 1679-1685Crossref PubMed Scopus (46) Google Scholar)].2.People at high risk of foot ulceration and amputation should receive foot care education (including counselling to avoid foot trauma), professionally fitted footwear and early referrals to a healthcare professional trained in foot care management if foot complications occur [Grade C, Level 3 (33Arad Y. Fonseca V. Peters A. Vinik A. Beyond the monofilament for the insensate diabetic foot.Diabetes Care. 2011; 34: 1041-1046Crossref PubMed Scopus (47) Google Scholar, 82Valk G.D. Kriegsman D.M. Assendelft W.J. Patient education for preventing diabetic foot ulceration: a systematic review.Endocrinol Metab Clin North Am. 2002; 31: 633-658Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar, 83McCabe C.J. Stevenson R.C. Dolan A.M. Evaluation of a diabetic foot screening and protection programme.Diabet Med. 1998; 15: 80-84Crossref PubMed Scopus (189) Google Scholar)].3.Individuals who develop a foot ulcer should be managed by a multidisciplinary healthcare team with expertise in the management of foot ulcers to prevent recurrent foot ulcers and amputation [Grade C, Level 3 (36Dargis V. Pantelejeva O. Jonushaite A. et al.Benefits of a multidisciplinary approach in the management of recurrent diabetic foot ulceration in Lithuania: a prospective study.Diabetes Care. 1999; 22: 1428-1431Crossref PubMed Scopus (181) Google Scholar)].4.There is currently insufficient evidence to recommend any specific dressing type for diabetic foot ulcers [Grade C, Level 3 (40Vermeulen H. Ubbink D. Goossens A. et al.Dressings and topical agents for surgical wounds healing by secondary intention.Cochrane Database Syst Rev. 2004; 2: CD003554PubMed Google Scholar)]. General principles of wound management involve the provision of a moist wound environment, debridement of nonviable tissue (nonischemic wounds) and offloading of pressure areas [Grade B, Level 3 (38Steed D.L. Donohoe D. Webster M.W. Lindsley L. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group.J Am Coll Surg. 1996; 183: 61-64PubMed Google Scholar)].5.Evidence is currently lacking to support the routine use of adjunctive wound-healing therapies, such as topical growth factors, granulocyte colony-stimulating factors, dermal substitutes or HBOT in diabetic foot ulcers, but they may be considered in nonhealing, nonischemic wounds when all other options have been exhausted [Grade D, Level 4 (53Buchberger B. Follmann M. Freyer D. et al.The importance of growth factors for the treatment of chronic wounds in the case of diabetic foot ulcers.GMS Health Technol Assess. 2010; 6 (Doc12)doi:10.3205/hta000090PubMed Google Scholar, 74Cruciani M. Lipsky B.A. Mengoli C. de Lalla F. Granulocyte-colony stimulating factors as adjunctive therapy for diabetic foot infections.Cochrane Database Syst Rev. 2009; 3: CD006810PubMed Google Scholar, 80Löndahl M. Fagher K. Katzman P. What is the role of hyperbaric oxygen in the management of diabetic foot disease?.Curr Diabetes Rep. 2011; 11: 285-293Crossref PubMed Scopus (24) Google Scholar)].Abbreviations:HBOT, hyperbaric oxygen therapy; PAD, peripheral arterial disease. Targets for Glycemic Control, p. S31 Neuropathy, p. S142 Appendix 9: Diabetes and Foot Care: A Patient's Checklist Appendix 10: Diabetic Foot Ulcers: Essentials of Management Appendix 9: Diabetes and Foot Care: A Patient's ChecklistCanadian Journal of DiabetesVol. 37PreviewMany people with diabetes have problems with their feet. You can prevent serious problems by following these basic guidelines. Ask your doctor to explain your risk factors for foot problems. Full-Text PDF Appendix 10: Diabetic Foot Ulcers: Essentials of ManagementCanadian Journal of DiabetesVol. 37Preview Full-Text PDF