Management Of Diabetic Foot Syndrome Research Articles

(Wound) management of diabetic foot syndrome (DFS)

ZusammenfassungZu glauben, das diabetische Fußsyndrom (DFS) sei nur eine Wunde am Fuß eines an Diabetes erkrankten Menschen, verkennt die Komplexität und Tragweite dieser multifaktoriellen Komplikation einer Diabeteserkrankung. Das DFS geht mit relevanten Einschränkungen bis hin zu Amputationen und reduzierter Lebenserwartung für die Betroffenen sowie einem hohen Ressourcenverbrauch für unser Gesundheitssystem einher. Komplizierte Verläufe und auch Amputationen können signifikant reduziert werden, wenn die Patienten ohne Verzögerung spezialisierten interdisziplinären Behandlungsteams zugeführt werden. Vor der Therapie steht die Diagnose – vor Behandlungsbeginn sollten stets 2 Fragen beantwortet werden: Die nach der Ursache des aktiven diabetischen Fußulkus (DFU; Bedingung) und die nach dessen Lokalisation (Auslöser). Eine Wundbehandlung beim DFS muss stets in ein strukturiertes Diagnose- und Behandlungskonzept eingebettet sein. Dafür bieten IRBESA-PP (Infektionsmanagement, Revaskularisierung, Begleiterkrankungen, Entlastung, stadiengerechte Wundbehandlung, [Grenzzonen-]Amputation, Physiotherapie und psychosoziale Unterstützung, Prävention inklusive Podologie) und das Entitätenkonzept eine geeignete konzeptionelle Grundlage. Dabei ist von essenzieller Bedeutung, dass sämtliche an der Behandlung Beteiligten verstehen und verinnerlichen, welche konkreten Auswirkungen der neuropathiebedingte Verlust schützender sensibler Empfindungen („loss of protective sensations“ [LOPS]) im Behandlungsalltag hat: Aufgrund der neuropathischen Defizite fehlt eine schützende schmerzreflektorische Schonhaltung. Die Patienten laufen im wahrsten Sinne des Wortes in ihre komplexen Probleme hinein. Alle an der Behandlung beteiligten Leistungserbringer und Professionen müssen ein solides Maß an Erfahrungs- und Behandlungskompetenz besitzen und interprofessionell so gut koordiniert und abgestimmt arbeiten, dass sie das im (neuropathiebedingten) Verlust der leiblichen Ökonomie begründete Fehlverhalten des Patienten bei allen Maßnahmen bereits mit einkalkulieren.

L’elefante nella stanza

Despite its increasing prevalence, severity and mortality, the Diabetic Foot Syndrome (DFS) still remains an unaddressed critical issue in Diabetology. The management of DFS is adequately performed only in few Centres, and clinical outcomes vary, depending on the possibility of patients to access optimal standards of care. To rivitalize the debate upond DFS and to make concrete proposals to improve the quality of therapy and the accessibility to optimal care, we wrote this editorial.

Analysis of Clinical Profiles, Deformities, and Plantar Pressure Patterns in Diabetic Foot Syndrome

Diabetic foot syndrome refers to heterogeneous clinical and biomechanical profiles, which render predictive models unsatisfactory. A valuable contribution may derive from identification and descriptive analysis of well-defined subgroups of patients. Clinics, biology, function, gait analysis, and plantar pressure variables were assessed in 78 patients with diabetes. In 15 of them, the 3D architecture of the foot bones was characterized by using weight-bearing CT. Patients were grouped by diabetes type (T1, T2), presence (DN) or absence (DNN) of neuropathy, and obesity. Glycated hemoglobin (HbA1c) and plantar lesions were monitored during a 48-month follow-up. Statistical analysis showed significant differences between the groups for at least one clinical (combined neuropathy score, disease duration, HbA1c), biological (age, BMI), functional (joint mobility, foot alignment), or biomechanical (regional peak pressure, pressure-time integral, cadence, velocity) variable. Twelve patients ulcerated during follow-up (22 lesions in total), distributed in all groups but not in the DNN T2 non-obese group. These showed biomechanical alterations, not always occurring at the site of lesion, and HbA1c and neuropathy scores higher than the expected range. Three of them, who also had weight-bearing CT analysis, showed >40% of architecture parameters outside the 95%CI. Appropriate grouping and profiling of patients based on multi-instrumental clinical and biomechanical analysis may help improve prediction modelling and management of diabetic foot syndrome.

Шляхи корекції модифікованих факторів ризику в лікуванні синдрому діабетичної стопи

У роботі визначено модифіковані фактори ризику, що впливають на розвиток і перебіг виразкових дефектів стоп у хворих на цукровий діабет (ЦД) із синдромом діабетичної стопи (СДС). У більшості хворих на ЦД при надходженні до стаціонару з приводу СДС відзначаються: тривала декомпенсація ЦД, порушення ліпідного обміну, супутня серцево-судинна патологія (ішемічна хвороба серця), артеріальна гіпертензія). Встановлено, що формування сенсомоторної нейропатії у пацієнтів із ЦД є основним фактором ризику утворення виразкових дефектів стоп. На момент виявлення виразки у більшості пацієнтів спостерігається поєднання сенсомоторної нейропатії з іншими факторами ризику — деформацією стоп, наявністю виразок і/або ампутацій в анамнезі, макроангіопатією. Наявність інфекції у виразковому дефекті є значущим фактором ризику несприятливого перебігу СДС. Досягнення стабільної компенсації ЦД, цільових значень ліпідного спектра крові та артеріального тиску дозволяє у коротші терміни забезпечити загоєння виразкових дефектів.

Ортопедические аспекты классификаций синдрома диабетической стопы

Introduction For long, orthopedic approaches to the management of diabetic foot syndrome (DFS) remained underexplored in Russia. Deformities of the distal segments of lower extremities play a role in the pathogenesis of DFS. There are limitations and a paucity of research on classifications of DFS within the existing literature. Methods We reviewed 183 DFS patients aged 24 to 82 years treated for various foot deformities between 2015 to 2018. Results Analysis of clinical studies allowed us to systematize deformities of the distal segments of lower limbs in DFS patients. DFS related foot deformities were classified; clinical and radiological classification of foot deformities caused by Charcot neuro-osteoarthropathy (CN) developed and amendments to the generally accepted classifications of DFS with emphasis on the orthopedic management offered. Discussion Lack of a clear understanding of locomotor function disorders, staging of clinical, radiological and anatomical changes in the foot bones at different stages of the disease strongly influence on the potential for multidisciplinary collaborative practice (endocrinologists, surgeons and orthopedists) to ensure an optimal clinical outcome, and an orthopedist may even refuse to treat. The approaches we offered for classification of DFS and foot deformities are different from the known ones and are made from the perspective of the orthopedic and trauma surgeon whose service is rarely used for the treatment of DFS patients in Russia. Conclusion The orthopaedic classification of DFS offered can be helpful in determining the optimal surgical treatment, predicting the course of the pathological process and the functional outcome.

Interdisciplinary approach to the management of the neuropathic form of diabetic foot syndrome. The role of the orthopedist

The article presents the experience of an interdisciplinary approach to the management of diabetic foot syndrome using the example of treating a patient with a neuropathic form, which manifests itself as a chronic wound of the foot plantar surface.

Evaluation of mortality risk factors in diabetic foot infections.

Identifying risk factors for mortality is crucial in the management of diabetic foot syndrome. We aimed to evaluate risk factors for mortality in patients with diabetic foot infection (DFI). A retrospective chart review was conducted on 401 patients from 2010 through 2019. Our primary endpoint was in-hospital mortality. Patients were divided into two groups according to the outcome (survival or death). Clinical data were compared between the two groups statistically. A total of 401 patients were enrolled in the study, 280 (69.8%) of them were male and the mean age was 59.6 ± 11.1 years. The mean follow-up period was 23.7 ± 22.9 months. In-hospital mortality rate was 3%. Univariate analysis indicated that ischaemic wound (P = .023), hindfoot infection (P = .038), whole foot infection (P = .010), peripheral arterial disease (P = .024), high leucocyte levels (>12 040 K/μL) (P = .001), high thrombocyte levels (>378 000 K/μL) (P < 0.001), high C-reactive protein levels (>8.81 mg/dL) (P = .022), and polymicrobial growth in deep tissue culture (P = .041) were significant parameters in predicting mortality. In multivariate analysis, peripheral arterial disease (odds ratio [OR]: 13.430, 95% confidence interval [Cl]: 1.129-59.692; P = .040), high thrombocyte levels (OR: 1.000, 95% Cl: 1.000-1.000; P = .022), and polymicrobial growth in deep tissue culture (OR: 7.790, 95% Cl: 1.592-38.118; P = .011) were independent risk factors for mortality. In conclusion, peripheral arterial disease, high thrombocyte levels, and polymicrobial growth in deep tissue culture were independent risk factors for mortality in DFI.

Predictors of major lower limb amputation in type 2 diabetic patients referred for hospital care with diabetic foot syndrome.

PurposeThis study was conducted to determine the risk factors of major lower extremity amputations in type 2 diabetic patients referred for hospital care with diabetic foot syndrome.Patients and methodsThis retrospective study involved 225 type 2 diabetic patients referred for management of diabetic foot syndrome at King Abdullah University Hospital in the period between January 2014 and December 2015. A structured customized diabetic foot data collection form with diabetic foot characteristics chart was used for documentation of relevant information, which checks for age, sex, body mass index, smoking, duration of diabetes, diabetic control therapy, associated hypertension, cardiac diseases, stroke, chronic renal impairment, renal replacement therapy (hem-dialysis), and history of diabetes-related complication in both feet prior to the study period. The predictors for major lower limb amputations were compared between groups using chi-square test, and binary logistic regression was used to determine the factors associated with major amputation.ResultsTwenty-seven limbs underwent major amputations with an overall rate of major amputation of 11.6%. The following predictors were found to be associated with the higher incidence of major lower limb amputations: duration of diabetes ≥15 years, HbA1c ≥8%, patients on insulin, with hypertension, cardiac diseases, chronic renal impairment, stroke, having gangrene, higher number of components, higher Wagner classification, and ischemia. However, the rate did not differ significantly between men and women.ConclusionPresentation with gangrenous tissue and poor glycemic control are the important risks and significant predictive factors for type 2 diabetes-related major lower limb amputations.

Modern management of diabetic foot syndrome

Healing of diabetic foot ulcers is limited by multiple factors and therefore therapeutic strategies require a multifactorial approach. Reduction of the amputation rates is one of the primary goals. Up to 70% of all lower-leg amputations are performed on people with diabetes, and more >1 million people undergo a lower-limb amputation as a consequence of diabetic foot syndrome (DFS) every year. Lifelong observation and continuity of care of people with a foot at risk are essential in both prevention and management. The important principles are regular inspection, cleansing, removal of debris and/or regular debridement with a scalpel. The principles of care of diabetic foot ulcer are (1) treatment of any associated infection, (2) revascularization if feasible, (3) off-loading, and (4) management of the wound bed in order to promote healing. Adequate pressure relief is an essential component of successful and consistent healing for the majority of neuropathic diabetic foot ulcers. Every diabetic foot wound should be assessed routinely for the presence of infection. The diagnosis of infection in DFS is based on clinical findings of inflammation. Infected diabetic foot ulcers often require surgical therapy and hospital stay. In DFS, the rate of ulcer recurrence are 27% in the first year and 100% after 4 years.

Femoral and sciatic nerve block with 0.25% bupivacaine for surgical management of diabetic foot syndrome: an anesthetic technique for high-risk patients with diabetic nephropathy

A case series of patients with diabetic nephropathy, who underwent lower limb debridement or amputation below the knee during successful combined sciatic and femoral nerve block with bupivacaine 0.25%, is presented. Because impaired nerve conduction in diabetes mellitus results in lower local anesthetic agent requirement, a dose-sparing, minimal effective concentration for surgical anesthesia for peripheral nerve blockade may be more favorable for patients with diabetes and chronic renal disease.

Review Paper: Basic Concepts to Novel Therapies: A Review of the Diabetic Foot

Diabetes mellitus is a global epidemic. Peripheral neuropathy and peripheral vascular disease are complications of diabetes mellitus and the primary causative factors for foot ulceration. Foot ulceration is the leading cause of hospitalization in people with diabetes mellitus. The burden of foot ulceration on health care systems and individual patients is immense. Despite conventional treatment, there persists a high incidence of amputation. A multidisciplinary approach is required to prevent ulcers. This review describes the etiology and risk factors for diabetic foot ulceration and a system for evaluating the diabetic foot. The assessment of neuropathy and the grading of foot ulcers are critically examined. This is important to allow for standardization in clinical trials. The management of diabetic foot syndrome is reviewed. The treatments to ensure vascular supply to the lower limb and control of infection as well as novel therapies, which are becoming available to treat nonhealing, "no-option" diabetic ulcers, are discussed.