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What is the diabetic foot?
Diabetic foot is defined as infection, ulceration or destruction of the deep tissues of the foot in diabetic patients.
What are the causes of diabetic foot?
Diabetic foot occurs due to neuropathy (peripheral nerve disease) and / or peripheral vascular disease (micro or macroangiopathy) of the lower extremities. Its prevalence increases with age and is favored by poor blood glucose control, which can appear in at least 20% of people with diabetes. When the diabetic foot is not treated early by specialists, ulcers and infection can appear.
What signs or symptoms warn of its appearance?
The predominance of the involvement of the peripheral nerves, the arteries or both, will condition the symptoms that patients present.
In the case of neuropathy or loss of protective sensation predominates, patients will notice a dryness of the feet that will tend to crack, a loss of sensitivity to pain, pressure, changes in temperature or the perception of the body itself. foot, a feeling of coldness and even atrophy and weakness of the muscles which can evolve into deformities. These deformities, together with the lack of perception of pain, cause repeated microtrauma that can lead to the appearance of ulcers.
Peripheral arterial disease, on the other hand, if it is of large vessels causes intermittent claudication or "window disease", a lack of blood supply to the muscles of the lower limb that forces the patient to stop every few meters. If this affectation progresses, rest pain, cold or pale feet can occur and even in the final stages, cause an ulcer due to lack of blood perfusion in the skin, to which an underlying microangiopathy may contribute.
How can it be prevented and what treatment does it have?
As we have seen, among the signs that a patient with diabetic foot presents are foot ulcers and bone deformities. Ulcer is a serious complication that produces high morbidity and mortality, with the risk of loss of the limb or part of it from the moment it appears. In addition, once it is cured, the risk that it may appear again is 40% in the first year and 65% in the following 3 years.
Therefore, prevention of this serious complication is essential. To do this, and taking into account that the diabetic foot is exceptional in people without associated neuropathy or arteriopathy, an annual review carried out by a health professional trained in diabetic patients is essential, aimed at ruling out the presence of loss of the sensation of protection and macro or microvascular involvement. This is done through a directed clinical history accompanied by simple tests such as the Semmes Weinstein monofilament, the tuning fork, the palpation of the pulses, the measurement of the arterial pressure in the arteries of the foot including the ankle-brachial index and the obtaining of waves doppler using an ultrasound machine.
There are people with diabetes who are at high risk of developing an ulcer:
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advanced age
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poorly controlled diabetes, long-standing or with involvement of other organs (nephropathy, retinopathy, etc).
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known neuropathy or arteriopathy
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biomechanical alterations of the foot
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previous ulcer / amputation
In these cases they should be examined in shorter periods of time and in some cases, additional tests performed.
In addition, a specific education is necessary so that they protect their feet avoiding walking barefoot or with socks without shoes, or in thin-soled slippers, either at home or abroad. Daily inspection, washing with warm water and thorough drying of the surface of both feet must be instilled in them, as well as the use of emollients to hydrate dry skin. Special care must be taken when cutting the nails, having to be done in a straight line, avoiding the use of chemical or abrasive products to remove calluses or calluses and going to the podiatrist if they cannot do it themselves. In addition, they should check the inside of the shoe for protrusions that can rub against the foot and sometimes use specific footwear or relief insoles. Due to the lack of sensitivity that patients with diabetic neuropathy present, they should avoid the use of braziers, electric blankets or heat sources near the feet due to the risk of burns that can be the origin of an ulcer that is difficult to heal.
Once the deformity of the foot has already established, it is sometimes necessary to perform some surgery to restore the shape of the foot and prevent the appearance of an ulcer.
Physical exercise has numerous benefits in diabetic people, but its performance must be supervised by establishing adequate preventive measures to avoid an inappropriate overload of a specific area of the foot.
Diabetic people who present with an ulcer must undergo additional tests that allow us to obtain very valuable information about the perfusion of the foot, its probability of healing and the vascular anatomy, which is mandatory if they have an ulcer that does not heal despite treatment correct for 6 weeks. Based on these, the cardiovascular surgeon evaluates the arterial circulation of the lower limb in its entirety, which allows establishing an adequate revascularization strategy.
This may consist of an angioplasty , that is, restoring flow in the blood vessel by inserting a catheter with a balloon that, when inflated, dilates the interior of the artery at the site of the stenosis, with or without subsequent implantation of a stent. ; or in an arterial revascularization surgery , consisting of extracting the atheroma plaque that occludes the artery (endarterectomy) or performing an arterial bypass or bypass, either through a vein from the patient or through an artificial graft. The choice of one or the other technique will depend on the anatomy of the patient, the injuries that he presents, the age, comorbidities and experience of the surgical team.
On other occasions and when arterial revascularization techniques are not possible, complementary techniques such as hyperbaric oxygenation can be used, which can help wound healing in case of infections due to anaerobic bacteria or ozone therapy during cures.
In case of infection, a culture of the ulcer should be taken and the patient may require antibiotic treatment, initially broad spectrum and later directed according to the result of the culture and antibiogram.
Patients with neuropathic ulcers that take time to heal may require removable or non-removable discharge devices and the orthopedic surgeon should assess in case of biomechanical alteration if any foot surgery is required: tenotomy, metatarsal head resection, arthroplasty, Achilles tendon lengthening , etc.
Ulcer care must be entrusted to adequately trained nursing professionals, and cure may require specific measures such as regular tissue debridement or vacuum systems to promote granulation.
What is the risk for people with diabetes?
The diabetic foot is one of the most serious complications of diabetes because ulceration in diabetics has a great predisposition to infection, and can progress to gangrene and loss of the limb due to the circulatory disorders that often occur in these patients.
It involves great suffering for the patient, entails high economic costs and causes a considerable burden on the family, the health system and society in general. Diabetes is the most common cause of lower limb amputation and it is estimated that 40 to 70% of amputees are diabetic. In 85% of the cases of diabetic patients who end up with an amputation, the triggering factor is the ulcer, associated with infection and gangrene.
