Diabetic Foot Syndrome: An Unpleasant Scare for Diabetics and Their Attending Doctors
Diabetic foot syndrome is a very serious complication of diabetes mellitus (DM). It often leads to destructive tissue damage distal to the ankle. Due to the complex therapy, it is advisable to focus on thorough and meticulous prevention of this complication.
Combination of Microvascular and Macrovascular Changes
Diabetic foot syndrome arises from a combination of local ischemic and neuropathic changes. It is characterized by the presence of an ulceration on the lower limb below the ankle level. The presence of neuropathy leads to easier mechanical injury to the tissue of the lower limb. The basic defense mechanism - pain - is absent. Due to neuropathy and microangiopathy, there is a reduction in capillary perfusion, tissue hypoxia, and consequently local ischemia. When the skin cover is injured, the wound is often secondarily complicated by infection, making defect healing very difficult.
“Diabetic Foot”
Due to impaired sensation, patients often do not perceive minor injuries, local pressure sores, or fissures during mycoses. These injuries, however, are often a provoking factor for the development of diabetic foot syndrome. Inervation of the interosseous muscles is impaired, which leads to a collapse of the transverse and longitudinal arches of the foot, deformities, and increased loading of the sole.
The decrease in innervation also affects bone trophism. Their remodeling is poor, there is increased resorption, osteoporosis develops, and pathological fractures can occur. Such combined foot involvement is referred to as Charcot's osteoarthropathy.
Thorough Prevention or How to Save the Lower Limb
A patient with DM is invited for check-ups every 3 months. In addition to laboratory and physical examinations and blood pressure control, the attending physician also performs a careful inspection of both lower limbs. The physician actively inquires about problems when walking, the presence of rest pain, changes in sensitivity to heat and cold, or changes in sweating of the lower limbs. Regular foot care, however, is mainly the patient's duty.
The role of the attending physician is to instruct the patient repeatedly and thoroughly on the importance of these measures. Emphasis is placed on daily foot inspection (utilizing a mirror or a second informed person in case of impaired mobility), removal of hyperkeratosis, treatment of minor injuries, protection from sharp objects, cold, heat, and wearing suitable footwear to prevent pressure sores. It is important to inform the patient about the necessity of visual control. Due to neuropathy, painful injuries or tight shoes may not be felt. Consistent control and management of hyperglycemia, hypertension, hyperlipidemia, and other risk factors are a given.
When to Refer the Patient to a Specialist
Diabetic foot syndrome can be classified according to the Wagner scale:
- Wagner 0 - risk factors without ulceration
- Wagner 1 - uncomplicated superficial ulcerations
- Wagner 2 - infected superficial ulcerations
- Wagner 3 - infected deep ulcerations
- Wagner 4 - localized gangrene on parts of the foot
- Wagner 5 - gangrene of the whole foot
When reaching stage 1 or 2, the patient must be immediately referred for examination and follow-up in a podiatric clinic. This also applies to patients with Charcot's osteoarthropathy.
Treatment Measures
The basis is monitoring the limb and treating all injuries. In the presence of infection, antibiotics must be administered. Diagnostics and potential therapy of ischemia in the lower limb are also essential. Charcot's osteoarthropathy and fractures require immobilization and offloading of the limb with subsequent recalcification treatment. Amputation is indicated in the presence of extensive gangrene and osteomyelitis resistant to treatment.
Key Compliance of the Patient
In the Czech Republic, approximately 45 thousand diabetics suffer from diabetic foot syndrome. The progression of this complication can only be halted by thorough prevention. The most crucial factor, however, is the cooperation of the patient, who must be instructed by the attending physician on how to properly care for their feet.
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Sources:
1. Karen I., Svačina Š. Diabetes mellitus. Novelization 2020. Recommended diagnostic and therapeutic procedures for general practitioners. Society of General Medicine CLS JEP, 2020. Available at: www.svl.cz/files/files/Doporucene-postupy/2020/DIABETES-MELLITUS-2020.pdf
2. Češka R., Štulc T., Tesař V., Lukáš M. (eds.). Internal Medicine. 2nd updated edition. Triton, Prague, 2015.
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