diabetic foot
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Pathology
- neuropathy (sensory & motor)
- motor neuropathy appears 1st
- more common than angiopathy
- non painful
- Charcot joint: neuropathic osteoarthropathy
- X-ray
- bone scan negative
- indium-labeled WBC scan negative
- angiopathy
- poor prognosis
- ischemic ulcers painful
- pallor with elevation or dependent rubor
- limb-threatening
- posterior tibial artery much bigger than dorsalis pedis thus better indicator of ischemic potential
- combination of neuropathy & angiopathy
- diabetic foot ulceration
- mixed infection with Staphylococcus aureus, anaerobes & aerobic gram negative organisms
- osteomyelitis
- diagnosis is difficult
- if bone can be probed through ulcer, likelihood of osteomyelitis is high
- risk factors[4]
- loss of protective sensation due to peripheral neuropathy
- peripheral vascular disease
- foot deformities
- prior ulceration &/or amputation (greatest risk factor)
- also see grading of diabetic foot ulcer
- callus formation
- increased formation of keratin
- calluses prone to crack & act as entry points for cutaneous bacteria
- foot ulcers may originate from callus-induced lesions
- loss of sweating results in dryness & cracking of skin
Laboratory
- ankle/brachial index by doppler ultrasound
- bone biopsy for suspected osteomyelitis
Radiology
- radiographs may be helpful in diagnosis of osteomyelitis if there are erosive changes contiguous with the ulcer, especially if worsening with time
- magnetic resonance imaging (MRI) is recommended if further imaging (after radiograph) is needed[5]
- bone scan
- may show multiple areas of increased radioactive uptake unrelated to osteomyelitis
- overlying cellulitis confounds interpretation of bone scan
Management
- prevention
- foot inspection
- 4 times per year
- all diabetics at least yearly[1]
- inspect for sensation, ulcers, calluses, foot deformities, pain, abnormal pressure sensation, peripheral pulses[1]
- 10 gram monofilament test defines loss of protective sensation
- nightly self inspection
- extra depth & custom-molded shoes for patients with foot deformity or history of ulceration
- patients must NOT go barefoot
- callouses indicate pressure points in footwear
- petroleum jelly or lanolin relieves dry, cracking skin of neuropathic foot
- no benefit of therapeutic shoes[2]
- foot inspection
- ulceration
- reduce pressure
- prolonged courses of antibiotics may be necessary
- debridement if evidence of sinus tract
- infection
- extensive spreading cellulitis, tissue ischemia, & sepsis portend life-threatening infection
- antibiotic coverage should include
- Staphylococci (including MRSA)
- Streptococci
- gram negative organisms (including Pseudomonas)
- anaerobes[1] (see pathology)
- treatment of cellulitis
- treatment of osteomyelitis[5]
- adjunctive rifampin for diabetic foot osteomyelitis associated with improved amputation-free survival[10]
- ischemia: hyperbaric oxygen does not improve outcomes in diabetic patients with ischemic foot ulcers[9]
- glycemic control is key to optimizing healing[1]
More general terms
Additional terms
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16. American College of Physicians, Philadelphia 1998, 2009, 2012
- ↑ 2.0 2.1 Journal Watch 22(12):93, 2002 Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. Reiber GE et al, JAMA 287:2552, 2002 PMID: https://www.ncbi.nlm.nih.gov/pubmed/12020336
- ↑ Diabetic Foot Disorders Clinical Practice Guideline American College of Foot and Ankle Surgeons http://www.acfas.org/pubresearch/cpg/diabetic-cpg.htm
- ↑ 4.0 4.1 Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - ↑ 5.0 5.1 5.2 Lipsky BA et al Executive Summary: 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections Clin Infect Dis. (2012) 54 (12): 1679-1684 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22619239 <Internet> http://cid.oxfordjournals.org/content/54/12/1679.full
- ↑ American Diabetes Association. (9) Microvascular complications and foot care. Diabetes Care. 2015 Jan;38 Suppl:S58-66 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25537710
American Diabetes Association. Microvascular complications and foot care: standards of medical care in diabetes-2021. Diabetes Care 2021 Jan; 44:S151 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33298422 - ↑ Game FL Osteomyelitis in the diabetic foot: diagnosis and management. Med Clin North Am. 2013 Sep;97(5):947-56. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23992902
- ↑ Peters EJ, Lipsky BA. Diagnosis and management of infection in the diabetic foot. Med Clin North Am. 2013 Sep;97(5):911-46. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23992901
- ↑ 9.0 9.1 Santema KTB, Stoekenbroek RM, Koelemay MJW et al. Hyperbaric oxygen therapy in the treatment of ischemic lower-extremity ulcers in patients with diabetes: Results of the DAMO2CLES multicenter randomized clinical trial. Diabetes Care 2018 Jan; 41:112 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29074815 <Internet> http://care.diabetesjournals.org/content/41/1/112
- ↑ 10.0 10.1 Wilson BM, Bessesen MT, Doros G et al. Adjunctive rifampin therapy for diabetic foot osteomyelitis in the Veterans Health Administration. JAMA Netw Open 2019 Nov 1; 2:e1916003. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31755948 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2755865
- ↑ Schmidt BM, Holmes CM. Updates on diabetic foot and Charcot osteopathic arthropathy. Curr Diab Rep 2018 Aug 15; 18:74 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30112582
- ↑ ElSayed NA, Aleppo G, Aroda VR, et al. 12. Retinopathy, neuropathy, and foot care: standards of care in diabetes - 2023. Diabetes Care. 2023;46:S203-S215. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36507636
- ↑ National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Diabetes and Foot Problems https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/foot-problems