Anatomical Changes in Diabetic Foot

Abstract

Objective: Diabetic patients are 15 times more likely to develop gangrene, requiring amputation. Most of the non-traumatic limb amputations are due to complications of diabetes. The aim of this study was to analyse the various anatomical changes occurring in patients with diabetic foot ulcers.
Materials and Methods: A prospective study was carried out in 70 patients presenting to the Diabetic Clinic at a tertiary care hospi-tal in Delhi, India under the Professor and Head of Department Surgery BHDC India, regarding the site, size, nature of foot le-sion, etiology of foot lesions and culture and sensitivity patterns of the wound swabs.
Results: Most common lesions were noticed to have skin and nail changes (47 patients,67.1%) in the form of corns, callosities, dry skin, fissures, hypertrophied and brittle nails.20 patients (28.5%) presented with ulcers and 3 patients (4.2%) had gangrene. 56 patients (80%) were managed by multiple wound debridements and serial dressings.11 patients (15.7%) required skin grafting for wound healing.3 patients (4.2%) required some form of amputa-tion.
Conclusion: It was found that with strict diabetic control, daily dressings, surgical intervention in the form of adequate, aggressive and timely debridement and culture specific antibiotics, the diabetic foot wounds healed well. Amputation at appropriate levels should be performed as life-saving measures in severe infections to pre-vent septicaemia and lifesaving takes precedence over limb / toe saving.

Keywords

• Amputation,foot lesions,neuropathy,wound debridement

Diyabetik Ayakta Anatomik Değişiklikler

Öz

Amaç: Diyabetik hastaların, amputasyon gerektiren, kangreni geliştirme olasılığı 15 kat daha fazladır. Travmatik olmayan uzuv amputasyonlarının çoğu, diyabetin komplikasyonlarından kaynak-lanmaktadır.Bu çalışmanın amacı diyabetik ayak ülseri olan has-talarda meydana gelen çeşitli anatomik değişiklikleri analiz etmek-tir.
Materyal ve Metod: Hindistan BHDC Profesör ve Cerrahi Ana-bilim Dalı Başkanı yönetimindeki üçüncü basamak hastanesinde Diyabet Kliniğine başvuran 70 hastanın ayak lezyonunun doğası, yerleşim yeri, büyüklüğü, ayak lezyonlarının etiyolojisi ve yara bezlerinin hassasiyet ve kültürü konusunda prospektif bir çalışma yürütüldü.
Bulgular: En sık görülen lezyonlar nasır, kuru cilt, fissür, hiper-trofik ve kırılgan tırnak formlarında cilt ve tırnak değişiklikleri (47 hasta,% 67.1) görülmüştür. 20 hastada (% 28,5) ülser mevcuttu ve 3 hastada (% 4,2) kangren vardı. 56 hasta (% 80) çoklu yara de-bridmanları ile tedavi edildi ve seri pansumanlar yapıldı.11 has-tadan (% 15.7) yara iyileşmesi için cilt grefti istedi. 3 hasta için (% 4.2) bir çeşit amputasyon gerektirdi.
Sonuç: Kesin diyabetik kontrol, günlük pansumanlar, yeterli, agresif ve zamanında debridman ve kültüre özgü antibiyotikler şeklinde cerrahi müdahale ile diabetik ayak yaralarının iyileştiği tespit edildi. Uygun seviyelerde amputasyon, septisemiyi önlemek için şiddetli enfeksiyonlarda hayat kurtarıcı önlemler olarak yapılmalı ve hayat kurtarıcı, kol ve ayak tasarrufundan daha önce-liklidir.

Anahtar Kelimeler

• Amputasyon,ayak lezyonları,nöropati,yara debridmanı

Kaynakça

1. 1. Reiber GE, Lipsky BA, Gibbons GW. The burden of diabetic foot ulcers. Am J Surg. 1998;176(2A Suppl):5S-10S.
2. 2. Sanders LJ. Diabetes mellitus:Prevention of amputation. J Am Podiatr Med Assoc.1994; 84( 7): 322-328.
3. 3. Quebedeaux TL, Lavery LA, Lavery DC. The development of foot deformities and ulcers after great toe amputation in diabetes. Diabetes Care. 1996 ;19(2):165-167.
4. 4. Singh G, Chawla S. Amputation in Diabetic Patients. Med J Armed Forces India. 2011;62(1):36–39.
5. 5. Edwards et al.: Health service pathways for patients with chronic leg ulcers: identifying effective pathways for facilitation of evidence based wound care. BMC Health Services Research 2013 13:86.doi:10.1186/1472-6963-13-86
6. 6. Trautner C, Haastert B, Giani G, Berger M. Incidence of lower limb amputations and diabetes. Diabetes Care. 1996; 19(9):1006-9.
7. 7. Naves CC. The Diabetic Foot: A Historical Overview and Gaps in Current Treatment. AdvWound Care (New Rochelle). 2016;5(5):191–197. doi:10.1089/wound.2013.0518
8. 8. Apelqvist J, Ragnarson-Tennvall G, Persson U, Larsson J. Diabetic foot ulcers in a multidisciplinary setting. An economic analysis of primary healing and healing with amputation. J Intern Med. 1994 ;235(5):463-71.

9. 9. Giugliano D, Ceriello A, Paolisso G. Oxidative stress and diabetic vascular complications. Diabetes Care. 1996 ;19(3):257-67.
10. 10. Olokoba AB, Obateru OA, Olokoba LB. Type 2 diabetes mellitus: A review of current trends. Oman Med J. 2012;27(4):269–273.doi: 10.5001/omj.2012.68.
11. 11. Karamanou M, Protogerou A, Tsoucalas G, Androutsos G, Poulakou-Rebelakou E. Milestones in the history of diabetes mellitus: The main contributors. World J Diabetes. 2016;7(1):1–7. doi:10.4239/wjd.v7.i1.1
12. 12. Vecchio I, Tornali C, Bragazzi NL and Martini M. The Discovery of Insulin: An Important Milestone in the History of Medicine. Front. Endocrinol. 2018; 9:613. doi: 10.3389/fendo.2018.00613
13. 13. Amin N, Doupis J. Diabetic foot disease: From the evaluation of the "foot at risk" to the novel diabetic ulcer treatment modalities. World J Diabetes. 2016;7(7):153–164. doi:10.4239/wjd.v7.i7.153
14. 14. Nabuurs-Franssen MH, Houben AJ,Tooke JE et al..The effect of polyneuropathy on foot microcirculation in Type II diabetes. Diabetologia. 2002;45:1164–1171.doi: 10.1007/s00125-002-0872-z
15. 15. Mayfield JA, Sugarman JR. The use of the Semmes-Weinstein monofilament and other threshold tests for preventing foot ulceration and amputation in persons with diabetes. J FamPract. 2000;49(11 Suppl):S17-29.
16. 16. Smieja M, Hunt DL, Edelman D, Etchells E, Cornuz J, Simel DL. Clinical examination for the detection of protective sensation in the feet of diabetic patients. International Cooperative Group for Clinical Examination Research. J Gen Intern Med. 1999 ;14(7):418-24.
17. 17. Boyko EJ, Ahroni JH, Stensel V et al. A prospective study of risk factors for diabetic foot ulcer. The Seattle Diabetic Foot Study. Diabetes Care. Jul 1999 ;22(7):1036-42.
18. 18. Gooch C, Podwall D. The diabetic neuropathies. Neurologist. 2004;10(6):311-22.
19. 19. Boulton AJ, Kubrusly DB, Bowker JH et al. Impaired vibratory perception and diabetic foot ulceration.Diabet Med. 1986;3(4):335-7.
20. 20. Armstrong DG, Lavery LA. Diabetic foot ulcers: prevention, diagnosis andclassification. Am Fam Physician. 1998 ; 57(6):1325-32.
21. 21. Brand PW. Management of the insensitive limb. Phys Ther. 1979 ;59(1):8-12.
22. 22. Guy RJ, Clark CA, Malcolm PN, Watkins PJ. Evaluation of thermal and vibration sensation in diabetic neuropathy. Diabetologia. 1985 ;28(3):131-7.
23. 23. Andersen H. Motor dysfunction in diabetes. Diabetes Metab Res Rev. 2012 ;28Suppl 1:89-92.
24. 24. Shaw JE, Boulton AJ. The pathogenesis of diabetic foot problems: an overview. Diabetes. 1997 ;46Suppl 2:S58-61.
25. 25. Chung T, Prasad K, Lloyd TE. Peripheral neuropathy: clinical and electrophysiological considerations. Neuroimaging Clin N Am. 2014;24(1):49–65. doi:10.1016/j.nic.2013.03.023
26. 26. Pryce TD. A case of perforating ulcers of both feet associated with diabetes and ataxic symptoms. Lancet . 1887 : 11-12.
27. 27. Martin MM. Neuropathic lesions of the feet in diabetes mellitus. Proc R Soc Med. 1954 ;47(2):139-40.
28. 28. Ellenberg M. Diabeicneuropathic ulcer. J Mt Sinai Hosp. 1968; 35: 585-594.