Management of the Diabetic Foot: Preventing Amputation

Marvin E. Levin, MD

South Med J. 2002;95(1)

Peripheral Arterial Disease

The atherosclerotic plaques that occur in patients with diabetes are no different than those occurring in the nondiabetic; in both, such plaques are composed of deposits of cholesterol, calcium, lipids, smooth muscle cells, and macrophages. There are, however, some important differences in the characteristics of PAD in these two groups of patients; these differences are listed in Table 2 .

Patients with diabetes should have a vascular examination at least once a year, while those who have evidence of PAD should be examined at least every 4 months. The most important steps in evaluating PAD are a medical history and a thorough vascular examination. In general, a history of intermittent claudication is one of the first symptoms of vascular insufficiency. Because of loss of sensation, however, diabetic patients may have ischemia without symptoms. Coldness of the foot and absence of pulses are hallmark clinical signs of PAD, as are shiny, atrophic skin and loss of hair.

Epidemiology Of Diabetic Foot Ulcer

16 million diabetics
15% have foot ulcers
6% require hospitalization

When the medical history and physical examination reveal signs or symptoms of ischemia, the vascular laboratory can be of help. Patients with diabetes may have normal ankle pressures but significantly decreased toe pressures. It is extremely important, therefore, to measure toe pressures in patients with diabetes. Arterial waveforms as well as segmental pressures help to indicate areas of arterial narrowing.

Telling patients with PAD not to cross their legs is of little protective value. A study of diabetic patients with known PAD showed that crossing their legs did not decrease Doppler pressures.^[8]

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Introduction
Peripheral Arterial Disease
Peripheral Neuropathy
Neuropathic Ulcer
Management of the Neuropathic Foot Ulcer
Infection
Adjunctive Therapies
Posttreatment Management of Healed Foot Ulcers
Therapeutic Shoes
Teamwork
Patient Education
Legal Issues
Conclusion
References

Limitation of daily activities
Impairment of physical activity
Depression
Early retirement
Decreased income
Loss of social contacts
Impairment of sexual activity

Table 2. Differences in Diabetic and Nondiabetic Peripheral Artery Disease
	Diabetic	Nondiabetic
Clinical	More common	Less common
	Younger patient	Older patient
	More rapid	Less rapid
Male/female ratio	Male = female	Male >> female
Occlusion	Multisegmental	Single segment
Vessels adjacent to occlusion	Involved	Not involved
Collateral vessels	Involved	Usually normal
Lower extremities	Bilateral involvement	Unilateral involvement
Vessels involved	Tibial artery	Aortic artery
	Peroneal artery	Iliac artery
	Small vessels	Femoral artery
	Arterioles

Adapted from Levin and O'Neal's The Diabetic Foot. ^[7]

Evaluation:

Clinical appearance

Establish for depth

X-ray for:

Osteomyelitis

Foreign objects

Subcutaneous air

Biopsy if indicated

Metabolic control

Debridement, sharp radical

Bacterial cultures (aerobic, anaerobic)

Antibiotics:

Oral

Parenteral

Do not soak the feet

Do not use whirlpool

Non-weight-bearing

Bed rest

Crutches

Walkers

Contact casting

Special shoes

Improve circulation (vascular surgery)

Consultation

Adapted from Levin and O'Neal's The Diabetic Foot. ^[7]

Vascular
- Atherosclerosis
- Increased viscosity
Neurologic:
- Insensate foot
Infection:
- Inadequate debridement
- Poor blood supply
- Microthrombi
- Hyperglycemia
- Decreased neutropil function
- Polymicrobial infection
- Changing bacterial flora
- Osteomyelitis
Immunosuppression
Mechanical
- Edema
- Weight bearing
Poor nutrition:
- Low serum albumin
Poor patient compliance
Delayed treatment and referral
Managed care

Adapted from Levin and O'Neal's The Diabetic Foot. ^[7]

Living skin equivalents
Autologous growth factors
Recombinant growth factors
Hyperbaric oxygen
Electrical stimulation
Ultrasound stimulation
Granulocyte-stimulating factor

Primary physician
Endocrinologist
Diabetologist
Podiatrist
Nurse-educator
Physician assistant
Enterostomal nurse
Infectious disease specialist
Neurologist
Radiologist
Specialist in hyperbaric medicine
Surgeon
- Vascular
- Orthopedic
- Plastic
Physiatrist
Physical therapist
Pedorthist
Orthotist
Prosthetist
Social worker
Home care nurse
Sex therapist

Inspect the feet daily for blisters, cuts, scratches, and reddened areas. The use of a mirror can aid in seeing the bottom of the foot. Always check between the toes.

Wash feet daily. Dry carefully, especially between the toes.

Avoid extreme temperatures. Test water with hand or elbow before bathing.

If feet feel cold at night, wear socks. Do not apply a hot water bottle, electric blanket, or heating pad.

Do not walk on hot surfaces, such as sandy beaches or the cement around swimming pools.

Do not walk barefoot.

Do not cut corns. Do not use chemical agents for removal of corns and calluses. Do not use corn plasters. Do not use strong antiseptic solutions on your feet.

Do not use adhesive tape on your feet.

Inspect the inside of shoes daily for foreign objects, nail points, torn linings, and rough areas.

If your vision is impaired, have a family member inspect feet daily, trim nails, and buff down calluses.

Do not soak your feet unless specifically instructed.

For dry skin, use a very thin coat of a lubricating oil or cream. Apply after bathing. Do not put the oil or cream between toes. Consult physician for type of lubricant and detailed instructions.

Wear stockings that fit properly. Do not wear mended stockings. Avoid stockings with seams. Change stockings daily. Do not wear garters.

Shoes should be comfortable at the time of purchase. Purchase shoes in the afternoon when feet tend to be the largest. Do not depend on them to stretch. Shoes should be made of leather. Running or walking shoes may be worn after checking with the physician.

Inform your shoe salesperson that you are diabetic.

Do not wear shoes without stockings.

Do not wear sandals with thongs between the toes.

Ask about therapeutic shoes if you have a foot deformity, such as bunions or claw toes, or if you have had a previous ulcer.

Take special precautions in the winter. Wear wool socks and protective footgear, such as fleece-lined boots.

Cut nails straight across or follow the curve of the nail.

Do not cut corns and calluses. Follow special instructions from your physician or podiatrist. If the nails are thick or difficult to cut, have a family member, physician, or podiatrist do it.

See your physician regularly and be sure that your feet, including between the toes, are examined at each visit.

Do not smoke.

Notify your physician or podiatrist at once should you develop a blister or sore on your foot.

Be sure to inform your podiatrist that you are diabetic.

Adapted from Levin and O'Neal's The Diabetic Foot. ^[7]

Failure to educate the patient about proper foot care
Failure to perform a neurologic or vascular examination
Failure to control blood glucose level
Failure to adequately debride ulcer
Failure to culture the wound for aerobes and anaerobes
Failure to x-ray
Failure to recognize worsening infection
Failure to inform patient of the signs and symptoms of worsening infection
Failure to prescribe non-weight bearing
Failure to hospitalize or delayed hospitalization in the face of worsening infection
Failure to obtain consultation or delay in doing so

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