Management of the Diabetic Foot: Preventing Amputation

Marvin E. Levin, MD

Disclosures

South Med J. 2002;95(1) 

In This Article

Neuropathic Ulcer

The plantar neuropathic ulcer is the condition that most commonly leads to amputation.[15] Foot ulcers are extremely common in patients with diabetes. Reiber et al,[5] in their review of diabetic foot ulcers in several populations, found a prevalence of 4.4% to 10.5%. Approximately 15% of all patients with diabetes will have foot ulcers during their lifetimes.[16]

Neuropathic foot ulcers result from repetitive stress on feet rendered insensitive by PN. This condition, which is the most important factor leading to ulceration, is present in more than 80% of diabetic patients with foot ulceration.[17,18] When stress persists, the foot develops "hot spots" and callus buildup.

Callus buildup can increase the foot pressure by as much as 30%[19]; increased foot pressure contributes to plantar ulceration. Periodic reduction of calluses is, therfore, extremely important. Wearing cushioned shoes[20] and pressure-reducing hosiery[21] can also be beneficial in reducing the rate of callus build up. Patients should not go barefoot, not only because of possible trauma, but also because significantly more pressure is exerted on the feet when walking barefoot compared with walking on cushioned shoes.[22]

Calluses and ulceration occur most often at the site of maximum pressure, usually over the plantar surface of the metatarsal heads and on the plantar surface of the hallux. When ulceration occurs on the side of the foot, it is most likely due to ill-fitting shoes and ischemic pressure necrosis. When the ulceration is on the dorsum of the foot, it is usually the result of trauma.

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