Management of the Diabetic Foot: Preventing Amputation

Marvin E. Levin, MD

Disclosures

South Med J. 2002;95(1) 

In This Article

Management of the Neuropathic Foot Ulcer

Table 3 lists the steps in the management of diabetic foot ulcers, while Table 4 notes the impediments to wound healing in the diabetic patient, all of which must be considered in planning a management strategy.[7] The first step in management of the ulcer is to establish its size and depth; what appears to be a superficial ulceration may be only the tip of the iceberg. Penetration may extend deep into the tissues.

Radiographs are necessary to rule out osteomyelitis, gas formation, the presence of foreign objects, and asymptomatic fractures. Cavanagh et al[22] found that diabetic patients without neuropathy did not have excessive bone abnormalities. Diabetic patients with PN, however, and particularly those with a history of previous foot ulceration, had significantly more radiographic abnormalities. Previously unrecognized traumatic fractures were found in 22% of patients with neuropathic foot ulceration.[22] Radiographs should, therefore, be taken of any foot with ulceration or infection.

Neuropathic ulcers should be aggressively debrided by sharp dissection, with removal of all necrotic material and eschar. Not infrequently, there is infection beneath the eschar; the infection must be identified so that it can be treated. Removal of eschar in a patient with severe PAD should be done cautiously, since healing can be significantly impaired.

Debridement of a diabetic foot ulcer should be carried down to healthy, bleeding tissue. After debridement, the ulcer will probably be larger than it was at presentation. Whirlpool is not an effective method of debridement. Enzymatic debridement will be superficial. Debridement using maggots is an old form of treatment used for centuries by military surgeons. It was introduced to the civilian population in the 1930s, and recent reports have again suggested the effectiveness of maggots in cleansing wounds.[23,24]

When the foot is insensitive, minor sharp debridement can be carried out at the bedside. In many cases, however, the patient must be taken to the operating room for adequate debridement under anesthesia. Taylor and Porter[25] have reported that aggressive foot debridement and, when indicated, revascularization resulted in long-term salvage of threatened limbs, even in high-risk patients.

Biopsy should be considered when ulcers appear at an atypical location (not over the metatarsal heads or the plantar surface of the hallux), when they are unrelated to trauma, or when they are unresponsive to aggressive therapy. In a number of such cases, biopsies revealed primary and metastatic malignancies.

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