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Complications of Diabetes (Charcot Joints/Foot Ulcers)
How significant are diabetes related foot and ankle problems?
More than 2 million of the estimated 14 million Americans living with diabetes will develop foot ulcers at some time. Without proper treatment these wounds can rapidly become limb threatening. In fact 45% of non-traumatic amputations are performed for diabetes related problems.
How can diabetic foot ulcers and infections be prevented? |
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The causes of diabetic foot ulcers are multifactorial. Impaired circulation (atherosclerosis), loss of sensation (neuropathy) and impaired immune response are all contributing factors. Local problems such as calluses, deformed nails, inadequate hygiene and poorly fitting foot wear also play an important role.
Individuals with diabetes can take an active role in ulcer prevention. Daily inspections of the feet can be performed with a hand held mirror. The feet can be washed daily in lukewarm water that has been tested with the more sensitive part of the hand. Bland lotion is utilized to keep the skin well hydrated. Calluses and nail abnormalities should be under the careful watch of an orthopedic surgeon or podiatrist. Chemical exfolients should be avoided.
Tight blood sugar control can further reduce the risk of ulcer formation. Ones primary care physician can track hemoglobin A1c levels to assess the effectiveness of current treatment. Discontinuing smoking, following a reduced fat and sodium diet, utilizing antihyperlipidemic medicines and controlling high blood pressure can all reduce the development of atherosclerosis and impaired local circulation. In general, weight reduction and a moderate exercise program guided by ones physcian can prove beneficial.
Great care must be taken when breaking in shoes. New foot wear should not be worn for more than two hours at a time and walking barefoot is strictly prohibited. Local pressure reduction can be achieved with the aid of an orthotist. Customized insoles and shoes can be fashioned to off-load regions of concern and accommodate bony abnormalities.
Awareness, healthy lifestyles, good local care, pressure reduction footwear and access to a multidisciplinary team remain the best defense in ulcer prevention.
What treatments are available for diabetic foot wounds and infections?
Small, superficial ulcers without significant contamination are often managed on an outpatient basis with frequent follow-up. More complex wounds with deep space infection and exposed bone, tendon or joint will necessitate hospital admission and a multidisciplinary team evaluation. A careful examination will be performed to determine the cause of the ulcer. X-rays will be obtained to look for fractures, foreign bodies and bone infection. Findings may be confirmed with additional tests such as MRI. If vascular disease and impaired circulation is thought to be adversely affecting wound healing then flow studies will be obtained. Angioplasty or vascular bypass may be required to enhance local blood flow and healing potential.
The cornerstone of complex diabetic wound care is thorough surgical removal of unhealthy tissue (debridement). Devitalized skin, muscle and bone will be excised and deep tissue cultures sent to allow for optimization of antibiotic therapy. After the wound has been cleansed and the acute infection controlled dressing changes, growth factors and wound vacuum systems may all be utilized to encourage the wound to heal without further surgery (healing by primary intention).
If debridement has resulted in exposure of important structures such as nerves, bones, tendons or joints then plastic surgical techniques may be required to close the wound. This may include local rearrangement of tissues (local flap), application of skin grafts or importing healthy tissue from a distant site utilizing microsurgical techniques (free flap).
Infected diabetic foot wounds are complex problems that are optimally managed by a multidisciplinary team. Orthopedic, plastic and vascular surgeons can combine efforts to maximize cleansing, soft tissue coverage, local circulation and function. Infectious disease specialists customize antibiotic therapy and endocrinologists optimize control of blood sugar. Nutritionists, physical therapist and orthotists also play an important role in regaining trouble free ambulation.
How can major amputations be prevented?
The estimated risk for major amputation in the individual with diabetes is 15-40X higher than the general population. This risk can be reduced by awareness, lifestyle modification, careful blood sugar control, good skin care and pressure reduction footwear.
Despite these preventive measures limb threatening wounds and infections do develop. A coordinated surgical approach optimizes the prospects of limb salvage in these difficult situations.
Amputation may be unavoidable in some patients. However, an experienced surgical team will be able to preserve length and number of functioning joints to maximize motion in the extremity. Individuals with amputations of the distal third of the foot (transmetatarsal level) often achieve near normal mobility with the aid of a custom insole. As the amputation level rises so does the energy expenditure necessary to walk. A below knee amputation (BKA) requires a 25% increase in energy expenditure to ambulate. Walking with an above knee amputation (AKA) requires 65% more energy than the normal state. Clearly, reducing the level of amputation is an important goal for an individual's long-term function.
The surgical team assembled by the Limb Center has expertise in othopedic, plastic and vascular surgery. A coordinated approach is frequently necessary achieve limb salvage. An angioplasty or vascular bypass may be required to enhance local circulation. Bone grafting contouring and fusion may also be indicated. Tendons may be rerouted or lengthened to enhance motion and balance the foot. Soft tissue may be required to cover exposed bones, nerves and tendons while providing durable padding. Local skin and muscles (local flap) may be shifted to fill the defect or new tissue imported from a distant site utilizing microvascular techniques (free flap). The transplantation of expendable muscle or skin segments from an area of relative excess to the lower extremity is a powerful reconstructive tool. A microvascular connection must be created between the transferred tissue and local blood vessels in the new location. The connections are created under a powerful microscope with stitches finer than a hair. These techniques are complex and best performed at a dedicated center by an experienced reconstructive microsurgeon.
In some patients distant amputation levels cannot be preserved, however, significant benefit can still be gained by creation of a well-padded, durable stump. A dedicated lower extremity surgeon working in close association with a prosthetist and physical therapist can ease the road to recovery.
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