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Diabetes and Diabetic Foot

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 CHAPTER

239 Diabetes and Diabetic Foot

SS Dariya, Puneet Saxena, Deepak Chadha, Lalita Verma

Abstract 
The spectrum of diabetic foot diseases ranges from infection and ulceration to destruction of tissues of the foot that holds
the potential to severely affect the livelihood of around 6% of diabetic patients. Around one-third of diabetic foot diseases
require amputation thereby impeding the quality of life and social participation of the patient. However, good foot care can
maximally prevent and retard the occurrence of diabetic foot diseases. Also early screening of the risk factors in population
at risk of such diseases also holds high potential in curbing this menace to occur. The below article through some light
in describing the spectrum of diabetic foot and heralds some of the important points in prevention and management
guidelines of diabetic foot care.

Introduction most feared complications of diabetes. Despite of many

Diabetes is one of the major health problems that has
increased substantially over the past 2–3 decades in
health systems and is currently considered to be a global
public health threat.1,2 The burden of the disease is very
high and is rising in every country, fuelled by the global
rise in the prevalence of obesity and sedentary lifestyles.3
According to the latest data that showed that a global
prevalence of 360 million people with diabetes in the
year 2013 and is expected to rise to more than 600 million
by the year 2035. 4 The widely acceptable etiological
classification of diabetes broadly dividing into two major
subtypes: type 1 and type 2, out of which type 2 diabetes
accounts for the majority (>85%) of the prevalence of
total diabetes. Both forms of diabetes are associated with
multitude of complications like microvascular category,
including neuropathy, nephropathy, and retinopathy and
macrovascular category that constitute stroke, ischemic
heart disease, and peripheral vascular disease. One of
the major manifestations of peripheral vascular disease
is diabetic foot, which is considered to be one of the
refinements in medical and surgical care during the past
decade, diabetic foot problem still remain one of the major
public health issues and also one of the most common
reasons for hospitalization of diabetic patients. The goal of
this article is to summarize key points regarding diabetic
foot problems and emphasizing over prevention and
management strategies of diabetic foot problems.
Epidemiology
The lifetime risk for a diabetic patient to acquire a
lesion in foot is estimated around 15–25% with annual
incidence ranges 1.0–4.1%. 5,6 The spectrum of diabetic
foot diseases includes infection, formation of ulcers, and,
finally, destruction of tissues of the foot or amputation.
In approximately 15% of patients, ulcers ultimately lead
to amputation.6 The level of amputation proportionately
increases the mortality of patients as nearly about 70%
of diabetic patients with a Diabetic Foot Ulcers (DFU)-
related amputation die within 5 years of their amputation.7
The major defined risk factors for ulcer formation are

Chapter-239.indd 1 22-12-2020 09:42:30

 2
male gender, duration of diabetes more than 10 years,
poor glycemic control, and patients with well established
cardiovascular, retinal, and renal comorbidities.8
Pathogenesis
The etiologic triad or the three major contributors in the
causation of diabetic foot complications are ischemia,
neuropathy, and infection as is described in Figure 1.
Ischemia
The prolonged duration of diabetes coupled with poor
glycemic control contributes to the development of
peripheral arterial diseases (PADs) via interplay of
complex metabolic pathways causing microvascular and
macrovascular changes finally leading to ischemia.
These micro- and macrovascular changes include
atherosclerosis along with microcirculator y and
Fig. 1: Pathogenesis of diabetic foot infections
Chapter-239.indd 2
endothelial dysfunctions causing reduced skin blood
flow, poor healing of the ulcers, and arising need for
amputuation.9
Neuropathy
Diabetic neuropathy majorly affects sensory, motor,
and autonomic fibers. There are two major theories that
provide explanation about the pathogenesis of neuropathy
in diabetes. The first theory arises from the fact that there
is excess formation of sorbitol in the intima and media of
major arteries in diabetic patients because of increased
activity of sorbitol (polyol) pathway in diabetics.10 The
sorbitol impairs the axonal conduction and also damages
the Schwann cells thereby promoting demyelination of
nerves. The second theory explains about the nutrient
vessels that supply the nerves also known as vasa
nervorum. These vessels may narrow with progression of
22-12-2020 09:42:31

diabetes thereby contributing to the ischemic injury to the
nerves.
The manifestations arising from the sensory neuro­
pathy are loss of pain, pressure, and temperature sensation
because of first affection of small-diameter fibers of pain
and temperature. This increases susceptibility to injury
as patients are less sensitive to pressure-related trauma
or other minor skin injuries. The features of motor
neuropathy include muscle weakness and atrophy of
the lower foot and ankle because of affection of intrinsic
muscles of leg and foot, causing abnormal loading of the
plantar aspect of the foot. All kinds of deformities of foot
like hammer toes and claw foot develop secondary to
motor neuropathy, promoting focal areas of increased
pressure thereby leading to calluses and ulcers formation.
The long fibers are affected in motor neuropathy. The term
Charcot arthropathy denotes progressive destruction of the
bones, joints, and soft tissues, most commonly involving
ankle and foot joints as sequelae to motor neuropathy.
Autonomic neuropathy causes decrease sweating, dry
skin with cracks, and fissures leading to creation a portal
of entry for bacteria. There is also shunting of blood away
through arteriovenous connections resulting in decreased
tissue perfusion, even in the presence of normal arterial
supply hence Oxygen saturation is markedly reduced in
the skin of diabetic patients, and this accentuates the ulcer
formation.11
Infection
There is blunting of the neuroinflammatory response in
diabetic patients causing lack of the important first-line
defense against pathogens causing more susceptibility
to an ensuing foot infection. 12 This occurs because of
structural and functional changes within the arteriolar
and capillary systems in diabetic patients.
Clinical Features
The most hallmark presentation of diabetic foot disease is
wound that fails to heal or pain at the bony prominence,
pressure point, or site of a callus. These symptoms often
occur along with other features of PAD like intermittent
claudication, resting pain, and ulcer formation, with or
without gangrene.
Severity scale: A newer, classification system proposed
by the International Working Group on the Diabetic Foot
Chapter-239.indd 3
Diabetes and Diabetic Foot CHAPTER 239 3
(IWGDF) and the Infectious Diseases Society of America
(IDSA) have developed four level grading system for
infection.
Diagnostic Evaluation
Multidisciplinary approach is required for the evaluation
and assessment of DFU. It should include patient’s
medical history, laboratory values, dermatological,
musculoskeletal, neurological, and vascular status.
History and Lab Assessment
There should be initial estimation of baseline blood
glucose values with HbA1c estimation followed by detailed
account of patients past history focusing on any significant
history of smoking, any presence of comorbidities, any
presence of sensory disturbances (dysesthesias), any
previous positive history of diabetic foot ulcers or any
episodes of amputation.
Local Examination
The detail clinical examination is essential to determine
the depth and extent of involvement. On inspection of
diabetic foot, the overlying skin may be dry and scaly
with multiple fissures and there may be notable atrophy
of the intrinsic musculature of the foot. The foot may be
in the characteristic “clawed” position because of pull
action of the flexor muscles when atrophy of the intrinsic
muscles occurs. There may be the prominence of heads of
metatarsals with emergence of new pressure points at the
tips of the toes.
All of the normal systemic manifestations of infection,
like fever, leukocytosis, and tachycardia may be completely
absent and so are the normal signs of inflammation in the
infection like erythema, rubor, or tenderness.13,14
The undrained abscesses in deeper planes of the
tissues can be detected by palpation of the foot for areas
of fluctuance or tenderness. The deep space abscesses
can be unfolded by careful inspection and probing, with
unroofing of superficial eschar.
Concept of charcot arthropathy: It occurs secondary
to neuropathy and majorly affects the midfoot. In this
arthropathy acute inflammation is associated with
collapse of the foot and the ankle. The mechanism of
charcot arthropathy evolves around sustenance of an
unperceived injury by the patient initially but continues to
22-12-2020 09:42:31
 4
walk until a severe inflammatory process causes distention
of joints, osteopenia, and dislocation of foot and ankle.
Finally, the foot develops arthropathy deformity in the
form of “rocker bottom” appearance. Charcot arthropathy
in diabetic patients is associated with higher mortality
than in non-diabetic patients.
Neurological Examination
Vibration sensation is evaluated by using 128-Hz tuning
fork tested bilaterally over the tip of the hallux. The loss
of vibratory sensation by the patient when the examiner
still perceives vibration is considered to be an abnormal
response.
Loss of pin-prick sensation can be evaluated by
Semms-Weinstein monofilament, which is a kind of
nylon monofilament that is attached to a plastic handle,
and is applied under pressure to a patient’s foot at ten
different dermatome points and level of sensation
is assessed. A test is considered to be positive when
clinically significant large-fiber peripheral neuropathy is
present and is characterized by patient’s inability to feel
the monofilament when is pressed against the foot with
enough force to bend the filament.
If temperature discrimination is absent, it signifies
small nerve fiber damage causing burning or electric
shock type pain.
Vascular Evaluation
When the patients classically present with ulcers that
are characteristically non-healing in nature associated
with or without gangrene or when the patient present
with symptoms suggestive of intermittent claudication or
ischemic rest pain then vascular examination becomes
imperative to evaluate. There may be no antecedent
vascular symptoms in many diabetic patients who require
urgent revascularization procedures for limb-threatening
ischemia.
Vascular evaluation begins with palpation of the
peripheral arterial pulsations like femoral, popliteal,
posterior tibial, and dorsalis pedis. Ankle brachial
indices (ABI) is also one of the noninvasive modalities to
determine grade of ischemia. An ABI value of less than
0.9 is indicative of arterial blood flow impairment. ABI
<0.4 indicates severe ischemia. The resting ABI may be
normal in many patients complaining of claudication,
and change in the ABI occurs only after exercise testing
Chapter-239.indd 4
in up to 31% of patients.15 Also many diabetic patients
have falsely positive ABI due to atherosclerosis of arterial
wall.16 Other alternatives to ABI are toe-to-brachial index,
transcutaneous oxygen measurements, and Doppler
ultrasound.17
The gold standard method to assess lower extremity
arterial circulation is intra-arterial digital subtraction
arteriography (DSA).18 This technique is much superior
to magnetic resonance arteriography because of
compounding problem of nephrogenic systemic fibrosis
in patients with deranged renal function.19 The addition
of N acetylcysteine has not been definitively proven in
prevention of contrast induced nephropathy in diabetic
patients.20
New techniques like laser scanner to detect perfusion21
and an optical scanner to measure tissue oxygen
saturation22 also assess viability of tissues around wounds.
Infection Control
The organisms most commonly responsible for infection
DFU are polymicrobial in nature and majorly includes
Gram-positive cocci—like Staphylococcus aureus and
Staphylococcus epidermidis, Gram-negative bacilli like
Escherichia coli, Klebsiella, Proteus and Pseudomonas,
and Anaerobic pathogens. These are mainly isolated and
identified by obtaining cultures most ideally from the base
of the debrided wound.
Assessment of Osteomyelitis
Osteomyelitis is known as infection of bone or bone
marrow due to spread of superficial infection from
surrounding soft tissue.23 It is one of the most dreadful
complication of DFU and is also one of the most common
causes for non-traumatic amputuation. The screening
test of choice for diagnosing osteomyelitis is probe
to bone test. 24 In this test blunt sterile metal probe is
inserted through a wound and if it strikes the bone then
osteomyelitis is the definite cause.25 The X-ray imaging
can also reveal the presence of osteolysis, joint effusion,
or foreign body. Leukocyte or antigranulocyte bone scans
are considered an alternative option if bone to probe
test is equivocal. Magnetic resonance imaging is a highly
sensitive (up to 100%) but is only about 80% specific
because osteomyelitis and fracture may have similar
appearances.26 The gold standard for diagnosis is bone
biopsy.
22-12-2020 09:42:31
 Diabetes and Diabetic Foot CHAPTER 239 5

Treatment Options to prevent future recurrences like custom-molded

orthotics, custom-molded shoes, extra-depth
„„ Important principles guiding the treatment options:
shoes, and running shoes.
—— Superficial ulcers with no deep infection or necrosis
—— Dressings of the wounds: Topical therapy often
or minor infections managed conservatively.
aims at maintenance of moist environment that
—— In patients with advanced foot ischemia and no
promote healing of DFU, examples include, films,
palpable pulses of foot contrast arteriography is
foams, hydrogels, hydrocolloids, iodine, simple
done at first point as pivotal diagnostic tool and
saline, silver- or heparan sulfate-impregnated,
then therapeutic action taken up.
alginates and honey-impregnated dressings.
—— If revascularization is required in a patient with
The dry wounds may also need addition of
marked arterial occlusive disease then there are
moisture through hydrogels, hydrocolloids or
mainly two options for revascularization namely
non-absorbent dressings. The ulcer also needs to
surgical approach versus endoscopic intervention.
be protected from excessive pressure by putting an
The elderly, moribund, debilitated patients with
accommodative pad for distribution of pressure to
underlying malignancy or multiple comorbidities,
surrounding tissues.
with flexure contractures developed of knee
—— Hyperbaric oxygen therapy: Multiple trials point
or hip joint poorly tolerate traditional surgical
toward effectiveness of HBOT. It promotes
approaches and endoscopic interventions are
wound healing through many mechanisms like
mainly preferred.
antiedema, antibacterial, and neovascularization
—— In patients with active infections underlying
effects ultimately causing statistically significant
diabetic foot lesions with concomitant salvageable
improvements in amputation rates.27
foot lesions, control of underlying infections is done
—— Vacuum-Assisted closure (VAC) pump: This
first followed by vascular surgical intervention.
technique is for closure of the diabetic wounds
The control of underlying infections is mainly
where a negative pressure is applied to the ulcer
done by use of broad spectrum antibiotics along
via a tube and all its exudates are sucked and
with open debridement and drainage with or
collected into a collecting chamber thereby
without partial amputation.
causing increase vascularity and stimulation of
„„ Medical treatment options:
granulation of the wound.
—— The first goal of diabetic foot disease focuses
—— Role of antibiotics: Infections from the DFU
on primary prevention to correct underlying
are mainly polymicrobial in nature thereby
abnormalities that include aggressive glycemic
necessitating the need for initiation of empirical
control, mo dification of r isk factors like
broad spectrum antibiotics. There are multitude
hypertension, hyperlipidemia, obesity and
of antibiotic regimens that are available as initial
smoking, proper foot care behavior by counseling
therapy for limb-threatening infections. Common
strategies and hygiene strategies.
examples include addition of vancomycin to cover
—— Restriction of weight bearing: This concept
the increasing prevalence of MRSA in hospital-
is known as Off loading. The uncomplicated
acquired as well as community isolates, similarly
DFU often heals with restricted weight bearing
addition of fluoroquinolones to cover both Gram-
strategies alone. Off loading helps in redistribution
positive and Gram-negative organisms. The
of loading forces across the plantar surface thereby
anaerobic bacteria are mainly covered by addition
elimination of isolated excessive forces across
of metronidazole or clindamycin. These empirical
single concentrated point of DFU ultimately
regimens are then tailored according to the culture
promoting healing process. There are many devices
sensitivity patterns to prevent development of
that act upon the principle of Off loading strategy
resistance as well as to prevent unnecessary
like crutch-assisted walking, non-removable knee-
overuse and abuse of antibiotics.
high devices, removable cast walkers (RCWs) and
walker air casts. There are also many more devices

Chapter-239.indd 5 22-12-2020 09:42:31

 6
  The duration of antibiotic therapy is usually ranges
7–10 days in case of mild infections to up to 3 weeks in
case of severe infections.
„„ Surgical and endovascular revascular ization
techniques:
—— The major indications for revascularization
denoted by development of critical ischemia which
is further described by paleness, pulselessness, and
coldness of feet. The main aim of such procedures
is to ensure salvage of the limb. The major pre-
requisites for revascularization are presence of
at least good caliber distal artery with a proper
receiving axis and presence of plantar arch.
The options available are:
—— Bypasses technique
—— Endovascular techniques including
 transluminal angioplasty and
 subluminal recanalization
—— Combined procedures involving angioplasty and
recanaization
—— Finally, hybrid of both bypasses and endovascular
procedures.
„„ Amputation—it remains the last remaining option in
DFU:
—— Amputation is now considered to be an acceptable
modality to treat diabetic foot complications
rather than treatment failure due to rising in
prostheses coupled with aggressive approaches to
rehabilitation. Surgeons generally should strive to
preserve the knee joint because of its significance
for rehabilitation with data suggests that patients
undergoing below-knee amputation ambulating
from 34% to 62% whereas 9% to 23% of above-
knee amputees. The above-knee amputations
are mainly reserved for debilitated patients with
severe tissue loss or with no capacity to ambulate.
Conclusion
For obtaining the utmost outcome in regards to the patients
presenting with diabetic foot diseases, a multidisciplinary
approach is required collaborating with the team of doctors
ranging from podiatric and vascular surgeons to physicians
dealing with medicine aspects of diabetes, wound care, and
infections.
Chapter-239.indd 6
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