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Diabetic foot ulcers, as shown in the images below, occur as a result of various factors, such as mechanical changes in conformation of the bony architecture of the foot, peripheral neuropathy, and atherosclerotic peripheral arterial disease, all of which occur with higher frequency and intensity in the diabetic population.
Diabetic ulcer of the medial aspect of left first toe before and after appropriate
Diabetic ulcer of left fourth toe associated with mild cellulitis.
Nonenzymatic glycosylation predisposes ligaments to stiffness. Neuropathy causes loss of protective sensation and loss of coordination of muscle groups in the foot and leg, both of which increase mechanical stresses during ambulation. (See Pathophysiology and Etiology.) Diabetic foot lesions are responsible for more hospitalizations than any other complication of diabetes. Diabetes is the leading cause of nontraumatic lower extremity amputations in the United States, with approximately 5% of diabetics developing foot ulcers each year and 1% requiring amputation. (See Epidemiology.) Physical examination of the extremity having a diabetic ulcer can be divided into examination of the ulcer and the general condition of the extremity, assessment of the possibility of vascular insufficiency,  and assessment for the possibility of peripheral neuropathy. (See Clinical Presentation.) The staging of diabetic foot wounds is based on the depth of soft tissue and osseous involvement. [2, 3, 4] A complete blood cell count should be done, along with assessment of serum glucose, glycohemoglobin, and creatinine levels. (See Workup.) A vascular surgeon and/or podiatric surgeon should evaluate all patients with diabetic foot ulcers so as to determine the need for debridement, revisional surgery on bony architecture, vascular reconstruction, or soft tissue coverage. (See Treatment and Management.) Cilostazol is contraindicated in patients with congestive heart failure. See Medication regarding the product's black box warning. For more information, see Diabetes Mellitus, Type 1 and Diabetes Mellitus, Type 2.
Atherosclerosis and peripheral neuropathy occur with increased frequency in persons with diabetes mellitus (DM).
Overall, people with diabetes mellitus (DM) have a higher incidence ofatherosclerosis, thickening of capillary basement membranes, arteriolar hyalinosis, and endothelial proliferation. Calcification and thickening of the arterial media (Mönckeberg sclerosis) are also noted with higher frequency in the diabetic population, although whether these factors have any impact on the circulatory status is unclear.
If a Charcot foot is neglected. Multiple fractures are unnoticed until bone and joint deformities become marked. may result in complete loss of digital collaterals and precipitate gangrene.  The result of loss of sensation in the foot is repetitive stress. microvascular disease and suboptimal glycemic control contribute. such as aortoiliac and femoropopliteal atherosclerosis. such as hammertoes. The result is a convex foot with a rocker-bottom appearance. These factors. when compounded by an infected ulcer in close proximity. Charcot change can also affect the ankle. ulceration may occur at pressure points. and foot deformity. Charcot deformity with mal perforans ulcer of plantar midfoot. causing displacement of the ankle mortise and ulceration. Epidemiology . further stress. confer a high risk of limb loss on the patient with diabetes. please go to the main article by clicking here. structural foot deformity. combined with poor arterial inflow. However. present in 60% of diabetic persons and 80% of diabetic persons with foot ulcers. particularly the medial aspect of the navicular bone and the inferior aspect of the cuboid bone. significant atherosclerotic disease of the infrapopliteal segments is particularly common in the diabetic population. may develop atherosclerotic disease of large-sized and medium-sized arteries. elevated plasma fibrinogen levels. Motor neuropathy. Underlying digital artery disease. unnoticed injuries and fractures. as depicted in the image below. metatarsal deformities. and eventual tissue breakdown. and effects of increased sorbitol and fructose. compounds this trauma. bunions. including high low-density lipoprotein (LDL) and very-low-density lipoprotein (VLDL) levels. deficiency of myoinositol-altering myelin synthesis and diminishing sodium-potassium adenine triphosphatase (ATPase) activity. This is termed a Charcot foot (neuropathic osteoarthropathy) and most commonly is observed in diabetes mellitus. endothelial dysfunction. The reason for the prevalence of this form of arterial disease in diabetic persons is thought to result from a number of metabolic abnormalities. causing edema of nerve trunks. Charcot foot Sensory neuropathy involving the feet may lead to unrecognized episodes of trauma due to ill-fitting shoes. inhibition of prostacyclin synthesis. pressure from a poorly fitting shoe. To see complete information on Diabetic Neuropathy. Diabetic peripheral neuropathy The pathophysiology of diabetic peripheral neuropathy is multifactorial and is thought to result from vascular disease occluding the vasa nervorum. elevated plasma von Willebrand factor. or Charcot foot (see the image below). or damage from a blunt or sharp object inadvertently left in the shoe may cause blistering and ulceration.Diabetic persons. Diabetic peripheral neuropathy.  arterial disease. which can lead to the need for amputation. like people who are not diabetic.pressure. Sinus tracts progress from the ulcerations into the deeper planes of the foot and into the bone. and increased platelet adhesiveness. chronic hyperosmolarity. confers the greatest risk of foot ulceration. Etiology The etiologies of diabetic ulceration include neuropathy. causing intrinsic muscle weakness and splaying of the foot on weight bearing. Unnoticed excessive heat or cold. affecting about 2% of diabetic persons.
therefore. Prognosis Mortality in people with diabetes and foot ulcers is often the result of associated large vessel arteriosclerotic disease involving the coronary or renal arteries. please go to the main article by clicking here. and the 5year risk of needing a contralateral amputation is 50%. diabetic foot deformity and ulceration occur sometime thereafter. Among patients with diabetes. Age distribution for diabetic ulcers Diabetes occurs in 3-6% of Americans. every year approximately 5% of diabetics develop foot ulcers and 1% require amputation. Among Medicare-aged adults. in African Americans. History The history should focus on symptoms indicative of possible peripheral neuropathy or peripheral arterial insufficiency. particularly if treatment has been delayed. who tend to have the highest prevalence of diabetes in the world. 90% have type 2 diabetes). Also. 15% develop a foot ulcer. and adequate glycemic control. Symptoms of peripheral neuropathy The symptoms of peripheral neuropathy include the following: Hypesthesia Hyperesthesia Paresthesia Dysesthesia Radicular pain Anhydrosis Symptoms of peripheral arterial insufficiency . the prevalence of diabetes is about 10% (of these. control of hyperlipidemia. even if successful management results in healing of the foot ulcer. For excellent patient education resources. and millions more are considered to be at risk for developing the disease. Diabetic foot lesions are responsible for more hospitalizations than any other complication of diabetes. and in Native Americans. 10% have type 1 diabetes and are usually diagnosed when they are younger than 40 years. diabetes is the leading cause of nontraumatic lower extremity amputations in the United States. Limb loss is a significant risk in patients with diabetic foot ulcers. Diabetic neuropathy tends to occur about 10 years after the onset of diabetes. and. appropriate shoes. the recurrence rate is 66% and the amputation rate rises to 12%. In fact. Diabetes is the predominant etiology for nontraumatic lower extremity amputations in the United States. and 12-24% of individuals with a foot ulcer require amputation. In diabetic people with neuropathy. an estimated 16 million Americans are known to have diabetes.According to the National Institute of Diabetes and Digestive and Kidney Diseases. Of these. To see complete information on Diabetic Foot. see eMedicine’s patient education article Diabetic Foot Care. visit eMedicine’s Diabetes Center. Prevalence of diabetic ulcers by race The issue of diabetic foot disease is of particular concern in the Latino communities of the Eastern United States. Patient Education The risk of foot ulceration and limb amputation in people with diabetes is lessened by patient education stressing the importance of routine preventive podiatric care. avoidance of cigarette smoking. Half of all nontraumatic amputations are a result of diabetic foot complications. Indeed.
The onset of claudication may occur sooner with more rapid walking or walking uphill or up stairs. However. and the tips of hammer toes (ulcers also occur over the malleoli because these areas commonly are subjected to trauma) Areas most subjected to stress. This symptom increases with ambulation until walking is no longer possible. loss of the femoral pulse just below the inguinal ligament occurs with a proximal superficial femoral artery occlusion. ischemic pain at rest.8% of . such as the dorsal portion of hammer toes Other physical findings include the following: Hypertrophic calluses Brittle nails Hammer toes Fissures Assessment of possible peripheral arterial insufficiency Physical examination discloses absent or diminished peripheral pulses below a certain level. typically in the adductor canal.Most people harboring atherosclerotic disease of the lower extremities are asymptomatic. Examination of extremity Diabetic ulcers tend to occur in the following areas: Areas most subjected to weight bearing. On the other hand. a fissure. Patients who are symptomatic may present with intermittent claudication. Some patients attribute ambulatory difficulties to old age and are unaware of the existence of a potentially correctible problem. such as the heel. Discomfort. When a diabetic patient presents with gangrene. The claudication of infrainguinal occlusive disease typically involves the calf muscles. In some cases. Specifically. the posterior tibial pulse is present in 99. Physical Examination Physical examination of the extremity having a diabetic ulcer can be divided into 3 broad categories: Examination of the ulcer and the general condition of the extremity Assessment of the possibility of vascular insufficiency Assessment for the possibility of peripheral neuropathy Remember that diabetes is a systemic disease. it is often the result of infection. the tips of the most prominent toes (usually the first or second). nonhealing ulceration of the foot. Cramping or fatigue of major muscle groups in one or both lower extremities that is reproducible upon walking a specific distance suggests intermittent claudication. Loss of the popliteal artery pulse suggests superficial femoral artery occlusion. Calf muscle atrophy may also occur. Loss of pedal pulses is characteristic of disease of the distal popliteal artery or its trifurcation. Rest pain is less common in the diabetic population. or frank ischemia of the foot. infrainguinal disease alone is characterized by normal femoral pulses at the level of the inguinal ligament and diminished or absent pulses distally. and it is relieved by resting for several minutes. be aware that absence of the dorsalis pedis pulse may be a normal anatomic variant that is noted in about 10% of the pediatric population. cramping. Hence. or other break in the integrity of the skin envelope is the first sign that loss of perfusion has occurred. Symptoms that occur in the buttocks or thighs suggest aortoiliac occlusive disease. Although diminished common femoral artery pulsation is characteristic of aortoiliac disease. others develop ischemic symptoms. or weakness in the calves or feet is particularly common in the diabetic population because they tend to have tibioperoneal atherosclerotic occlusions. ulcer. a comprehensive physical examination of the entire patient is also vital. plantar metatarsal head areas.
Use of this technique probably is best left to the discretion of the vascular specialist. particularly of the aorta or popliteal segments. Wound healing is impaired by anemia. In the face of underlying arterial insufficiency. magnetic resonance imaging. In mild disease. computed tomography. especially overlying pressure points such as the heel. uses pneumatic cuffs encircling the thighs. General use filaments can be obtained from the National Institute of Diabetes and Digestive and Kidney Diseases. feet. pulse-volume recording. The resulting tracings provide useful information about the hemodynamic effects of the arterial disease at each level. cyanosis of the toes. Duplex scanning is quite useful in visualizing aneurysms. radiography. loss of deep tendon reflexes (especially loss of the ankle jerk). foot drop. the test is positive for neuropathy. skin atrophy. or plethysmography. to localize arteries to facilitate palpation of pulses. If the patient does not feel the wire at 4 or more of these 10 sites. PVR is noninvasive and rapid and. and creatinine levels helps to determine the adequacy of acute and chronic glycemic control and the status of renal function. and angiography. loss of pedal hair growth. or the clinician can use professional Semmes-Weinstein filaments. Blood testing should also include hemoglobin A1C assessment because a normal value is a surrogate marker for wound healing. ultrasonography. and simultaneous Doppler measurement of flow velocity can help estimate the degree of stenosis. ulceration or ischemic necrosis. Assessment of possible peripheral neuropathy Signs of peripheral neuropathy include loss of vibratory and position sense. glycohemoglobin. arterial evaluation PVR provides no useful information. In severe disease. if pedal pulses are satisfactory. may be repeated frequently to help assess the overall hemodynamic response to medical or surgical treatment. toes to sense segmental volume changes with each pulse beat. and pallor of the involved foot followed by dependent rubor after 1-2 minutes of elevation above heart level. PVR tracings may appear normal at rest and become abnormal only after the patient walks until symptoms occur. . absence of both pedal pulses is a more specific indicator of peripheral arterial disease. bone scans. Assessment of serum glucose. Hence. Leukocytosis may signal plantar abscess or other associated infection. A handheld Doppler scanner may be used to assess arterial signals. Blood Tests A complete blood count should be done. anemia may precipitate rest pain. particularly involving the aortoiliac segment. muscle atrophy. Other findings suggestive of atherosclerotic disease include a bruit heard overlying the iliac or femoral arteries.persons aged 0-19 years. Pulse-Volume Recording Pulse-volume recording (PVR). anklebrachial index. tracings at the transmetatarsal level may become nearly flat. The nylon monofilament test helps diagnose the presence of sensory neuropathy. therefore.  A 10-gauge monofilament nylon is pressed against each specific site of the foot just enough to bend the wire. and. Ultrasonography Duplex ultrasonography can provide images of arterial segments that help localize the extent of disease. trophic ulceration. and excessive callous formation. Approach Consideration Patient workup for diabetic ulcers includes blood tests. or to determine the loss of Doppler signal as a proximal blood pressure cuff is inflated (as in measurement of systolic pressure in extremity arteries). ankles. occasionally. calves. Ordinarily.
In general. This is because arterial calcification seen on plain radiographs is not a specific indicator of severe atherosclerotic disease. and contrast is power-injected into the infrarenal aorta. Conventional Angiography If vascular or endovascular surgical treatment is contemplated. This is a sizable hole in the femoral artery. as with aortic occlusion. In this case. computed tomography (CT) scanning or magnetic resonance imaging (MRI) is indicated if a plantar abscess is suspected but not clear on physical examination. Normal ABI averages 1. Calcification of the arterial media is not diagnostic of atherosclerosis.3 suggests a poor chance for healing of distal ischemic ulcerations. which is diagnostic of atherosclerotic disease. angiography is needed to delineate the extent and significance of atherosclerotic disease. An ABI less than 0. does not necessarily imply hemodynamically significant stenosis. with a sensitivity of approximately 95%.Laser Doppler studies also have been used but may not be reliable. Computed Tomography and Magnetic Resonance Imaging Although an experienced clinician usually can diagnose a plantar abscess by physical examination alone. Plain radiographs are not routinely obtained in the workup of peripheral arterial occlusive disease. the ABI often is falsely elevated (and thus may be unreliable) if the underlying arteries are heavily calcified. a catheter is inserted retrograde via a femoral puncture. the physician performing the angiogram may elect to use a small device to aid in closing the puncture site (“closure device”). Successful deployment of these devices eliminates the need for prolonged pressure application. which may be only 6-10 mm in diameter. vascular surgeon. such as via the brachial or axillary artery. a femoral approach to the aorta may not be possible. and clotting or dislodgement of an intimal flap. or interventional radiologist) may use an alternative entry point.0. Ankle-Brachial Index The systolic pressure in the dorsalis pedis or posterior artery divided by the upper extremity systolic pressure is called the ankle-brachial index (ABI) and is an indication of severity of arterial compromise. Major risks associated with conventional contrastinjection angiography are related to the puncture and to the use of contrast agents. In most cases. After the catheter is removed. Plain Radiography Plain radiographic studies of the diabetic foot may demonstrate demineralization and Charcot joint and occasionally may suggest the presence of osteomyelitis. . See alsoInfrainguinal Occlusive Disease. an ABI below 0. which may acutely occlude the artery at or near the entry site. a finding common in diabetic persons. Films are taken as the contrast is followed down to both feet. and even calcification of the arterial intima. Use of percutaneous closure devices on the puncture sites has significantly reduced site complication rates. gentle pressure must be applied to the puncture site for approximately 30 minutes.9 suggests atherosclerotic disease. Unfortunately. pseudoaneurysm formation. A recent study suggests Technetium-99m-labeled ciprofloxacin is a somewhat useful marker for osteomyelitis. In certain cases. the interventionalist (interventional cardiologist. Puncture-related complications Risks associated with catheter insertion include hemorrhage.6 mm in diameter. Bone Scans Bone scans are of questionable use because of a sizable percentage of false-positive and false-negative results. Technique Typically. See recommendations for the workup of patients with atherosclerotic disease of the extremities in the eMedicine article Infrainguinal Occlusive Disease. The arterial catheter is usually passed through a 5F sheath that is 1.
patients with diabetes who are taking metformin (Glucophage) must not take this medication immediately following contrast angiography. 21] daily saline or similar dressings to provide a moist wound environment. Carbon dioxide angiography Carbon dioxide angiography is an alternative for patients with renal insufficiency. MRA is not innocuous.[8. particularly in the smaller infrapopliteal arteries.Contrast-related risks Angiographic contrast material is nephrotoxic. MRA is contraindicated in patients with implanted hardware such as a hip prostheses or pacemakers. Alternatives to Conventional Angiography Magnetic resonance angiography Magnetic resonance angiography (MRA) is an alternative for patients who are allergic to iodinated contrast material. an acceptable serum creatinine level must be confirmed prior to elective angiography. osteomyelitis is likely. Transcutaneous Tissue Oxygen Studies Transcutaneous tissue oxygen studies are reserved for borderline situations in which the advisability of arterial bypass surgery may be unclear. In addition. Patients may resume taking the medication when normal renal function is confirmed 1-2 days after contrast exposure. use a minimal volume of contrast material. multidetector (16 or 64 channel) CT scanners can generate angiographic images of excellent resolution and at a relatively high acquisition speed. providing adequate hydration prior to. although MRA technology and contrast agents continue to improve. and after the procedure is essential. The resolution provided by MRA may be inadequate for the vascular surgeon in planning reconstructive procedures. Hence. Avoid contrast angiography (if possible) for patients with any significant degree of renal impairment. The risk of precipitating acute renal failure is highest in patients with underlying renal insufficiency and those with diabetes. Gadolinium chelates. Staging Stage diabetic foot wounds based on the depth of soft tissue and osseous involvement. [2. 3. MDCT angiography carries the contrast-related risks described above. it is not widely available and requires some iodinated contrast material in addition to the carbon dioxide gas in order to provide useful images. By using precisely timed intravenous contrast injection. however. have been linked recently to 3 potentially serious side effects in patients with renal insufficiency: acute renal injury. Oral administration of the antioxidant acetylcysteine (Mucomyst) the night prior to and then just before angiography may be protective of renal function for patients at risk of contrast-induced nephropathy. the contrast agents used in MRA. 4] Any ulcer that seems to track into or is deep to the subcutaneous tissues should be probed gently. and nephrogenic systemic fibrosis. pseudohypocalcemia. Patients with both of these risk factors have a 30% rate of acute renal failure following contrast angiography. Approach Considerations The management of diabetic foot ulcers requires offloading the wound by using appropriate therapeutic footwear. and if bone is encountered. during. Multidetector CT angiography Multidetector CT (MDCT) angiography avoids arterial puncture. If contrast angiography is absolutely required despite renal impairment. Metformin warning To prevent the possibility of fatal lactic acidosis.  debridement when .
Type 1 and Diabetes Mellitus. [22. OpSite. Aquacel. vital. moisture. Wound coverage After debridement. such as calcium alginates (eg. Wound and Foot Care The basic principle of topical wound management is to provide a moist. surgeons. 30. twice-daily dressing changes may be needed. Curasorb). If a patient presents with a new diabetic foot ulcer. 23] or heterogeneic dressings/grafts. a hydrofibersilver dressing (Aquacel-Ag) can help control wounds that are both exudative and potentially colonized. They are a good choice for relatively desiccated wounds. Physicians of diabetic patients with ulcers must decide between the sometimes conflicting options of (1) performing invasive procedures (eg. and bacteria. such as hypertension. Management of Systemic and Local Factors Treatment of diabetic foot ulcers requires management of a number of systemic and local factors.[24. which is useful for packing deep wounds. application of recombinant growth factors. is crucial. Exudative wounds: Absorptive dressings. 25. and evaluation and correction of peripheral arterial insufficiency. and failure to treat the wound carefully. such as DuoDERM or IntraSite Hydrocolloid. 29. offloading the area of the ulcer. Wound coverage recommendations for some other wound conditions are as follows (see the Table. Duoderm). are highly absorptive and are appropriate for exudative wounds. In general. atherosclerotic heart disease. irrigation using one-fourth strength Dakin solution and 0. Very exudative wounds: Impregnated gauze dressings (eg. [28. A polyvinyl film dressing (eg. Mesalt) or hydrofiber dressings (eg. he or she should receive care from physicians. and support autolytic debridement. hyperlipidemia. Type 2. antibiotic therapy if osteomyelitis or cellulitis is present. see Diabetes Mellitus. . obesity. failure to aggressively debride and treat infection. which support autolytic debridement. but only if arterial insufficiency is not present. not only in achieving resolution of the current wound. treatment of infection with appropriate antibiotics. 33]Management of arterial insufficiency. absorb exudate. if a sulfa allergy exists.necessary. of course.25% acetic acid may be useful for a brief period of time. Alginates are available in a rope form. Optimal wound coverage requires wet-to-damp dressings. but also in minimizing the risk of recurrence. and wound care are also essential. podiatrists. 34] For more information. and protect surrounding healthy skin. either bacitracin-zinc or Neosporin ointment is a good alternative. Kaltostat. For more information. Infected wounds: For infected superficial wounds. Normlgel. [18. 26. bypass surgery) for limb salvage and (2) avoiding the risks of unnecessarily aggressive management in these patients. Tegaderm) that is semipermeable to oxygen and moisture and impermeable to bacteria is a good choice for wounds that are neither very dry nor highly exudative. 19] optimal control of blood glucose. In these cases. and pedorthotists who have an active interest in this complex problem. the greatest legal risks are associated with delay in diagnosis of ischemia associated with diabetic ulceration. wound bed. 27] and hyperbaric oxygen treatments also may be beneficial at times. below): Dry wounds: Hydrocolloid dressings. Aquacel-Ag) are useful for extremely exudative wounds.[32. Management of contributing systemic factors. are impermeable to oxygen. IntraSite gel) or a hydroactive paste (eg. apply a moist sodium chloride dressing or isotonic sodium chloride gel (eg. angiography. Where heavy bacterial contamination of deeper wounds exists. Wound coverage by cultured human cells[20. maintain a moist environment. or renal insufficiency. who may have significant cardiac risk. use Silvadene (silver sulfadiazine) if the patient is not allergic to sulfa drugs. see Diabetic Foot Infections. but not wet. 31] Precise diabetic control is.
helps remove nonviable tissue from the surface of wounds. an uninfected dry heel ulcer in a well-perfused foot is perhaps best managed in this fashion. These are secured with secondary coverage. not one with a necrotic wound base. acetic acid. Alginate rope is particularly useful to pack exudative wound cavities or sinus tracts. Becaplermin gel 0. Comfeel Curasorb Kaltogel Kaltostat Sorbsan . povidone iodine. Fragile periwound skin: Hydrogel sheets and nonadhesive forms are useful for securing a wound dressing when the surrounding skin is fragile. such as a wafer hydrocolloid. Cytotoxic agents. Areas that are difficult to bandage: Bandaging a challenging anatomical area. the enzyme collagenase. Enzymatic debridement: Collagen comprises a significant fraction of the necrotic soft tissues in chronic wounds. such as an extra thin hydrocolloid. However. securing a dressing in a highly moist challenging site. and Dakin solution (sodium hypochlorite). antacids. Characteristics and Uses of Wound Dressing Materials (Open Table in a new window) Category Alginate Examples AlgiSite Description This seaweed extract contains guluronic and mannuronic acids that provide tensile strength and calcium and sodium alginates. Occasionally. derived from fermentation of Clostridium histolyticum. a recombinant human PDGF that is produced through genetic engineering is approved by the US Food and Drug Administration (FDA) to promote healing of diabetic foot ulcers. and vitamin A and D ointment. such as hydrogen peroxide. should be avoided. such as around a heel ulcer.01% (Regranex). requires a highly conformable dressing. Applications These are highly absorbent and useful for wounds having copious exudate. Wounds covered by dry eschar: In this case. granulating wound. requires a conformable and highly adherent dressing. painting the eschar with povidone iodine (Betadine) is beneficial to maintain sterility while eschar separation occurs. Miscellaneous topical agents: Various other topical agents that have been used for wound management include sugar. which confer an absorptive capacity. it is not a substitute for an initial surgical excision of a grossly necrotic wound. such as around a sacrococcygeal ulcer. Other topical preparations that occasionally may be useful in the management of diabetic foot ulcers are as follows: Platelet-derived growth factors (PDGF): Topically applied PDGF has a modestly beneficial effect in promoting wound healing. except as noted above under infected wounds. Some of these can leave fibers in the wound if they are not thoroughly irrigated. and is contraindicated with known skin cancers at the site of application.Regranex is meant for a healthy. simply protecting the wound until the eschar dries and separates may be the best management. Table.
Tegagel Hydrofiber Aquacel Aquacel-Ag Versiva An absorptive textile fiber pad. Aquacel-Ag contains 1. The granules change from a semihydrated state to a gel as the wound exudate is absorbed. and clean granulating wounds. including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. Debriding agents Hypergel (hypertonic saline gel) Various products provide some degree of chemical or enzymatic debridement.2% ionic silver that has strong antimicrobial properties against many organisms. also available as a ribbon for packing of deep wounds. They are useful for dry necrotic wounds. such as gelatin or pectin. These are absorbent dressings used for exudative wounds. wounds having minimal exudate. Santyl (collagenase) Accuzyme (papain urea) Foam LYOfoam Polyurethane foam has some absorptive capacity. in an adhesive matrix. These are useful for cleaning granulating wounds having minimal exudate. Spyrosorb Allevyn Hydrocolloid Aquacel CombiDERM These are made of microgranular suspension of natural or synthetic polymers. . The hydrofiber combines with wound exudate to produce a hydrophilic gel. These are useful for necrotic wounds as an adjunct to surgical debridement. This material is covered with a secondary dressing.
Comfeel Duoderm CGF Extra Thin Granuflex Tegasorb Hydrogel Aquasorb Duoderm These are water-based or glycerin-based semipermeable hydrophilic polymers. or as a final dressing for chronic wounds that have Skintact . These are useful for dry. such as skin tears. These gels can lose or absorb water depending upon the state of hydration of the wound. They are secured with secondary covering. IntraSite Gel Granugel Normlgel Nu-Gel Purilon Gel (KY jelly) Lowadherence dressing Mepore These are various materials designed to remove easily without damaging underlying skin. necrotic wounds (eschar). cooling properties may decrease wound pain. These are useful for acute minor wounds. sloughy.
Vacuum-assisted closure Clean but nonhealing deep cavity wounds may respond to repeated treatments by application of negative pressure under an occlusive wound dressing (vacuum-assisted closure [VAC]). Tegaderm Bioclusive For more information. and options for soft tissue coverage. and they may be vapor permeable or perforated. see Diabetic Foot Infections. infected.nearly healed. Surgical Care All patients harboring diabetic foot ulcers should be evaluated by a qualified vascular surgeon and/or podiatric surgeon who will consider debridement. They are used for protection of highfriction areas and areas that are difficult to bandage such as heels (also used to secure IV catheters). revisional surgery on bony architecture. The wound usually requires an initial surgical debridement and probing to determine the depth and involvement of bone or joint structures. curettage of underlying osteomyelitic bone. Visible or palpable bone implies an 85% chance of osteomyelitis. Skintact Release These are useful for clean dry wounds having minimal exudate. Treatment of Charcot foot Charcot foot is treated initially with immobilization using special shoes or braces but eventually may require podiatric surgery such as ostectomy and arthrodesis. and revascularization. removal of excess callus. Debridement Surgical management is indicated for debridement of nonviable and infected tissue from the ulceration. vascular reconstruction. cavity wounds sometimes improve with hydrotherapy using saline pulse lavage under pressure (PulsEvac). Release Transparent film OpSite These are highly conformable acrylic adhesive film having no absorptive capacity and little hydrating ability. and they also are used to secure an underlying absorptive material. skin grafting. For more information. see Perioperative Management of the Diabetic Patient. Hydrotherapy Intractable. .
the indications for vascular surgery in the presence of a reconstructible arterial lesion include intractable pain at rest or at night. Meshing the graft allows wider coverage and promotes drainage of serum and blood. This provides a scaffold for inducing wound healing.Revisional surgery Revisional surgery for bony architecture may be required to remove pressure points. Allergic reactions to its bovine protein component have been reported. A multicenter study of 314 patients demonstrated significantly better 12-week healing rates with Dermagraft (30%) versus controls (17%). intractable foot ulcers. [7. Surgical wound closure Delayed primary closure of a chronic wound requires well-vascularized clean tissues and tension-free apposition. Hyperbaric Oxygen Treatment . Allergic reactions to the agarose shipping medium or its bovine collagen component have been reported. Vascular reconstruction In general. 23] It is not appropriate for infected ulcers. Options for Soft Tissue Coverage of the Clean But Nonhealing Wound Once a wound has reached a steady clean state. Tissue-cultured skin substitutes Dermagraft (Smith & Nephew) is a cryopreserved human fibroblast–derived dermal substitute produced by seeding neonatal foreskin fibroblasts onto a bioabsorbable polyglactin mesh scaffold. acellular collagen matrix derived from porcine small intestinal submucosa in a way that allows an extracellular matrix and natural growth factors to remain intact. Such intervention includes resection of metatarsal heads or ostectomy. Clinical experience and observation of the healing progress in each case dictate the appropriate management. Ltd) is a xenogeneic. Xenograft Oasis (Healthpoint. only a temporary solution. The graft can be harvested under local anesthesia as an outpatient procedure. or those that have sinus tracts. those that involve tendon or bone. Dermagraft is useful for managing full-thickness chronic diabetic foot ulcers.[41. Surgical options include skin grafting. a decision has to be made about allowing healing by natural processes or expediting healing by a surgical procedure. application of bioengineered skin substitutes. Do not use this for patients with allergies to porcine materials. the efficacy is questionable. and the cost is high. bilayered human skin substitute. 39] Intermittent claudication alone is only infrequently disabling and intractable enough to warrant bypass surgery. A cadaveric skin allograft is a useful covering for relatively deep wounds following surgical excision when the wound bed does not appear appropriate for application of an autologous skin graft. of course. it usually requires undermining and mobilization of adjacent tissue planes by creation of skin flaps or myocutaneous flaps. those that involve bone or tendon. The use of bioengineered skin substitutes has been questioned because the mechanism of action is not clear. Apligraf (Organogenesis) is a living. and impending or existing gangrene. Skin grafts The autologous skin graft is the criterion standard for viable coverage of the partial thickness wound. It is not appropriate for infected ulcers. The allograft is. and flap closures. 38. or those that have sinus tracts.
 Dietary Chages The recommended diet is diabetic and low in saturated fat. This trial found that uncontrolled hyperglycemia correlates with the onset of diabetic microvascular complications and that good glycemic control can reduce or even prevent the complications of diabetes. Avoid hot soaks. Restriction of Activity Offloading of the ulcerated area is imperative. neuropathy. and patient education.Hyperbaric oxygen therapy is used rarely and is certainly not a substitute for revascularization. and hypertension and hyperlipidemia should be controlled. heating pads. appropriate shoes. and retinopathy. 5 d/wk for 8 wk) resulted in complete healing of chronic diabetic foot ulcers in 52% of patients in the treatment group. Glycemic control The Diabetes Control and Complications Trial. 85% are estimated to be preventable with appropriate preventive medicine. This may require bed rest acutely. hyperbaric oxygen therapy may be beneficial (in selected cases). Custom footwear or custom clamshell orthosis (for severe deformities) or total contact casting (a fiberglass shell with a walking bar on the bottom) are required for patients who are ambulatory. Among patients in the placebo group. please go to the main article by clicking on the title: Diabetic Neuropathy Diabetic Nephropathy Diabetic Retinopathy Consultations Any of the following evaluations may prove productive: Endocrinologist Cardiologist Nephrologist Infectious diseases specialist Vascular surgeon Podiatrist Orthopedic specialist . Prophylactic podiatric surgery to correct high-risk foot deformities may be indicated. To see complete information on the conditions below. Cigarette smoking should be stopped. including the following: Daily foot inspection Gentle soap and water cleansing Application of skin moisturizer Inspection of the shoes to ensure good support and fit: Medicare covers custom shoes with appropriate physician documentation confirming that the patient is at risk for ulceration. including nephropathy. Minor wounds require prompt medical evaluation and treatment. 29% had complete healing at 1-year follow-up. and irritating topical agents. Of diabetic foot ulcers.studiedthe effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus (1993). performed by the Diabetes Control and Complications Trial ResearchGroup. In the presence of an intractable wound and associated noncorrectible ischemic arterial disease. Löndahl et al found that 40 hyperbaric oxygen treatments (85 min daily. Measures for Prevention of Diabetic Ulcers The risk of ulceration and limb amputation in people with diabetes can be improved by routine preventive podiatric care. Diabetic clinics should screen all patients for altered sensation and peripheral vascular disease.
View full drug information Pentoxifylline (Trental) Pentoxifylline is indicated to treat intermittent claudication. It may alter rheology of red blood cells. Empirin) . there is no conclusive evidence of any direct beneficial effect of either pentoxifylline or cilostazol on the healing of diabetic foot ulcers. especially PDE III. For example. diabetic ulcers are managed in the outpatient setting. the complications of diabetes. Antiplatelet agents Class Summary Antiplatelet therapy with aspirin or clopidogrel (Plavix) may be warranted in some cases for the prevention of the complications of atherosclerosis. Two to eight weeks of therapy may be required before symptomatic improvement occurs. Plastic surgeon Wound care specialist Nutritionist Long-Term Monitoring For the most part. and reversible inhibition of platelet aggregation. The mechanism of cilostazol involves inhibition of PDE. View full drug information Cilostazol (Pletal) Cilostazol is indicated to reduce symptoms of intermittent claudication. but treatment for as many as 12 weeks may be needed before a beneficial effect is experienced. Hemorrheologic Agents Class Summary Hemorheologic agents such as pentoxifylline (Trental) improve intermittent claudication in approximately 60% of patients after 3 months. Cilostazol is contraindicated in patients with congestive heart failure. thereby inhibiting platelet aggregation. possibly. although neither has a direct benefit in healing diabetic foot ulcers. which in turn reduces blood viscosity. View full drug information Aspirin (Bayer. with brief hospital stays often occurring for initial evaluation and debridement. hemorheologic agents and antiplatelet agents are sometimes used in the management of underlying atherosclerotic disease. and the etiologies of diabetic ulcer. and. It is indicated as antiplatelet therapy in some patients with atherosclerotic disease. Renal arteries were not found to be responsive to its effects. and only about 60% of patients respond to this drug. Anacin. Cilostazol (Pletal) is an alternative hemorheologic agent for patients who cannot tolerate pentoxifylline. Patients may respond as early as 2-4 weeks after initiation of therapy. flap or skin graft wound management. or superior mesenteric arteries. as indicated by an increased walking distance. Medication Summary Many medications may have a role in the treatment of diabetes. Antiplatelet agents inhibit platelet function by blocking cyclooxygenase and subsequent platelet aggregation. with greater dilation in femoral beds than in vertebral. View full drug information Clopidogrel (Plavix) Clopidogrel selectively inhibits ADP binding to platelet receptor and subsequent ADP-mediated activation of glycoprotein GPIIb/IIIa complex. However. carotid. It affects vascular beds and cardiovascular function and produces nonhomogeneous dilation of vascular beds. subsequent vascular procedures.
not one with a necrotic wound base. Wound Healing Agents Class Summary Topically applied platelet-derived growth factors (PDGF) such as becaplermin gel (Regranex) have a modestly beneficial effect in promoting wound healing. and it is contraindicated with known skin cancers at the site of application.01% (Regranex). granulating wound. Becaplermin gel (Regranex) Becaplermin gel 0. It may be used in low dose to inhibit platelet aggregation and to improve complications of venous stases and thrombosis. The recommended dose varies with indication.Aspirin inhibits prostaglandin synthesis. Regranex is meant for a healthy. the literature is unclear on the optimal dosing. . is approved by the US Food and Drug Administration (FDA) to promote healing of diabetic foot ulcers. preventing formation of platelet-aggregating thromboxane A2. and. often. a recombinant human PDGF that is produced through genetic engineering.
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