دکتر بیژن فروغ

• 20-25% of diabetic admissions are foot-related ۲۰-۲۵ درصد بستريهاي ديابت مربوط به پا مي باشد
• 50% of non traumatic lower extremity amputations are performed on diabetics پنجاه درصد قطع عضو اندام تحتاني غير تصادفي مربوط به ديابت است.
• Not all diabetic ulcers are infected همه زخمهاي پاي ديابتي عفوني نيستند
• Not all infected diabetic feet have visible ulcers; although most of these cases turn to be Charcot تمام زخمهاي عفوني ناشي از ديابت قابل رويت نبوده و غالبا ايجاد جمود مفصل شاركوت مي نمايند
• Glycosylation of soft tissues reduces joint mobility (Hypomobility syndrome)گليكوليز شدن بافت نرم موجب كم تحركي مفصل مي شود

Classification (Wagner)طبقه بندي

• Grade 0 : Intact epidermisاپيدرم سالم
• Grade 1 :
  • Superficial ulcerزخم سطحي
  • No deeper than subcutaneous tissueعميقتر از بافت زير پوستي نماباشد
• Grade 2 : Tendons/ligaments/muscles/bone/joint exposedتاندون ليگامن  عضله و استخوان قابل ديد است.
• Grade 3 : Osteomyelitis/abcessاستئوميليت  و آبسه مشاهده مي شود
• Grade 4 : Gangrene of forefootگانگرين جلوي پا
• Grade 5 : Gangrene of entire footگانگرين كل پا

Pathophysiology پاتوفيزيولوژي

• Dorsal ulcers are the result of poor shoes زخمهاي پشت پا ناشي از كفش نامناسب است
• Peripheral neuropathyنوروپاتي محيطي و گرفتاري اعصاب محيطي
• The most common causeشايعترين علت
• Affects 60% of diabetics شصت درصد ديابتيها
• Ulcers occur on plantar high pressure areas زخمهاي ناحيه كف پا در بيشترين محل فشار
• Distal symmetric form is common نوع متقارن و انتهايي رايج است
  • Sensory neuropathy  گرفتاري اعصاب محيطي حسي
    • The first nervous functions to go are vibration and proprioception
    • Patient can not perceive 5.0 Semmes-Weinstein filament
    • Usually coexists with vascular disease
  • Autonomic neuropathy
    • Affects thermoregulation
    • Patients show abnormal sweating pattern, leading to dry foot and increased chance of skin breach
    • Causes Charcot arthropathy
  • Motor neuropathy
    • Can be mono/polyneuropathic
    • The most common mononeuropathy is peroneal involvement leading to dropfoot
    • Distal polyneuropathy manifests as clawtoes; prone to pressure ulcers at toe-tips
• Vascular involvement
  • 30 times more common in diabetics
  • Medium-size vessel disease is the rule
  • Whether small vessel disease per se occurs in diabetics is a matter of debate
• Immune system dysfunction
  • Abnormal phagocytosis
  • Reduced capacity to kill ingested bacteria
  • Poor chemotaxis

Clinically

• Assess depth of ulcer and presence/absence of infection
• Most patients do not show any systemic sign of infection; e.g. fever
• Hyperglycemia is the most common sign of serious infection
• Charcot presents with erythema and warmth; easily confused with infection
• X-Rays : look for
  • Osteomyelitis
  • Foreign body
  • Gas

Work up

• Superficial cultures are not reliable
• Tc/In scans can differentiate infection from Charcot
• Indications for vascular evaluation
  • Any foot surgery in diabetics
  • Foot ulcer plus no DP/PT pulse
  • Vascular involvement of other major organs; kidney, heart
• Evaluation :
  • Doppler
    • Normal >0.45
    • Arterial calcification falsifies the reading
  • Ankle-Brachial Index (ABI)
    • Normal >1
    • A minimum of 0.45 is necessary for healing
  • Toe arterial pressure
    • Normal 100 mm
    • Values <40 mm indicate poor healing potential/need for revasularisation
• MRI is the most sensitive tool for showing osteomyelitis

Treatment درمان

• Educate diabetic patients آموزش بيماران
• Foot care مراقبت از پا
• Nail care مراقبت از ناخن
• Frequent inspection مشاهده مكرر پا
• Cushioned socks جوراب نرم
• Footwear كفي مناسب
  • Cushionedنرم
  • Molded insole كفي قالب پا 
  • Extra-depthكفي داري عمق اضافه
• Adequate perfusion (vascular reconstruction) and thorough debridement are the cornerstone of successful treatment
• Vascular consultation/evaluation is necessary, unless there is
  • Palpable pulses
  • Bleeding ulcer edges
• Vascular evaluation is necessary before any major foot surgery

Adequate perfusion

• Debride ulcer
• Some distinct bony prominences may need surgical removal
• Eliminate pressure from affected areas
  • Total contact cast
    • Even large ulcers heal with casting, if perfusion conditions are acceptable
    • Weekly inspection and cast change is required
  • Shoe modification
  • Orthotics
  • NWB

Inadequate perfusion

• Severe circulatory compromise needs revascularisation, if amenable to surgery
• Irreparable perfusion defects/gangrene may need amputation
• The level of amputation is determined by
  • Viability of tissues
  • The most distal level of adequate perfusion, as shown by vascular evaluation studies
• Limb salvage vs. amputation
  • Limb preservation reduces energy expenditure of patient
  • More distal level of amputation saves more energy
  • Futile attempts to keep an ischemic dysfunctional limb can only slow down the healing, increase chance of infections and lead to revision surgeries