Indian Write- Ups

While the old assumption that the diabetic foot is the result of a complex interplay of three factors neuropathy, arterial disease and infection is still very valid, certain new realities have been recognized by experienced clinicians, worldwide.

Randomized clinical studies, properly designed, well controlled and done prospectively, have unequivocally demonstrated the benefits of:

• Good glycemic control
• Aggressive BP control
• LDL-cholesterol target of 100 mg%
• Complete cessation of smoking
• Use of aspirin therapy

No clinician caring for a diabetic patient can afford to ignore these 5 aspects of prevention. The impressive clinical benefits of early insulin therapy, B.P. control with ACE inhibitors and achieving NCEP-ATP-III targets for LDL-cholesterol beckons every physician to wake up to the newer realities in the treatment of Type 2 diabetes.

This involves identifying those with early peripheral neuropathy and those with early peripheral arterial disease.

All good diabetologists use the Semmes-Weinstein 5.07 monofilament. The tip of this monofilament is placed gently perpendicular on the surface until it buckles. The approach, skin contact and departure of the monofilament should be for approximately 1.5 seconds. Do not allow the filament to slide across the skin or make repetitive contact to the site. Avoid callused areas. Inability to sense, is consistent with severe neuropathy and loss of protective sensation. A custom footwear is indicated.

Rather than intermittent claudication, it is cold foot that is an early complaint in patients with peripheral arterial disease. This is generally accompanied by absent dorsalis pedis or posterior tibial pulse on one or both sides. Certain skin changes like shiny skin, loss of hair on foot and toes and thickened nails may be seen.

• Examine all surfaces: Remember, ulcers on the dorsal and plantar surfaces are evenly distributed.
• Examine the nails: Look for fungal infections, in-growing toe nails and injury from nail self care.
• Identify foot deformity: Look for prominent metatarsal heads, claw or hammer toes, hallux valgus or bunions, prior amputation, etc.
• Examine the shoes and the socks: Look for drainage into socks, worn out soles, poorly fitting shoes, gait pattern.
• Remember that since dorsal ulcers are invariable shoe related, 50% of neuropathic foot ulcers can be prevented by using appropriately sized footwear.
• Establish the need for education: Talk to the patient. Ask him simple questions like do you walk barefoot to the temple, who trims your nails and how often, etc.

The evaluation and non-surgical management of foot lesions in diabetic patients has seen fascinating advances.

The first advance is in the field of biomechanics of the foot. There has been a rapid growth in the understanding of why people with diabetes have higher pressure under their feet that those without diabetes.

Today, unloading of the foot as a means of promoting wound healing in foot ulcers of neuropathic origin is employed by every surgeon.

Strict non-weight bearing is mandatory for faster wound healing. Specific and explicit instruction should be given to patients for situations at work, at home, at night, etc. For instance, treadmill, walking, jogging, etc., are disallowed whereas swimming, chair-cycling, rowing and basically any non-weight bearing allowed.

The field of debridement has also witnessed much progress. While surgical debridement was the normal method in vogue for many years, today we have a wide range of options in autolytic debridement. These include the elegant use of moist interactive dressings like hydrogels, alginates, transparent films, hydrocolloids, etc. (eg. Sorbalgon, Hydrocoll, etc.). There is liquefaction of slough and eschar as well as promotion of granulation tissue. Enzymatic debridement also is available in India with collagenase.

In addition to the traditional soaks, today a wide variety of cleaning agents are available commercially, although there is some degree of controversy regarding the superiority of these surfactants over saline soaks.

Concepts in wound dressing have also changed dramatically in the last 10 years. Today, we use advanced dressings with alginates, hydrogels and hydrocolloids to maintain an ideal moist wound environment by either absorbing exudates (e.g. alginates, foams, hydrocolloids) or maintaining moisture (hydrogels). Although these dressings are costlier compared to gauze dressings, they definitely hasten the speed of wound healing.

Unfortunately, in spite of all these advances in wound dressing and biomechanics as well as foot wear management of wounds, a small number of patients land up with the inevitable amputation. Here again, there has been a rethinking in the levels of amputations. Today, it is the ray amputations which are very popular. (A ray amputation consists of excision of a toe and its metatarsal). This gives greater functional results. Sometimes first ray amputation (removal of 1st metatarsal) or transmetatarsal amputation is done. Disarticulations are reserved for a minority. They include tarsometatarsal (Lisfranc), midtarsal (Chopart), Syme (Ankle). A transtibial amputation is done sometimes and is life saving.

Ultimately, a team work involving the primary care physician, the vascular surgeon, the podiatrist, the pedorthist (shoe maker), the physiotherapist and the psychologist can help us reduce both hospital stay & number of amputations.

The diabetic foot has thus, today, become the challenge for the practicing clinician caring for diabetic patient. An intelligent and down to earth approach to this potentially dangerous problem, can both save lives as well as reduce human suffering.