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Diagnosis, Treatment
and Prevention of the
Diabetic Foot Syndrome
Wundbehandlung
Published by
PAUL HARTMANN AG
D-89522 Heidenheim
http://www.hartmann.info
By
Dr. med. Stephan Morbach
Specialist for Internal Medicine
Marienkrankenhaus
Soest, Germany
2
Table of contents
Page
Preface 5
Foreword 6
3
Vascular and surgical interventions in the 71
diabetic foot syndrome
Importance of adjunctive treatment methods 76
Hyperbaric oxygen therapy (HBO) 76
Use of growth factors and bio-engineered tissues 78
Biomechanical wound treatment 79
Abbreviations 106
References 108
4
Preface
We warmly welcome Dr. Stephan Morbachs practical
book on the diagnosis, management and prevention
of diabetic foot problems. Over the past two decades,
interest in this Cinderella specialty has increased.
Numerous diabetic foot conferences have been
organised and books and papers written. However,
this book is a very useful addition to the literature.
5
Foreword
Foot lesions affect more than 10% of patients with diabetes
mellitus at some point in their life and are amongst the
most dreaded complications of this disease. They can
cause prolonged periods of immobility and discomfort
and some never heal. Year after year, one in every 200
diabetics loses a leg. The cost of foot ulcerations to the
individual and to society are considerable.
6
Diabetes mellitus
an introduction
Diagnosis and classification of diabetes mellitus
7
Under this classification, four types of diabetes may be
distinguished. Type 1 diabetes involves destruction of
the pancreatic insulin-producing cells, usually resulting in
an absolute insulin deficiency. Type 2 diabetes covers a
broad range from marked insulin resistance with relative
insulin deficiency to a marked impairment of insulin
secretion with slight insulin resistance. Type 3 relates to
genetic, endocrinological, infectious and immunological
underlying diseases, diseases of the pancreas and
iatrogenic or chemically induced forms. Type 4 (gesta-
tional diabetes) occurring during pregnancy and
disappearing again post partum. Type 1 and type 2 are
the most common.
8
New aetiological classification of diabetes mellitus
(American Diabetes Association, ADA 1997)
I. Type 1 diabetes
-cell destruction, usually resulting in absolute insulin
deficiency
A. immunologically mediated
B. idiopathic
9
is available for the treatment of type 1 diabetes. A
distinction is drawn here between conventional insulin
therapy (CT) with the administration of long-acting or
mixed insulin once to three times daily, and intensified
conventional insulin therapy (ICT) on the basal bolus
principle (covering basal requirements with administra-
tion of long-acting insulin once to four times daily and
an injection of normal (short-acting) insulin at mealtimes
depending on the quantity of carbohydrates ingested.
The insulin analogue (designer insulin) Humalog and
Novo Rapid (insulin lispro and insulin aspart) has
been available for this purpose since 1996. If basal and
mealtime requirements are provided constantly via a
pump, then this is referred to as continuous subcut-
aneous insulin infusion (CSII) or insulin pump therapy.
Since the end of the DCCT study in 19937, ICT has been
considered the gold standard in the treatment of type 1
diabetics. Compared to conventional insulin therapy, the
occurrence or progression of vascular complications
has been reduced by 50 to 70%. Similar reduction rates
have been published for an intensive treatment regime
in type 2 diabetes. In obese patients, treatment with
insulin or oral antidiabetics (e.g. glibenclamide6, metfor-
min8) is compared to less intensive (mainly dietary)
therapy with less specific target criteria. In this case the
early institution of insulin therapy is frequently necessary
to achieve the desired HBA1c value. Self-monitoring by
diabetics nowadays goes well beyond the self-measure-
ment of blood and urine glucose values:
10
Secondary complications of diabetes mellitus
11
In the worst-case scenario, diabetic nephropathy can
result in terminal renal insufficiency and the need for
haemo dialysis in the early stages. In Germany no less
than 35% of all dialysis patients in 1996 were diabetics,
(more than 90% of them type 2 diabetics). With annual
treatment costs of about 40,000 EUR per dialysis patient,
this complication alone generates direct treatment
costs of more than 500 million EUR annually13. Peripheral
arterial occlusive disease affects diabetics four to ten
times more often than non-diabetics, and the rate of
CVA is approximately threefold. Half of all deaths among
diabetics are due to a cardiac disease1. Some informa-
tion about the differing risk of micro- and macrovascular
complications may be deduced from the patient family
history. Late diagnosis of diabetes and genetic pre-
disposition appear to put an individual at increased risk
of secondary microvascular lesions. Macrovascular
problems are more likely to occur in patients with lipid
metabolism disorders, obesity and an increased
incidence of hypertension in the family14.
12
Definition and history of the
diabetic foot syndrome
The concept of diabetic foot syndrome incorporates
various clinical pictures characterised by different
aetiologies and pathological mechanisms. Common to all
is the fact that injuries to the foot of the diabetic patient
can result in complications that may lead to amputation of
the whole limb if treatment is delayed or ineffective.
13
derived from the procedures adopted in another disease
associated with a neuropathic impairment of sensory
perception, leprosy20. In the 1970s, special programmes
to improve the prognosis in diabetic foot complica-
tions were introduced for the first time in Atlanta, USA.
The amputation rate in diabetics was reduced by
50%. Institutions with similar success rates were subse-
quently set up in Europe, firstly in Geneva and London22,
and then in Germany in 1983 (Prof. Ernst Chantelau,
Dr. Maximilian Spraul and Prof. Michael Berger at the Uni-
versity Hospital of Dsseldorf 23, 24). In 1989, the St.Vincent
Declaration25 set a target of halving the amputation
rate in diabetics within a five-year period. Subsequently,
outpatient foot departments were created. In 1993
these joined together to form an association, the Diabetic
Foot Working Group, affiliated to the German Diabetes
Society.
14
Diabetes treatment and research in Europe:
The St. Vincent Declaration (1989)
15
Epidemiology of the
diabetic foot syndrome
A quarter of the diabetic population is at increased
risk of foot injuries as a result of the presence of dia-
betic neuropathy or an arterial circulatory disorder.
Every year 3 to 7% of diabetics suffer a foot lesion for
the first time. Following healing of the injury, the risk
of suffering a further ulceration (relapse) increases
annually to between 30 and 100%, depending on the
quality of the after-care. Like previous amputees,
these patients must also be regarded as high-risk
patients and require very intensive, structured moni-
toring and care. In Germany, more than 20,000 foot
lesions in diabetics still culminate in amputation per
year. Following an amputation, mortality is approxi-
mately 20%. Within 3 years 50% of the surviving
patients also undergo an amputation on the contra-
lateral side. The five year survival of patients after
amputation is low, approximating 25%.
16
Sensorimotor and autonomic diabetic neuropathy and
peripheral arterial occlusive disease must be regarded
as the most common underlying conditions for diabetic
foot complications. These can lead to foot injuries in
diabetics either alone or in combination. In 600 English
patients with ulceration, neuropathy was found to be
the cause in 45%. Fortyfive percent of these patients ex-
hibited both diabetic neuropathy and a circulatory dis-
order, and only 7% suffered exclusively from a peripheral
circulatory disorder. In aetiological terms, neuropathy
proved to be responsible for 90% of injuries30. In 260 of
our own patients with foot injuries, neuropathy was found
in 80% of cases, and of these 43% had accompanying
circulatory disorders. As in the British study30, an isolated
arterial occlusive disease occurred in only 10% of
patients.
17
Among non-selected patients in general practice,
an arterial occlusive disease is found in about a third of
diabetics, about four times as often as non-diabetics34.
18
The probability of survival and the risk of an amputation
on the opposite side are also closely correlated to
the amputation level. Mortality after two amputations is
approximately 3%, whereas this figure rises to 20%
after major amputation45. The 5 year survival rate after
amputation is 27% which compares to 60% of patients
whose foot lesion is healed with conservative treatment37.
The probability of a limb amputation on the opposite
side following a successful major amputation is 12% in
the first year and more than 50% after three years.
19
Socio-economic
significance of the diabetic
foot syndrome
Costs due to foot complications in diabetics
20
The costs of antibiotic treatment (less than 1% of the
overall costs) or technical orthopaedic measures (about
3% in the case of primary healing) are relatively small50.
The costs of local wound treatment are less determined
by the use of certain wound dressings, but to a much
greater extent by the frequency with which bandages are
changed.
21
Psychological aspects and effect on quality of life
1. Physical capacity
2. Subjective well-being
3. The individuals social relations with his environment
22
Tension in relationships is therefore unavoidable.
A few sufferers, however, regard the more intensive cont-
act with their relatives, even if involuntary, as a positive
factor and acquire more patience in dealing with other
everyday problems as a result of handling this parti-
cular situation. The ability to cope with these changes is
influenced by the patients age and social origins58.
Among younger patients, the anxiety of losing ones job,
impending financial losses and the reduction in selfes-
teem take precedence. Elderly sufferers rate social
isolation as more serious. Physical effects on the quality
of life are elicited in the form of side effects to any anti-
biotic treatment required and the tiredness and exhaus-
tion that result from the increased expenditure of energy
needed for moving about57.
23
Risk factors for foot
complications in diabetics
The main risk conditions for the occurrence of foot
lesions in diabetics are the loss of protective
mechanisms in the presence of a diabetic neuropathy
and the absence of sufficient tissue perfusion
as a result of an arterial occlusive disease (AOD).
24
The following section begins by presenting the different
risk factors for foot lesions which may lead to amputations
in diabetics and their importance, before going on to
investigate in detail the causative factors of foot injuries.
1. Peripheral neuropathy
2. Bony foot deformities
3. Existence of increased plantar pressure
4. History of ulcer
5. Peripheral arterial occlusive disease.
25
Typical localisation of foot
injuries as a result of narrow
footware or hard toecaps
26
This is supported by studies of rheumatoid arthritis
patients with foot deformities, but without concurrent
neuropathy65. More recent studies indicate hardening of
the peri-articular connective tissue and increasing
atrophy and fibrosis of the plantar fat pad as indepen-
dent risk factors, particularly in recurrent lesions66,67.
Such changes are found in the presence of even mild
neuropathy, but their intensity increases proportionately
to the severity of underlying the neuropathic disease.
An effect on the capillary blood flow as a result of the
increased plantar pressure load and increased fibrosis
as a result of a chronic inflammatory irritation are sug-
gested as possible pathological causes. Fibrosis and
atrophy of the plantar fat pad affect the biomechanical
properties of the sole of foot in the same way as the
frequently observed increased callus formation. Removal
of the callus reduces the pressure load on the sole
of the foot by about 25% and hence reduces the risk of
subcallous haematoma, as well as subsequent ulcer
formation68.
27
Ischaemia as a consequence of peripheral arterial
occlusive disease represents a minor contributory factor
to the occurrence of diabetic ulcer (23 to 35%62,71),
but assumes increasing significance as a risk factor in
the progression of a foot ulcer towards amputation38.
Critical limb ischaemia (CLI) is present in 50% of all
diabetic foot lesions that end in amputation. Whereas
ulcer formation is a multifactorial process, ischaemia
in itself can be sufficient to result in amputation.
28
The probability of a major amputation is increased by the
presence of:
29
In central Europe, the occurrence of diabetic foot
ulcerations is preceded in 28%78 to 55%79 of cases
by shoe-related injuries. Eighteen percent are the conse-
quence of injuries related to foot care, while 3% are
preceded by other minor trauma. Thermal traumas, parti-
cularly burns, are relatively rare (2% of all cases), but
are significant because of the risk of hypertrophic scar
formation and delayed recovery. At temperatures of
44 C, a theoretical exposure of six hours is required for
necrosis formation, whereas at a temperature of 50 C,
only a five-minute exposure is sufficient80. In diabetics, a
disorder of hot and cold perception is found in the hands
as well as in the lower limb. In other regions of the world,
causes of diabetic foot injuries include rat bites81, worm
infestations82 or burn injuries from the use of alternative
medical methods such as moxibustion, a traditional
Chinese medical procedure83.
30
Three frequent pathways, which together account for
60% of all ulcers, are:
31
Concurrent diseases
in diabetics with
foot complications
The average age of diabetics with foot injuries is
more than 65 years85,86. Mediocre response to treatment
in these patients is due in part to the multimorbidity
of sufferers. Patients with foot lesions suffer to a consider-
able extent from macrovascular disease and the con-
sequences of diabetic microangiopathy. Diabetic retino-
pathy, autonomic diabetic neuropathy and diabetic
nephropathy are more frequently found in type 1 dia-
betics than in type 2 diabetics with foot lesions, who
have a greater incidence of coronary vessel disease and
peripheral arterial occlusive disease (PAOD)85. In 243
patients from the Dortmund Hospital, neuropathy was
found in 80% of ulcer patients. Nephropathy, retinopathy
and coronary heart disease were found in 50% of
patients. Involvement of the arteries supplying the brain
in 22% and PAOD in almost 70%87. Similar figures
were obtained in our own patient population: neuropathy
80%, nephropathy 65%, retinopathy 55%, myocardial
infarct 19%, stroke 20% and PAOD 56%.
32
a marker of a progressive renal disease and a predictor
of a generalised arteriosclerosis and early death89.
Increased albumin excretion occurs most frequently in
patients with ischaemic and neuro-ischaemic lesions.
It is also found to a greater extent in patients with purely
neuropathic ulcers, as compared to ulcer-free
diabetics90.
Typical fundoscopic
findings in proliferative dia-
betic retinopathy:
diabetic retinopathy is con-
sidered a risk factor for
foot complications because
of the impairment of vision
33
The high incidence of concurrent micro- and macro-
vascular disease in patients with foot ulcers shows
the urgent need for the use of all available options for
early diagnosis and appropriate treatment, not only
to increase the chances of a positive outcome of the foot
lesion, but also to have a beneficial effect on the overall
fate of the patient affected.
34
Diagnosis and differential
diagnosis of the diabetic foot
syndrome
Diagnosis of sensorimotor and autonomic
diabetic neuropathy and diabetic neuropathic
osteoarthropathy
35
These tests provide information about the degree of
neuropathy and hence the risk of diabetics developing
foot lesions.
Findings in neuropathic
diabetic foot syndrome with
claw toe deformity as a result
of shortening of the small
muscles of the foot (a
consequence of motor
neuropathy) and degeneration
of the plantar aponeurosis
36
atrophy of the small foot muscles with a claw toe
position and prominent metatarsal bones may be consi-
dered signs of involvement of motor nerve fibres.
37
measurement because of its higher sensitivity (100% vs.
79%). Nylon filaments with a standardised application
force (1, 10 and 75 gram) are applied at specific points
on the patiants foot, bent and their perception tested96.
38
Acute diabetic osteoarthro-
pathy with swelling, redness
and excessive heat and
incipient deformity of the right
foot.
39
Diagnosis of arterial occlusive disease
40
Clinical and instrumental diagnosis in diabetic foot syndrome
Inspection: Inspection:
Warm, dry, cracked skin Cool, pale or livid, atrophic skin
Atrophy of the internal musculature of Loss of integumentary appendages,
the foot with foot deformities hair loss
Hyperkeratosis and subcallus Typical acral necrosis
haematomas
Examinations: Examinations:
Reflex test (ATR) Palpation of foot pulses
Vibration perception (Rydell-Seiffer Doppler examination with occlusive
Tuning fork, biothesiometer) pressure measurement
Semmes-Weinstein monofilament (10 g) (ankle-arm index, hydrostatic toe
Temperature perception (Tip-Therm) pressure)
Duplex ultrasonography
Transcutaneous oxygen measurement
Invasive and non-invasive radiological
procedures (DSA, angiography, CO2 -
angiography, MRI angiography)
41
In occlusive pressure measurements, an ankle-arm
index of less than 0.9 is an indicator of arterial occlusive
disease, irrespective of the existence or otherwise of
medial calcification119. Calcification of the tunica media of
the arteries, described for the first time in 1909 by
Mnckeberg and named after him, is found in a high per-
centage of diabetics120. As a result the vessels become
rigid and the occlusion pressures measured by Doppler
pressure measurement are false. The presence of
an occlusion of the vascular lumen or a reduction in the
circulatory reserve due to calcification cannot be
excluded121.
42
more frequently than diabetics without medial calcifica-
tion or non-diabetics. Depending on the literature source,
the arteries are assumed to be incompressible with an
ankle-brachial index (ABI) of 1.35 or 1.5123.
43
The significance of microcirculatory disorders at the
capillary level in the onset and course of diabetic
foot lesions is still a matter of debate. The presence of
lumen-occluding, processes in the microcirculation
of diabetics126,127 was used before as justification
for early and extensive limb amputation. Today, the pre-
sence of occlusive disease can be meassured and
hence excluded. However, functional abnormalities of the
microcirculation with deterioration of haemodynamic,
endothelial and cell function as a consequence of poor
blood glucose control, must be considered definite128.
These conditions impair healing. At present, capillary
microscopy, laser flow measurement and transcutaneous
oxygen measurement are standard procedures used in
the investigation of microcirculatory problems. There-
fore the presence of gangrene with palpable foot pulses
in patients with diabetic foot syndrome should no
longer be considered a consequence of an occlusive
microangiography, but much more as evidence of a
neuropathic infected foot with the presence of septic
emboli, and hence treated accordingly120,129.
44
Classification of diabetic foot lesions
45
advantage of being very simple, but the disadvantage
of being imprecise. Modifications by Harkless (supple-
mented with the suffix B for ischaemic extremities) or
Reike (indication of the main aetiopathogenetic factors)
have further refined these classification in terms of
their use in practice133,136.
Wagners classification
Grade
46
The authors Lavery, Armstrong and Harkless evaluated
the system in 1998 while studying more than 360
patients138. A grade III lesion (bone or joint involvement)
indicated an eleven-fold increase in the risk of ampu-
tation. Patients with ischaemia and infection (stage D)
exhibited a 90-fold higher risk of amputation.
47
University of Texas San Antonio Diabetic Wound Classification
(Armstrongs classification)
Grade
0 I II III
48
Diagnosis structure in diabetic foot syndrome
(modified by H. Reike)
1. Underlying disease
(neuropathy, arterial occlusive disease, mixed form,
osteoarthropathy)
2. Localisation
(e.g. toes, forefoot, heel region, scar regions)
3. Extent of injury
(e.g. Wagners stages 05;
Armstrongs classification)
5. Infection
(yes/no; limb threatening, non-limb threatening)
49
Basic principles of the
treatment of diabetic foot
lesions
50
foot. The combination of diabetic neuropathy and foot
deformities increase the risk of ulcer formation.
Therefore consistent pressure relief is an essential pre-
condition for the prevention and healing of foot ulcers.
51
increased difficulty of detection142. Probably the most
extensively used method of pressure relief in Germany
is the use of so-called partial foot relief shoes. These
walking aids are considerably cheaper than plaster
therapy, but slightly less effective in terms of healing rate
and degree of pressure relief140. In a case control study,
96% of wounds in patients with forefoot relief shoes
healed within an average of 70 days, whereas in patients
without such walking aids only 59% of ulcers healed
(mean healing time of 118 days). Hospitalisation was
necessary in half the patients without walking aids, but
in only one out of 26 patients fitted with forefoot relief
shoes143. The principal difficulties encountered by
patients from the use of such accessories include:
52
Differences are found between diabetics and meta- Schematic representation of
bolically healthy patients in all three phases and these the time course of the wound
healing phases:
are described in greater detail below.
1) inflammatory phase
2) proliferative phase
Immediately after an injury local blood coagulation 3) differentation phase
occurs with the formation of a fibrin network. This
then dissolves to allow the unimpeded extension of the
ensuing granulation tissue. In diabetics, these fibrin
coatings occasionally persist beyond the first phase144.
53
Subsequently a local inflammatory reaction develops,
in which first neutrophils (which release proteases and
are capable of phagocytosis) and then macrophages
migrate to the wound area where they release messen-
ger substances, known as cytokines (such as PDGF
or TGF-(). These mediators stimulate cell activities such
as angiogenesis, autolytic dbridement, keratinocyte
migration, matrix formation and fibroblast formation.
54
endothelial cells and fibroblast formation, a shiny red
granulation bed is formed and collagen synthesis is
increased.
55
Disruptive factors in wound healing may be systemic
or related to local conditions in the wound area. They are
listed here:
Systemic factors:
Hyperglycaemic metabolic situation
Malnutrition
Obesity
Nicotine abuse
Anaemia
Renal insufficiency/uraemia
Patients age
Drugs (steroids, antirheumatic agents).
Local factors:
Ischaemia and hypoxia of affected tissue
Pressure load
Repeated trauma
Inadequate local wound treatment
Infection
Necrosis
Oedema formation
Foreign body in the wound
It must:
56
In the first phase of wound healing, the mechanical
or physical removal of necrotic tissue, the provision of
drainage for exudate and where necessary the resection
of infected bone sequestra take precedence. In addition,
deoxyribonucleases (e.g. Fibrolan), streptokinase-
streptodornase (e.g. Varidase) or collagenases (e.g.
Iruxol N) may be used. There are at present no studies
that confirm the efficacy of these preparations.
57
In terms of special wound dressings, alginates
(e.g. Sorbalgon) are used at this stage for wounds with
profuse exudation and are also suitable for deep
and gaping wounds. Wound healing complications have
been described in individual cases with alginate
therapy in undiagnosed deep wound infections, osteitis
or minimally exudative wounds149,150.
58
macerate. The lack of adequate studies on the phase-
specific use of sufficient wound dressings results on the
one hand in inappropriate use by unspecialised users152,
and on the other in a constant debate among experts
about the risks of using specific wound dressings in
diabetics149,153,154. In a large English survey on the use of
specific wound dressings in diabetic foot syndrome,
five to eight different wound dressings were mentioned
by each user, among which hydrocolloids, hydrogels
and alginates were the most widely used. None of the
products, however, had more than 30% support in any
of the wound healing phases. This survey was unable to
clarify whether this finding is due to a lack of information,
or to the belief on the part of the users that there are
no essential differences between the various dressings152.
Encouraged by individual case reports, the use of hydro-
colloid dressings in diabetic foot syndrome has become
a subject of debate in recent years.
59
Moist wound treatment
60
from the wound pad (2).Thus, TenderWet continuously
renews the film of Ringers solution over several hours
and simultaneously absorbs micro-organisms, released
detritus and toxins. Hence, the wound is rinsed and
rapidly cleansed.
TenderWet is available in
various shapes and sizes to
ensure good adaption to the
various wound conditions.
TenderWet is activated with
Ringers solution directly in the
sterile peel off package
(right)
61
TenderWet has no
contraindications and can be
used in all wound conditions,
both infected and non-
infected. The rinsing effect of
TenderWet is optimal during
the cleaning phase and at the
beginning of the granulation
phase. The examples show
TenderWet used in the care of
a venous (1) and an angio-
pathic/diabetic ulcer (2) 1 2
62
Loosley packed Sorbalgon
dressings (left) and their
transformation to a gelatinous
structure by the absorption
of exudate (right)
63
Hydrosorb does not stick to the wound and can be
removed even after prolonged application without the
risk of irritation to the wound. Unlike hydrocolloids,
Hydrosorb can be removed in one piece since the gel
structure is not dissolved by the absorbed wound
exudate. No residues are left on the wound and the
wound condition can be assessed safely without prior
rinsing.
64
expandable hydrocolloids incorporated in a self-adhe-
sive elastomer with a semipermeable film that serves to
prevent the penetration of bacteria and moisture. Upon
absorption of exudate from the wound, the hydrocolloidal
particles swell to form a gel that expands into the wound 1
and maintains a moist wound environment (1). The gel
remains absorbent until the hydrocolloids are saturated.
Saturation of the hydrocolloids is indicated by a blister-
shaped protrusion of the dressing (2), whereupon the
Hydrocoll must be changed.
2
Due to the adhesiveness of the elastomer, Hydrocoll can The principle of action of
be laid on the wound like a plaster. With the formation Hydrocoll
of the gel, however, the adhesiveness in the area of the
wound surface is lost, so that Hydrocoll is attached only
to the intact border and thus does not affect the wound.
In addition, when the dressing is removed, it can be
removed without leaving residues of gel on the wound.
Prior irrigation is not necessary for assessing the wound
after a change of dressing. Hydrocoll has a high ab-
sorbency due to the special material composition.
Excess contaminated exudate is rapidly absorbed and
safely retained in the gel structure as a result of the
swelling process. In this way the microcirculation in
the wound area is simultaneously improved, so that the
bodys own cleansing mechanism is reactivated,
especially in those chronic wound conditions where
healing is delayed.
65
Product characteristics
Zetuvit
Wound-compatible absorbent dressing pads with
non-adherent material covering and an absorbent
core of cellulose fluff
Cosmopor steril
Self-adhesive wound dressing with waterrepellent
Comprigel
Impregnated, non-adhering gel dressing with
integrated absorbent core in medicated cotton
Atrauman
Wound-compatible water-repellent polyester
tulle, impregnated with a selfemulsifying, neutral
ointment, non-adherent
TenderWet
Superabsorbent polyacrylate wound pad with
an absorbing/rinsing core, activated before
use with Ringers solution which is delivered to
the wound in exchange for wound exudate
Sorbalgon
Conformable, non-medicated dressings made of
calcium alginate which form a moist gel in
contact with wound exudate
Moist wound treatment
PermaFoam
Hydroactive foam dressing with a high level
of water vapour permeability top layer; but liquid-
and germ-proof
Hydrocoll
Self-adhesive, absorbent hydrocolloid dressing
with semi-permeable, germproof and waterproof
layer.
Hydrosorb
Absorbent hydrogel dressing with high water
content in the gel structure, covered with semi-
permeable transparent germproof and water-
proof layer
66
Properties and use Commercial forms
rapid transfer of exudate into the absorbent pad as a result of Cosmopor sterile,
the water-repellent microgrid, no adhesion, good absorbency and 7.2 x 5, 10x6, 15x6, 10x8,
cushioning effect, permeable to air and water vapour, adhesive 15x 8, 20 x 8, 20 x 20, 25 x10
border ensuring good closure; for postoperative wound management and 35 x10 cm
and the sterile dressing of minor injuries, e.g. in first aid.
highly absorbent, permeable to secretions and air, does not adhere to Comprigel, sterile,
the wound and keeps wound edges supple; slightly cooling, pain- 5 x 7.5, 10 x10 and 10 x 20 cm
relieving effect; for the treatment of acute, small, superficial wounds
or minor injuries
rapid wound cleansing and promotion of tissue cell proliferation TenderWet, sterile,
through the continuous supply of Ringers solution and the 4, 5.5, 7.5 x 7.5 and
simultaneous absorption of contaminated exudate (= rinsing effect); 10 x10 cm
for the treatment of chronic, acute and infected wounds during TenderWet 24, sterile
the cleansing phase and at the beginning of the granulation phase 4, 5.5, 7.5 x 7.5 and
10 x10 cm
high absorbency with efficient cleansing effect, safe retention Sorbalgon, sterile,
of bacteria in the gel structure, maintains a moist environment for 5 x 5, 10 x10 and 10 x 20 cm
the wound after formation of a gel, promotes granulation, no ad- Sorbalgon T tamponade ribbon,
hesion, highly conformable; particularly suited for the cleansing and sterile, 1g/30 cm
management of deep and gaping or infected wounds and 2 g/30 cm
the special pore structure of the hydrophilic foam dressing enables PermaFoam, sterile,
rapid absorption of the wound exudate and creates a moist 10 x 10, 15 x 15, 10 x 20 and
wound environment that stimulates wound healing; change of the 20 x 20 cm
dressing is atraumatic PermaFoam comfort, sterile,
11 x 11, 15 x 15, 10 x 20
and 20 x 20 cm
as a result of the promotes granulation, no adhesion to the wound; Hydrocoll, sterile, 5x5, 7.5x7.5,
particularly suitable for the management of chronic, slow-healing 10 x10, 15 x15 and 20 x 20 cm;
wounds and where the granulation process is not functioning Hydrocoll sacral, 12 x18 cm;
satisfactorily Hydrocoll concave, 8 x12cm;
Hydrocoll thin, 7.5 x 7.5, 10 x 10
and 15 x 15 cm (all sterile)
from the very beginning provides a moist environment for the wound, Hydrosorb, sterile, 5 x7.5, 10 x 10
transparency allows inspection of the wound at any time without and 20 x 20 cm
the need to remove the dressing (= high cost effectiveness through Hydrosorb comfort, sterile,
reduction in frequency of dressing changes); ideal for moistening 4.5 x 6.5, 7.5 x 10, 12.5 x 12.5,
granulation tissue and epithelium following TenderWet or Sorbalgon 11.5 x 24 and 21.5 x 24 cm
therapy
67
Treatment of infection
68
and constitute the sole pathogenic agent in about
40%. Gram-negative aerobes (e.g. Klebsiella or Pseudo-
monas) and anaerobic micro-organisms are found in
36% and 13% of cases respectively, always in conjunc-
tion with polymicrobial infections. In the study quoted,
clindamycin and cephalosporins were used for antibiotic
therapy, which in our outpatient department are replaced
where necessary by Fluoroquinolones following the
results of cultures and in the absence of improvement in
local findings160. Ninety percent of infections are
healed with these agents, 75% of them within two weeks.
69
There are a variety of expensive imaging procedures for
the diagnosis of osteitis in diabetic foot syndrome,
such as leucocyte scans, Tc99m bone scan, magnetic
resonance imaging (MRI) and standard X-rays.
A simple and cheap method with at least as high a
70
ment of deeper structures were found in only 10% of
cases and a lack of foot X-rays was observed in 33% of
patients. Blood cultures were arranged in 62% of
cases but tissue cultures from the wound in only 51% of
cases167.
71
It is thus apparent that patients with lesions of ischaemic
origin should be examined as rapidly as possible
with a view to establishing their suitability for a surgical
procedure (e.g. angioplasty, graft).
72
the introduction of bypass procedures. In both the USA176
and Denmark177 the number of amputations in diabetics
more than halved between 1984 and 1989, while by-
pass surgery, angioplasty and above all the use of distal
bypass grafts in each case more than doubled. In ad-
dition, in those amputations that have still proved necess-
ary, the level of amputation has increasingly moved
distally. The amputation rates in Germany in centres
using such procedures175,178 are less than 10% for major
amputation. The extremity is preserved in 75% and
71% of cases after 2 and 5 years, respectively. The
patency rates of the bypasses created are about 60%.
This means that even short-term bypasses are frequently
sufficient to save a jeopardised extremity. As the dia-
meters of the vessels in the lower leg and foot are small,
73
Surgical measures in the treatment of the diabetic foot
syndrome are not simply based on amputation.
If vascular surgical principles are applied, then extensive
mutilation can be prevented. If an amputation cannot
be avoided because of insufficient perfusion or un-
controllable infection, the principle that is now applied,
is to preserve as much tissue and function as possible.
74
out the risk of talipes developing. Total resection of toes
involves a significant risk of the development of deficits
of mobility or rigid deformities180 which then require
particular management. Amputations of the toes (parti-
cularly of the first toe) also increase the risk of follow-up
interventions on the same side, as well as on the contra-
lateral side as a result of altered weight-bearing181.
75
amputees must be re-operated, whereas after a suc-
cessful revascularisation this applies in less than 20% of
cases. In contrast to patients with major amputations,
patients with amputations at the foot and ankle level have
a markedly higher probability of survival of almost 90%
after four years and more than 75% after eight years186.
However, re-ulceration occurs or further surgery is re-
quired in more than 50% of patients. The whole group of
such patients is characterised by high morbidity with
a further period of ulceration in almost 20% of cases
following a successful amputation. With appropriate
care, however, further surgery can be avoided in 52% of
patients over an eight-year period. More than 2/3 of
patients can be rehabilitated following a transmetatarsal
borderline zone amputation and are able to walk without
impairment185. In contrast to forefoot amputees, patients
with amputation of the posterior foot area (by the Chop-
art, Pirogoff and Syme methods) are not capable of
walking without a prosthetic device, but these operations
allow the lower leg to be preserved187. The prognosis
for a Syme amputation depends in particular on good
local perfusion. With good circulation, 90% of Syme
amputations heal and can be fitted with a prosthesis.
After 21/2 years, two-thirds of patients still wear their pros-
thesis throughout the day188. Among patients with a lower
leg amputation, 66% are able to walk with a prosthesis.
Upper leg amputated patients are capable of walking
with a prosthesis in 46% of cases, whereas bilaterally
amputated patients can be mobilised with a prosthetic
device in only 19% of cases189.
76
that the combination of hypoxia and infection is respon-
sible for the delayed healing of diabetic foot lesions,
the oxygen tension of the affected tissue should be
increased through the application of hyperbaric oxygen
in high-pressure chambers. It is thought that oxygen
tension remains high for a prolonged period after expo-
sure. Thus the development of necrosis in the affected
tissue is reduced. In addition, a direct inhibitory effect
on the growth and toxin production of anaerobic micro-
organisms and a potentiating effect on angiogenesis
are postulated192. This is offset by the frequent side
effects of such therapy (barotraumas in 1 to 2%, transient
lung and eye damage in 15 to 20% of treatment cases)
and the as yet far from convincing data on the treatment
of diabetic foot syndrome with hyperbaric oxygen
(HBO)193.
77
5. Cost-effectiveness, quality of life and the endpoints of
limb preservation, duration of hospitalisation and
healing rate must be determined in the studies to be
performed196.
78
with Dermagraft is regarded as cost-effective despite
the high costs of the product200.
79
forgotten before undergoing a resurgence of interest
in the 1980s in the USA and since the mid-1990s in Great
Britain202.
80
Tertiary prevention of the
diabetic foot syndrome
Patients with DFS remain extremely high-risk patients
throughout their life. Their education must include
information about what to do in the event of an injury
or impending amputation in addition to preventive
foot care aspects. Regular aftercare in special insti-
tutions considerably reduces the risk of recurrence of
lesions and subsequent amputations in these
patients. Successful tertiary prevention must also in-
clude risk-centred and phase-adapted shoe provision
for patients and the organisation of injury-free, profes-
sional foot care for those affected.
81
In the late 1980s, a series of studies were carried out,
firstly to establish the effect of patient education
alone and secondly to compare different types of foot
training programmes in terms of efficacy206.
82
The aim and form of training should be tailored to the
patient and their requirements, because education
is only successful if it manages to change habits and
patterns of behaviour. Particularly in elderly people
who are often no longer capable of undertaking simple
foot inspections on their own. Partners, relatives or
carers should be included in the training. Finally, intensi-
ve foot education should be directed towards specific
target groups most at risk. The over-education of
healthy diabetics may in the worst case even prove
counterproductive210.
83
callus formation) were found in 50% of a group of
unselected diabetics. Only 40% of patients with existing
blisters or foot ulcerations had undergone a foot
examination in the 12 months prior to this examination214.
84
The treatment of an ingrowing toenail (unguis incarna-
tus), which is traditionally done surgically for example
by means of wedge excision (Emmert-plasty) can
according to a more recent study be successfully treated
conservatively by means of packing, pressure relief
and, where necessary, antibiotics. Surgical operations
on the diabetic foot are associated with an increased risk
of development of gangrene218.
85
hospitalisation due to foot problems occurred in only
7 patients. Before the introduction of professional foot
care, 30% of patients had performed their foot care
themselves, half of whom had occasionally injured
themselves in the process. The costs generated by foot
problems were reduced by 80% as a result of this
measure.
86
Provision of adapted footwear for diabetics
Off-the-shelf, diabetes-
adapted protective shoe with
sole stiffening, a rocker
sole and raised toe room
(Buratto company)
87
of two years78. The occasional wearing of normal shoes
(27%), an incongruity between foot shape and
customised shoe in the presence of gross deformities
(27%) and hard toecaps are the reasons for further
lesions despite specialist shoe provision226.
88
provision of a sufficient number of suitable pairs of shoes
and the additional prescription of slippers could also
contribute to reducing relapses. Twenty-two percent of
patients with foot ulcers in a Southern German diabetes
clinic79 and a similar percentage of patients in our own
outpatient foot department were not prescribed
protective shoes in 1994 and 199578. Regular inspection
of the shoes and insoles, particularly in the period
after the prescription, and the consistent improvement of
deficiencies are essential for quality assurance and
avoidance of ulcers.
89
Compared with studies of the benefit of specialised
shoe provision in the prevention of relapses, the data on
shoe provision for prophylaxis in patients without
previous foot injuries is less extensive. In a German study
over a 2-year period, only one in 21 patients without
a previous foot lesion suffered a foot injury following the
provision of protective shoes226, and two out of 49
patients in another study237. Predictors of the occurrence
of foot lesions in this patient group are the purchase
of new shoes in the six months prior to the occurrence of
the ulcer and wearing the wrong size of shoes238. In 80%
of patients from a diabetic population, among whom 27%
had already suffered a foot ulcer, the feet were never
measured when buying shoes212. Recent studies on the
subject have shown that the feet of diabetics with
neuropathy match the normal size in terms of length.
Result of computer-assisted
plantar foot pressure measure-
ment in a patient with hallux
rigidus and increased foot
pressures in the area of the
metatarsus with diabetic
osteoarthopathy (Fastscan
measurement system,
Megascan company)
90
with such footwear to match the stage of their condition.
Only patients with gross deformities or who have al-
ready undergone amputations of part of the foot require
the more expensive hand-made customised footwear.
The value of computer-assisted foot pressure measure-
ment procedures in the production and follow-up of
specialised shoe provision for diabetics cannot be con-
clusively established at the present time.
91
Footwear provision for the diabetic foot Classification by risk groups
Ia: Diabetes mellitus without PNP/AOD*: IV. Foot as II and high grade deformity
Off-the-shelf shoe or osteoarthropathy:
92
Structures for screening, treatment and aftercare of
patients with diabetic foot syndrome
93
The fact that things could be different had been
impressively demonstrated many years ago: In the 1970s
Davidson in Atlanta had demonstrated the possibilities
of reducing amputations in diabetics through a team
concept with risk screening, education and systematic
aftercare of the patient21. The amputation figures halved
between 1973 and 1980 after the introduction of these
measures (from 13.3 to 6.7 amputations/1000 patients/
year). A total of 555 amputations were avoided over
this period. Similar figures were reported in the following
years from Switzerland, England221,224, Scandanavia245,246,
Italy247 and Germany24,248. The healing rates for diabetic
foot lesions reported from such centres were 72%
to 80% in ischaemic lesions and 86% to 95% in neuro-
pathically infected foot ulcers221,249. Between 1994
and 1998 in our own outpatient diabetic foot department
at the Marienkrankenhaus, (Soest/Germany) major
amputations were entirely avoided in purely neuropathi-
cally induced foot lesions. In purely ischaemic lesions a
40% reduction in all types of amputation was obtained250.
94
Not only have these outpatient diabetic foot departments
demonstrated their value in terms of improved prognosis
for manifest foot lesions, but also their efficacy in the
prevention of lesions in previously ulcer-free high-risk
patients is now documented. Over a three-year period,
patients who did not receive regular care from an out-
patient foot department suffered a foot ulcer 24 times
more often than patients who received constant attention
from such a department. A lack of patient compliance
(in this case defined as a failure to attend less than half
the arranged appointments) increased the probability
of ulcer 54-fold and the risk of amputation 20-fold for the
whole population, including patients with previous foot
lesions251.
95
Levels of care for the support of patients with diabetic foot syndrome (modified
by Reike)
96
In order to allow successful specialist treatment of
patients with diabetic foot lesions at an early stage, all
the existing centres must co-operate to streamline
treatment. In a current Swedish study, there was an
interval of between 31 and 189 days between the first
presentation of a foot injury at the general practitioners
and the institution of care by an outpatient foot depart-
ment. Antibiotic treatment was instituted in a primary care
setting in 44% of patients, but additional measures,
such as pressure relief, were implemented in only 8% of
cases255. In our own prospective study, the interval
between the occurrence of the lesion and the first pre-
sentation at the outpatient diabetic foot department
in 153 patients without any prior information about the
procedure to be followed in the event of foot problems
was on average 71 days. However in 62 patients with
previous education or contact with the outpatient foot
department for a previous lesion, the interval was
13 days. The corresponding amputation rates were 24%
and 10%, respectively256.
97
Successful co-operation in a network of this kind requires
seamless transitions (frequently complicated by the strict
separation of outpatient and inpatient structures in
Germany), the absence of fear of contact and the
presence and implementation of guidelines which are
valid for all participants. A consensus paper in this
respect on the diagnosis and treatment of the diabetic
foot was published for the first time in May 1999 by the
International Working Group on the Diabetic Foot.
98
In Eastern Europe, specialist centres for the treatment of
the diabetic foot are rare. In many places amputation is
still considered the standard. As a result of twinning
programmes with Western European countries, structural
improvements are gradually occurring in certain regions.
In South America, where the prevalence of diabetes is
more than 6%, the establishment of institutions has so far
only been observed in Costa Rica, Mexico and Brazil. In
some North African countries more than 10% of the
population are diabetics, up to 12% of patients with foot
ulcerations are found among hospital inpatients and 7%
of diabetics have had previous amputation. In Australia
programmes involving foot care in diabetics have already
been implemented countrywide. In some tropical
countries, the co-existence of diabetes mellitus and
leprosy has resulted in a particularly high occurrence of
patients with a potential risk of occurrence of foot
lesions259. In addition, a relatively high proportion of foot
99
(and hand) infections is found here in diabetics
without the conventional risk conditions, such as arterial
occlusive disease and diabetic neuropathy260,261.
100
Summary and prospects
More than half of all limb amputations are carried out in
patients with diabetes mellitus. In more than 70% of
cases, amputation is preceded by a foot ulcer
progressing to deep gangrenous infection. Most of these
ulcers are caused by minor trauma, frequently as a result
of poorly fitting footwear or inadequate foot care.
Sensorimotor diabetic neuropathy or a peripheral arterial
occlusive disease of varying severity are in most cases
present as risk conditions predisposing to injury.
101
The implementation of prevention and treatment
strategies has been shown to help avoid more than 50%
of amputations in diabetics.
102
Definitions and
explanations
Amputation
Resection of a part of a limb
Cellulitis
Presence of swelling, redness and heat as evidence of
an inflammatory reaction, irrespective of origin
Charcots deformity
Resulting from Charcots disease or arthritis; also neuro-
pathic arthritis - it is a rapid progressive degeneration
in a joint which lacks position sense and protective pain
Chopart amputation
Amputation through the talo-navicular joint
Deep infection
Presence of evidence of an abscess, septic arthritis or
osteomyelitis
Dbridement
Removal of dead tissue
Deep ulcer
Lesion affecting the whole thickness of the skin and
extending to the subcutis, possibly involving muscles,
tendons, bones and joints at the same time
Diabetic neuropathy
Presence of signs and/or symptoms of disorders
of peripheral nerve function in patients with diabetes
mellitus after the exclusion of other causes
103
Foot deformity
Structural changes in the foot, such as the presence of
hammer toes, claw toes, hallux valgus, prominent meta-
tarsals and conditions due to neuro-osteoarthropathy, as
well as surgery on the foot and amputations
Foot lesion
Blister, erosion, cut or ulcer on the foot
Gangrene
Progressive necrosis of the skin and deeper structures
(muscles, tendons, bones or joints) indicating irreversible
destruction, in which healing cannot be obtained without
the loss of part of the extremity
Infection
Penetration and proliferation of micro-organisms in body
tissue, which may be clinically insignificant or may
result in local cell death, as a result of toxins, intracellular
microbial proliferation or an immune response
Intermittent claudication
Pain in the foot, thigh or calf which is increased on walk-
ing and relieved on stopping, associated with evidence
of an arterial occlusive disease
Major amputation
Any amputation above the ankle joint
Minor amputation
Amputation at the level of the ankle joint or lower
Necrosis
Dead tissue, either dry or moist, regardless of the tissue
affected
Neuro-osteoarthropathy
Non-infectious destruction of the bone or joints
associated with a neuropathy
Neutropenia
Relative or absolute decrease in the number of neutro-
philic leucocytes in the blood
Osteomyelitis
Infection of the bone with involvement of the bone
marrow
104
Pirogoff amputation
The calcaneum is cut across so that the posterior 2 cm
remain in the heel flap and this is attached to the
lower end of the tibia, making a longer stump than in the
Symes amputation
Polymicrobial
Infections with more than one organism causing damage
Pressure relief
Relief of load-bearing areas of the foot through the
systematic use of crutches, wheelchairs, partial foot relief
shoes or other orthopaedic devices
Protective footwear
Footwear of proven benefit in the prevention of
ulcerations
Superficial infection
Infection of the skin without involvement of muscles,
tendons, bones or joints
Superficial ulcer
Lesion affecting the whole thickness of the skin without
extending to the subcutis
Symes amputation
The original level of amputation was through the ankle
joint with the medial and lateral malleolus trimmed.
The amputation has been modified to divide the tibia and
fibula 1 cm above the joint line. In an emergency the
patient is able to stand and walk without the prosthesis
105
Abbreviations:
ABI Ankle Brachial Index
ADA American Diabetes Association
AOD Arterial Occlusive Disease
ATR Achilles Tendon Reflex
bFGF b-Fibroblast Growth Factor
BMT Biochemical Wound Therapy
CNS Central Nervous System
CSII Continuous Subcutaneous Insulin Infusion
CT Conventional Insulin Therapy
CVA Cerebral Vascular Accident
DCCT Diabetes Control and Complication Trial
DDG Deutsche Diabetes Gesellschaft (German
Diabetic Association)
DFS Diabetic Foot Syndrome
DNOAP Diabetic Neuropathic Osteoarthropathy
DSA Digital Subtraction Angiography
ESR Erythrocyte Sedimentation Rate
EUR Euro
GAD Glutamic Acid Decarboxylase
GCSF Granulocytes Stimulating Factor
GDM Gestational Diabetes Mellitus
HbA1c Haemoglobin Receptor A1 c
HBO Hyperbaric Oxygen
ICA Islet Cell Antibodies
ICT Intensified Conventional Insulin Therapy
MRI Magnetic Resonance Imaging
PDGF Platelet Derived Growth Factor
PNP Polyneuropathy
PNS Peripheral Nervous System
PTA Percutaneous Transluminal Angioplasty
rhPDGF Recombinant Platelet Derived Growth Factor
TCPO2 Transcutaneous Partial Oxygen Pressure
TGF Tissue Growth Factor
UKPDS United Kindom Prospective Diabetes Study
V Volt
WHO World Health Organisation
106
Proposed further reading
Andrew JM Boulton, H Connor, Peter R Cavanagh (Eds).
The Foot in Diabetes, 3rd Edition. Wiley and Sons Ltd.,
Chichester 2000.
ISBN 0-471-48974-3
107
108
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