Surgical Management of the Diabetic Foot
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Diabetes and Lesions of the Foot
Diabetes is a common condition in the United States, affecting more than 10 million adults.1 Wounds of the foot are the most common reason for hospitalization in patients with diabetes;2,3 it is estimated that 15% to 20% of patients with diabetes will develop an ulcer on their foot at some point,4 and for many of these cases, the most appropriate treatment results in some form of surgery.
The foot is highly specialized to cope with a large degree of repetitive stress. Fatty tissue on the plantar surface and a thickened dermis and epidermis cushion and absorb repeated forces of compression, torsion, and shear during locomotion and standing. However, the pathophysiology of diabetes can significantly alter the wound healing process, leading to an increased risk for foot ulceration. McNeely et al5 found that a transcutaneous oxygen tension (TcPO2) of less than 30 mmHg, absence of the Achilles’ tendon reflex, and foot insensitivity are 3 factors that are strong predictors of ulceration.
A simple test for sensation involves pressing a nylon monofilament against the skin to the point of buckling.6 Patients who cannot feel the monofilament are at particular risk for ulceration. In patients without sensation, the likelihood for ulceration is 9.9 times higher and the likelihood of amputation is 17 times higher than in patients who can feel the monofilament.7
The pathogenesis of ulceration is complex and involves the interaction of angiopathy, neuropathy, and immunopathy. Briefly, vascular impairment has been found to correlate with the development of diabetic foot ulcers,8 probably through ischemic skin changes leading to ulceration. There is debate about the precise role of angiopathy in the microvasculature, but it is likely that thickening of the capillary basement membrane impairs the flow of nutrients and possibly white blood cell migration, yet there is no evidence of impairment of oxygen diffusion.9
Neuropathy is the most significant risk factor for diabetic foot ulcers and is present in over 80% of patients with diabetes and foot lesions.10–12 All aspects of nerve function including the motor fibers to the intrinsic muscles of the foot are affected. With the loss of function, the toes become drawn up into a claw-foot position, creating points of increased pressure or friction beneath the metatarsophalangeal joints, over the dorsum of the toes or at the tip of the toes. Autonomic dysfunction also results in the shunting of blood through direct arteriole-venule passages, reducing the extent of tissue perfusion.13,14 The decreased awareness of sensation and nerve-induced deformity predispose the diabetic foot to ulceration by causing imbalances in the tendons that shift the load-bearing areas to unprotected parts of the plantar surface. In the absence of a neuro-inflammatory response, infection may occur without the patient being alerted by the usual clinical signs of inflammation.
Although there does not appear to be any significant impairment of humoral immunity in diabetes, at the cellular level, impaired leukocyte function15 and intracellular killing have been noted16–18 and these can be partly or completely reversed with improved diabetic control. Cell-mediated immune responses are also impaired by elevated glucose levels.19
Charcot Neuroarthropathy
1. Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in US adults. The Third National Health and Nutrition Examination Surgery, 1988–1994. Diabetes Care. 1998;21(4):518–524.
2. Gibbons G, Eliopoulos G. Infections of the diabetic foot. In: Kozak GP, Campbell DR, Frykberg R, eds. Management of Diabetic Foot Problems. 2nd ed. Philadelphia, PA: WB Saunders: 1995.
3. Frykberg R. Diabetic foot ulcerations. In: Frykberg RG, ed. The High Risk Foot in Diabetes Mellitus. New York, NY: Churchill Livingstone; 1991.
4. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet. 2005;366(9498):1719–1724.
5. McNeely MJ, Boyko EJ, Ahroni JH, et al. The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration. How great are the risks? Diabetes Care. 1995;18(2):216–219.
6. Birke JA, Sims DS. Plantar sensory threshold in the ulcerative foot. Lepr Rev. 1986;57(3):261–267.
7. Rith-Naharian SJ, Stolusky T, Gohdes DM. Identifying diabetic patients at high risk for lower-extremity amputation in a primary care setting: a prospective evaluation of simple screening criteria. Diabetes Care. 1992;15(10):1386–1389.
8. Delbridge L, Appleberg M, Reeve TS. Factors associated with development of foot lesions in the diabetic. Surgery. 1983;93(1 Pt 1):78–82.
9. Calhoun JH, Overgaard KA, Stevens CM, Dowling JP, Mader JT. Diabetic foot ulcers and infections: current concepts. Adv Skin Wound Care. 2002;15(1):31–45.
10. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care. 1990;13(5):513–521.
11. Edmonds ME. Experience in a multidisciplinary diabetic foot clinic. In: Connor H, Boulton AJM, Ward JD, eds. The Foot in Diabetes: Proceedings of the First National Conference on the Diabetic Foot, Malvern, England, May 1986. Chichester, England: John Wiley; 1987:121–134.
12. Boulton AJM. The diabetic foot: neuropathic in aetiology? Diabetes Med. 1990;7(6):852–858.
13. Deanfield JE, Daggett PR, Harrison MJ. The role of autonomic neuropathy in diabetic foot ulceration. J Neurol Sci. 1980;47(2):203–210.
14. Edmonds ME, Nicolaides KH, Watkins PJ. Autonomic neuropathy and diabetic foot ulceration. Diabet Med. 1986;3(1):56–59.
15. Mowat A, Baum J. Chemotaxis of polymorphonuclear leukocytes from patients with diabetes mellitus. N Engl J Med. 1971;284(12):621–627.
16. Rayfield EJ, Ault MJ, Keusch GT, Brothers MJ, Nechemias C, Smith H. Infection and diabetes: the case for glucose control. Am J Med. 1982;72(3):439–450.
17. Bybee JD, Rodgers DE. The phagocytic activity of polymorphonuclear leukocytes obtained from patients with diabetes mellitus. J Lab Clin Med. 1964;64:1–13.
18. Bagdade JD, Root RK, Bulger RJ. Impaired leukocyte function in patients with poorly controlled diabetes. Diabetes. 1974;23(1):9–15.
19. MacCuish AC, Urbaniak SJ, Campbell CJ, Duncan LJ, Irvine WJ. Phytohemagglutinin transformation and circulating lymphocyte subpopulations in insulin-dependent diabetic patients. Diabetes. 1974;23(8):708–712.
20. Helm PA, Walker SC, Pullium G. Total contact casting in diabetic patients with neuropathic foot ulcerations. Arch Phys Med Rehabil. 1984;65(11):691–693.
21. Sinacore DR. Total contact casting for diabetic neuropathic ulcers. Phys Ther. 1996;76(3):296–301.
22. Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ, Harkless LB. Offloading the diabetic foot wound: a randomized clinical trial. Diabetes Care. 2001;24(6):1019–1022.
23. Müeller MJ, Diamond JE, Sinacore DR, et al. Total contact casting in treatment of diabetic plantar ulcers. Controlled clinical trial. Diabetes Care. 1989;12(6):384–388.
24. Frykberg R. Podiatric problems in diabetes. In: Kozak G, Campbell C, Hoar CJ, et al, eds. Management of Diabetic Foot Problems. Philadelphia, PA: WB Saunders; 1984: 5–67.
25. Jacobs RL. Hoffman procedure in the ulcerated diabetic neuropathic foot. Foot Ankle. 1982;3(3):142–149.
26. Armstrong DG, Stacpoole-Shea S, Nguyen H, Harkless LB. Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. J Bone Joint Surg Am. 1999;81(4):535–538.
27. Lountzis N, Parenti J, Cush G, Urick M, Miller OF III. Percutaneous flexor tenotomy— office procedure for diabetic toe ulcerations. WOUNDS. 2007;19(3):64–68.
28. Coughlin MJ, Dorris J, Polk E. Operative repair of the fixed hammertoe deformity. Foot Ankle Int. 2000;21(2):94–104.
29. Mann RA, Coughlin MJ. Lesser toe deformities. In: Jahss MH, ed. Disorders of the Foot and Ankle. Philadelphia, PA: WB Saunders; 1991:1208–1209.
30. Ross ER, Menelaus MB. Open flexor tenotomy for hammer toes and curly toes in childhood. J Bone Joint Surg Br. 1984;66(5):770–771.
31. Bono JV, Roger DJ, Jacobs RL. Surgical arthrodesis of the neuropathic foot. A salvage procedure. Clin Orthop. 1993;296:14–20.
32. Early JS, Hansen ST. Surgical reconstruction of the diabetic foot: a salvage approach for midfoot collapse. Foot Ankle Int. 1996;17(6):325–330.
33. Stuart MJ, Morrey BF. Arthrodesis of the diabetic neuropathic ankle joint. Clin Orthop Relat Res. 1990;253:209–211.
34. Tisdel CL, Marcus RE, Heiple KG. Triple arthrodesis for the diabetic peritalar neuroarthropathy. Foot Ankle Int. 1995;16(6):332–338.
35. Simon SR, Tejwani SG, Wilson DL, Santner TJ, Denniston NL. Arthrodesis as an early alternative to nonoperative management of charcot arthropathy of the diabetic foot. J Bone Joint Surg Am. 2000;82-A(7):939–950.
36. Wang JC. Use of external fixation in the reconstruction of the Charcot foot and ankle. Clin Podiatr Med Surg. 2003;20(1):97–117.
37. Garbalosa JC, Cavanagh PR, Wu G, et al. Foot function in diabetic patients after partial amputation. Foot Ankle Int. 1996;17(1):43–48.
38. Larsson U, Andersson GB. Partial amputation for diabetic or arteriosclerotic gangrene. Results and factors of prognostic value. J Bone Joint Surg Br. 1978;60(1):126–130.
39. Pinzur MS, Sage R, Schwaegler P. Ray resection in the dysvascular foot. A retrospective review. Clin Orthop Relat Res. 1984;191:232–234.
40. Pinzur MS, Sage R, Stuck R, Osterman H. Amputations in the diabetic foot and ankle. Clin Orthop Relat Res. 1993;296:64–67.
41. Giurini JM, Basile P, Chrzan JS, Habershaw GM, Rosenblum BI. Panmetatarsal head resection. A viable alternative to the transmetatarsal amputation. J Am Podiatr Med Assoc. 1993;83(2):101–107.
42. Dannels EG. Prevention of complications of partial foot amputations in American Indian diabetics. Clin Podiatr Med Surg. 1987;4(2):503–516.
43. Kucan JO, Robson MC. Diabetic foot infections: fate of the contralateral foot. Plast Reconstr Surg. 1986;77(3):439–441.
44. Lithner F. Epidemiology and economic impact of diabetic foot. IDF Bulletin. 1993:7–9
45. Reiber GE, Boyko EJ, Smith DC. Lower extremity foot ulcers and amputations in diabetes. In: Diabetes in America. 2nd ed. Washington, DC: National Diabetes Data Group, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health; 1995: 409.
46. Bowker J. Role of lower limb amputations in diabetes mellitus. In: Levin ME, O'Neal LW and Bowker JH, eds. The Diabetic Foot. 5th ed. St. Louis, MO: Mosby Co; 1993: 433–455.
47. Wagner FW Jr. Management of the diabetic-neurotrophic foot; Part II. A classification and treatment program for diabetic, neuropathic, and dysvascular foot problems. In: Cooper RR, ed. AAOS Instructional Course Lectures, Vol. 28. St. Louis, MO: CV Mosby; 1979.
48. Pinzur MS, Morrison C, Sage R, Stuck R, Osterman H, Vrbos L. Syme’s two-stage amputation in insulin-requiring diabetics with gangrene of the forefoot. Foot Ankle. 1991;11(6):394–396.
49. Tan JS, Joseph WS. Common fungal infections of the feet in patients with diabetes mellitus. Drugs Aging. 2004;21(2):101–112.
50. Larsson J, Apelqvist J. Towards less amputations in diabetic patients. Incidence, causes, cost, treatment, and prevention—a review. Acta Orthop Scand. 1995;66(2):181–192.
51. Steed DL, Donohoe D, Webster MW, Lindsley L. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group. J Am Coll Surg. 1996;183(1):61–64.
52. Edmonds M. Diabetic foot ulcers: practical treatment recommendations. Drugs. 2006;66(7):913–929.
53. Moss SE, Klein R, Klein BE, Wong TY. Retinal vascular changes and 20-year incidence of lower extremity amputations in a cohort with diabetes. Arch Intern Med. 2003;163(20):2505–2510.
54. Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes. N Engl J Med. 1994;331(13):854–860.
55. Rennekampff HO, Schaller HE, Wisser D, Tenenhaus M. Debridement of burn wounds with a water jet surgical tool. Burns. 2006;32(1):64–69.
56. Lipsky BA, Pecoraro RE, Larson SA, Hanley ME, Ahroni JH. Outpatient management of uncomplicated lower-extremity infections in diabetic patients. Arch Intern Med. 1990;150(4):790–797.
57. Brem H, Balledux J, Bloom T, Kerstein MD, Hollier L. Healing of diabetic foot ulcers and pressure ulcers with human skin equivalent: a new paradigm in wound healing. Arch Surg. 2000;135(6):627–634.
58. Frykberg RG, Veves A. Diabetic foot infections. Diabetes Metab Rev. 1996;12(3):255–270.
59. Grayson ML. Diabetic foot infections. Antimicrobial therapy. Infect Dis Clin North Am. 1995;9(1):143–161.
60. Nelson EA, O’Meara S, Golder S, Dalton J, Craig D, Iglesias C; DASIDU Steering Group. Systematic review of antimicrobial treatments for diabetic foot ulcers. Diabet Med. 2006;23(4):348–359.
61. Lipsky BA. Osteomyelitis of the foot in diabetic patients. Clin Infect Dis. 1997;25(6):1318–1326.
62. Little JR, Kobayashi GS. Infection of the diabetic foot. In: Levine ME, O'Neal LW, eds. The Diabetic Foot. 4th ed. St. Louis, Mo: Mosby; 1988:104–118.
63. Dean MRE. The role of the radiologist in the diagnosis and treatment of the diabetic foot. In: Connor H, Boulton AJM, Ward JD, eds. The Foot in Diabetes. London, England: John Wiley & Sons Ltd; 1987:33–58.
64. Lipsky BA, Pecoraro RE, Wheat LJ. The diabetic foot. Soft tissue and bone infection. Infect Dis Clin North Am. 1990;4(3):409–432.
65. Zhang N, Thompson CJ, Thompson CL, Nguyen KQ. Improving the performance of small planar detectors for dedicated PET instruments. Nucl Sci IEEE Trans. 2002;49(1):111–115.
66. Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW. Probing to bone in infected pedal ulcers: A clinical sign of underlying osteomyelitis in diabetic patients. J Am Med Assoc. 1995;273(9):721–723.
