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Diabetic Foot |
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Diabetes is likely to be an
epidemic of the century. As per the prediction of WHO, India will have
largest number of diabetic patients in the world. This number will be
approximately 57 million. 15% of these patients will get food problem.
1% will lose their limbs due to diabetic food gangrene. 50% of those
patients will be between the age group of 35 to 45 years. However to
avoid this disaster it is necessary to understand the basic mechanism of
the foot and the change which occurs in diabetes. The triad of factors
which cause foot problem in diabetes are : Neuropathy, Vasculopathy and
Injury. Almost all the patients have both neuropathy as well as
vasculopathy. However what triggers the problem is injury. It is
necessary to maintain the integrity of the epithelial barrier. If this
is done then in spite of the deformity, foot remains intact. The
diabetic foot injuries are missed because they are silent and it is
difficult to detect these injuries with High Index of suspicion. These
injuries are like ICEBERG. There are various types of injuries which
trigger the problem. However
In every human walking
cycle the forefoot bears 600 kPa pressure. This causes significant
ischemia and recovers instantly as soon as the foot goes into the next
phase. However this recovery is delayed or is absent in diabetes. This
causes continuous anorexia and inflammation. If the patient keeps on
walking then the exudates form and lead to blister which break down and
cause ulcer? The foot in diabetes changes the walking pattern and the
majority of the patients have hyper pronation. The 1st MTP joint remains
in the ground contact for longer time. The Limited Joint Mobility
increases the pressure. These factors together cause foot ulcer. In
small percentage of patients the foot supinates and the pressure and the
ground contact time is more on 5th MTP Joint. In these patients the
ulcer occurs on 5th MTP Joints. The impulse The infected foot needs to be treated aggressively and the debridement needs to be done on anatomical basis. The partial foot should at least be preserved as the higher amputation has very high 5 years mortality. It is safer to have deformed foot with good footwear than higher amputation with sophisticated prosthesis. The dressings of diabetic foot wounds and ulcers should be done by the material which maintains most wound environment. Also it is necessary to avoid the agents like Eusol/Salon/Hydrogen Peroxide. It is of utmost importance to maintain off loading of the affected foot till the wound heals. Vascular lesions require proper assessment and prompt revascularization. In any patient when A/B index is less than 0.6 then immediate full vascular assessment should be done followed by proper debridement. The footwear is the most important aspect of the diabetic foot management. The fundamental principle of the footwear in diabetes is "Foot Wear Should Do What Foot Cannot Do". Therefore the footwear has to be customized with areas of stress isolation to protect high pressure areas. It is necessary to persuade the patient to use the prescribed footwear indoor as well as outdoor. The International Consensus in 1999 decided on St. Vincent's Declaration, which stated that the major limb amputations due to diabetes should be reduced by 50% within 5 years. If we had to achieve this objective then off loading of the affected leg/foot should have been aggressively pursued. Our country is likely to face a major epidemic in near future and only way to prevent the disaster is to install preventive strategies of foot care and footwear, which only can prevent loss of limb(s). |
Diabetic Foot
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Report by
Dr. Arun Bal
