Diabetic foot (DF)
What is diabetic foot?
A: The diagnostic term “diabetic foot (DF)” was introduced by Oakley in 1956, and in 1999, the World Health Organization (WHO) defined diabetic foot (DF) as a condition in which a diabetic patient has a combination of neuropathy and various degrees of peripheral vasculopathy that results in Infection, ulcer formation, and/or deep tissue destruction in the lower extremity. “, “diabetic peripheral neuropathy”, “diabetic gangrene (DG)”, etc., all of which are actually classified as diabetic foot.
Diabetic foot disease is the major health problem of our time. Worldwide, people with diabetes are 15-20 times more likely to develop foot disease than the rest of the population. In 2004, according to U.S. insurance statistics, the average economic cost of each ulcer was $4,595. Thus, it seems that diabetic foot is not only a medical problem, but also a social and economic problem.
Why are diabetic patients prone to foot gangrene? How does it happen?
A: We know that there are three major nutrients in the human body —- sugar, fat, protein, their metabolism in the body is interrelated, of which the increase in blood sugar will affect the other two substances metabolism, the impact on lipids is particularly important, will cause disorders of lipid metabolism (mostly manifested as hyperlipidemia), and thus easy to cause arterial lumen narrowing, occlusion. The blood vessels of the lower extremities are the longest blood supply channels of the human body, and any narrowing or occlusion at any stage will affect the blood supply to the distal tissues up to the foot, and this lesion is medically called diabetic macroangiopathy.
In addition, hyperglycemia can cause degeneration and thickening of the microvascular wall, narrowing and occlusion of the lumen, resulting in ischemia and hypoxia in the lower extremity. At the same time, the physical and chemical properties of the blood of diabetic patients also change (including a decrease in the oxygen-carrying capacity of red blood cells, the tendency of platelets to adhere and gather to form thrombi, and an increase in blood viscosity), and the combined effect of these factors causes severe ischemia and hypoxia in the foot, which eventually leads to tissue necrosis – diabetic microvascular gangrene.
In addition, neurotrophic disorders and ischemic neuritis caused by macrovascular and microvascular lesions make the body lack protective measures for the foot (because the protective sensation at the end of the limb is weakened or lost), which can easily cause physical damage, and once damaged, the pathophysiological changes make it difficult to repair and control the infection, which eventually develops into foot gangrene.
Finally, infection is an important factor that contributes to the aggravation of diabetic foot. We all know that people with diabetes are prone to infections, most commonly skin infections, because of the low immunity of diabetic patients. The lower extremities are the most weight-bearing organs in the body, especially the feet, which are most prone to injury and are more prone to infection in ischemic limbs. Due to the presence of neuropathy and peripheral vascular lesions, a small trauma can cause microbial invasion and infection, and the high glucose status of diabetic patients provides abundant nutrients for bacterial growth and reproduction, thus making it easier for the infection to spread.
I am a diabetic and many of my friends have been diagnosed with diabetic foot. I am worried that I will get this disease too. Is it possible to have an amputation once you have it?
A: Diabetic foot is one of the most serious complications of diabetes, diabetes is not 100% will definitely get diabetic foot, but its incidence increases significantly with the extension of the history of diabetes, foreign literature statistics reported diabetes onset 5 years, 5-10 and more than 10 years of the incidence of lower limb vascular disease were 22.6%, 23% and 66.7%; diabetes with neurological dysfunction The incidence is 30-67% and is related to the duration of diabetes, which can be as high as 90% for those with more than 10 years of disease. This chance is quite large. So, once you have a diabetic foot, do you have to amputate it? In the past, due to the lack of awareness of diabetic foot, a considerable number of patients were found to be basically in the late stage, and the lesions are difficult to reverse, so the amputation rate is high. 1998 related statistics, amputation due to diabetic gangrene accounted for 50% of non-traumatic amputation in the United States, and the amputation rate reported in China is about 46%.
What are the clinical manifestations of diabetic foot?
A: (1) General manifestations: less sweating and dry skin of lower limbs and feet, abnormal sensation, atrophy of muscles, fractures, etc., clinical manifestations of combined diabetes mellitus and multi-organ vascular complications.
(2) Ischemia and neuropathy manifestations: decreased skin temperature, cold and fear of cold in the affected foot, cold and pale limbs, weakened or absent limb arterial pulsation, intermittent claudication, etc. When neuropathy appears, symmetrical pain and sensory abnormalities often appear, with pain in the form of pins and needles, burning or drilling, and sensory abnormalities appearing before pain, commonly with numbness, ants, insects, fever, cold and electric shock-like sensations, often moving up from the ends of the limbs, with symmetrical “glove” and “garters “-like sensory dullness, insensitivity to pain and temperature stimulation or loss, the so-called “painless foot”; can also be manifested as motor disorders, such as lower limb movement is limited, limb weakness, etc.
(3) Infection: often caused by trauma, foot odor, skin blisters, etc., the affected foot swelling becomes larger, skin edema, into light red or yellow, local redness and heat, ulceration, yellow discharge or pus; rapid progress, can spread to the whole foot or even calf, involving muscles, blood vessels, nerves, bones, the formation of abscesses, smelly or odorless; the whole body can be accompanied by fever, chills. Eventually, gangrene may develop.
Some patients have red and swollen feet when they are admitted to the hospital, and their feet are very badly rotten, and they smell very bad and have high fever, but they recover very well in the end, while some of them have just a little bit of rottenness, no redness, no swelling and no fever, but they do not grow well.
A: The diabetic foot contains a wide range of lesions, including vascular lesions, neuropathy; there are also ulcers or gangrene caused by infection. Several kinds of lesions can exist separately or simultaneously. Each individual has a different degree of lesion and a different focus of lesion, and the treatment and prognosis are also different. In view of this, clinical classification of diabetic foot gangrene into wet gangrene, dry gangrene, and mixed gangrene.
(1) Wet gangrene
The former type of patients belong to this type, and most of the diabetic feet seen clinically are of this type, mostly caused by skin injury, infection and sepsis and impaired circulation and microcirculation in the affected extremity, and often accompanied by peripheral neuropathy. The clinical characteristics are rapid onset, swelling of the affected foot, red and swollen skin, fever, ulceration, foul-smelling secretions and pus, rapid progress, spreading to the whole foot and even the lower leg, reaching the muscles, blood vessels, nerves and bones, accompanied by generalized hyperthermia and even septicemia. If not treated in time, it will not only cause amputation, but also can be life-threatening. In these patients, the blood supply to the lower extremity foot can still maintain tissue needs, so after active control of infection and reasonable treatment of trauma, such patients can often be successfully treated and recover faster than ischemic gangrene.
(2) Dry gangrene
Dry gangrene occurs in diabetic patients with atherosclerosis of the arteries and small arteries in the extremity and severe narrowing of the vascular lumen; or arterial thrombosis, resulting in blockage of the vascular lumen and gradual or abrupt interruption of blood flow, but venous blood flow remains unobstructed, resulting in a decrease in local tissue fluid, leading to dry gangrene in the corresponding area of the distal extremity supplied by the blocked artery, the degree of which is related to the site and degree of vascular obstruction. The clinical manifestations are atrophy of the affected foot, dry and thin skin, dark red or cyanotic color, long gangrene formation, and slow progression. This type of gangrene is caused by lesions in the small, medium, and large blood vessels and microvessels of the lower extremities, and necrosis occurs as a result of tissue ischemia and hypoxia, so that the gangrene cannot heal unless the ischemia is lifted. The second type of patient in the above example belongs to this type of gangrene.
(3) Mixed gangrene
Mixed gangrene in diabetic patients is slightly more common than dry gangrene, which is caused by blockage of an artery in one part of the limb and poor blood flow, resulting in dry gangrene, while another part is infected with septicemia. This is gangrene caused by combined infection on top of ischemic gangrene, and these patients are among the most at-risk patients with the highest rate of amputation.
What is the clinical staging of diabetic foot?
A: The clinical stages of diabetic foot are
Limb ischemic compensatory stage: cold limbs and then intermittent claudication (gastrocnemius is most common). Early manifestation is femoral or hip claudication. Most of this stage has obvious sensory abnormalities such as limb numbness, i.e. early complication of ischemic neuritis.
Ischemic decompensation stage: resting pain, pain mostly confined to the toes or distal foot, especially severe at night, aggravated when lying down, relieved by dropping the limb. It is often accompanied by pale or cyanotic limb skin color, obvious decrease in skin temperature, and in some patients, cold limb is the prominent manifestation, while limb pain sensation may be absent, forming a painless diabetic foot.
Necrotic phase: It is the main reason for patients to visit the clinic. Some patients start with a mere foot ulcer, which does not heal for a long time and then develops into gangrene.
What is the clinical classification of diabetic foot?
A: There are six grades based on the depth and extent of lesions.
Grade 0: No open lesions, but there are obvious signs of inadequate blood supply on examination, such as significantly weakened dorsalis pedis artery pulsation;
Grade 1: superficial ulcers, which can be caused by water scars or other injuries, or spontaneous;
Grade II: Ulcer formation, deep to tendons, ligaments, bones and joints;
Grade III: deep ulcerated infection with osteomyelitis and pus ulcer sinus formation;
Grade IV: gangrene of the toes and/or part of the foot;
Grade V: gangrene of the entire leg, usually requiring amputation.
I am a diabetic foot patient. Before I got the disease, I thought I was in good health and had no symptoms of diabetes such as dry mouth, thirst, eating too much and losing weight. Please tell me, doctor, why is this? How can I detect it early?
A: The situation you described is very representative, in clinical practice, a considerable number of patients are first found diabetic foot, and only later know that there is diabetes, this is why? Because there are two types of diabetes, namely type 1 diabetes and type 2 diabetes, the so-called typical manifestations of diabetes: three more and one less – more drinking, more eating, more urination, weight loss – common in type 1 diabetes or part of type 2 diabetes, while type 2 diabetes early mostly lack symptoms, but already have enough hyperglycemia to cause chronic complications and can be asymptomatic for a long time before being diagnosed. This is the reason why many patients only discover diabetes when the complications have already appeared. The only way to achieve early detection of diabetes is to have regular medical checkups and blood glucose tests. The diagnosis of diabetes is based mainly on blood glucose values, not clinical symptoms. The main factor in the formation of chronic complications of diabetes is hyperglycemia, so laboratory blood glucose testing, early diagnosis of diabetes and active control of blood glucose are important aspects of controlling complications.
What tests should diabetic patients have to do for early detection of diabetic foot?
A: Diabetic patients have a high probability of complications of diabetic foot, so diabetic patients should routinely perform examinations about diabetic foot, the most basic examinations are mainly the following two aspects
(1) Vascular examination: color ultrasound Doppler of lower extremity arteries: non-invasive, accurate, better showing plaque site, size and quantity. Ankle/brachial artery blood pressure ratio (ABI) and microcirculation examination.
(2) Electromyography: to understand the condition of peripheral nerves, which is very valuable for the diagnosis of diabetic peripheral neuropathy. Both tests are noninvasive, simple, and painless, and are ideal for the initial diagnosis of diabetic foot.
What tests do I need to do if I already have a diabetic foot?
A: Patients who have been diagnosed with diabetic foot and have developed gangrene need further tests to understand the condition, determine the prognosis and guide treatment. Commonly used tests
(1) X-ray: It can detect osteoporosis, decalcification, osteomyelitis, bone destruction, osteoarthrosis and arteriosclerosis, as well as gas gangrene and soft tissue changes in the extremity after infection, which are of diagnostic importance for gangrene of the extremity.
(2) MRI angiography: the diagnosis rate of osteomyelitis is close to 100%, and it can clearly show the site and degree of arterial obstruction, which is more intuitive and more accurate than Doppler examination.
(3) Selective angiography: It can accurately reflect various lesions in the lumen of blood vessels.
(4) Culture of gangrenous secretions + drug sensitivity test: to guide the clinical use of antibiotics.
(5) Blood examination: including routine blood, blood lipid, blood sugar, blood rheology, coagulation factors and other examinations, which provide the basis for clinical internal medicine treatment.
How to prevent diabetic foot?
A: Clinically, only 20% of the cases of DF are completely caused by ischemia. The reason why it is difficult to treat or even not treated is that patients lack knowledge of the disease and treat it as a general ulcer without paying attention to it. Therefore, strengthening knowledge propaganda is an important means to prevent DF, and active control of blood sugar, prevention of trauma, early treatment and control of infection are the keys to achieve satisfactory results. Education of diabetic foot has been paid more and more attention and taken as one of the important means of treatment. Patients and family members should understand the knowledge and treatment requirements of diabetes, learn dietary therapy, master the use of hypoglycemic drugs, maintain a regular life, pay attention to personal hygiene, prevent various infections, insist on participating in appropriate physical exercise or labor, and avoid or reduce obesity to improve the metabolic status and islet cell reserve function.
The active protection of diabetic foot is the key to improve the quality of life. The following points should be noted.
Actively treat diabetes and stabilize blood glucose: controlling diabetes and stabilizing blood glucose is the basis for preventing and treating its complications, and health education should be provided to diabetic patients to make them understand the relevant knowledge so that they can actively cooperate with the treatment.
Prevention and treatment of arteriosclerosis: Diabetic patients are prone to arteriosclerosis, which is the basis of limb ischemia in diabetic patients. Active dietary control, moderate physical activity and medication can help prevent its occurrence and development.
Avoid limb trauma: As a physician, you should remind your patients that a diabetic patient can lose a limb or even his or her life because of an ill-fitting pair of shoes. Patients should always be alert to prevent any kind of trauma to the limb, including very minor burns. Even skin trauma that is insignificant to a normal person should be taken seriously and treated aggressively and correctly to prevent complications of infection that could lead to serious consequences. In addition, strict prohibition of smoking and active prevention and treatment of microvascular and neuropathy are equally important.
I am a diabetic foot patient and I have heard from my doctor that exercise can help lower my blood sugar, but because of my foot disease, my doctor said that I should not walk long distances, so should I exercise? How should I master it?
A: For diabetic patients, exercise is one of the basic treatments for diabetes. Proper exercise can make light diabetic obesity reduce weight, help skeletal muscle increase sugar utilization, improve pancreatic function, increase tissue sensitivity to insulin, lower blood lipids, and improve cardiopulmonary function. For patients with combined chronic ischemia of the lower extremities, moderate exercise can also increase collateral circulation and improve lower extremity ischemia. However, diabetic foot patients are mainly in the foot, walking feet to withstand a variety of forces, so it is easy to be injured, so it is not appropriate to walk long distances. So should diabetic foot patients exercise? How should they exercise? First of all, for diabetic foot patients, reasonable exercise is indispensable, but it should be scientific and individualized.
This requires a comprehensive physical examination under the guidance of a doctor, to understand the condition, according to the specific circumstances of the patient to choose the appropriate individual exercise program, including exercise intensity, type, duration, that is, frequency and so on. Secondly, try to choose exercise programs that do not require foot weight or less weight, such as aerobics, swimming, bicycling, etc. Third, master the principle of gradual progress, each exercise amount to the patient does not appear discomfort as moderate. Fourth, master the principle of exercise in small amounts and many times. Fifth, the shoes and socks worn during exercise should be the same as the feet, soft and breathable texture, so as not to squeeze or wear the feet.
What kind of disease does diabetic foot belong to? What should I see if I want to be treated?
A: Diabetic foot is an interdisciplinary disease, the primary cause is endocrinopathy, and when the lower extremity arteriosclerosis and foot gangrene appear, it belongs to the vascular surgery. Therefore, most western hospitals endocrinology department is good at the treatment of the primary disease, and also apply some drugs to improve circulation and anti-infection, but the patient often seems helpless to gangrene; while surgery mainly adopts the method of amputation of toes and limbs for treatment, paying less attention to systemic treatment.
Therefore, diabetic foot patients always have a feeling that they cannot get comprehensive treatment in that department. In terms of the pathological changes of diabetes mellitus, it is mainly vascular lesions, and neuropathy is actually related to vascular lesions, therefore, the peripheral vascular surgery department established in recent years has included this disease in the scope of treatment of this department, whose advantage is to diagnose and treat the disease from the perspective of pathology, attaching importance to systemic treatment, but also long on local treatment, and if necessary, will apply the expertise of surgery and interventional surgery to open large blood vessels, and then with Chinese medicine This is a very thoughtful treatment. Therefore, if you are treating diabetic foot, it is best to choose peripheral vascular surgery.
What are the aspects of systemic treatment for diabetic foot?
A: (1) Treatment of diabetes and its complications: It is extremely important to control blood sugar and prevent and treat complications. For elderly people over 70 years old and patients with poor glycemic control by oral medication, with severe infections, complications of ketosis, and preoperative surgery, insulin therapy should be given.
(2) Control infection: systemic administration is required, antibiotics should be selected according to drug sensitivity, high dose, and drugs with serious damage to kidney should be used with caution or not.
(3) Improving circulation: this is the core aspect of treating diabetic foot, and is also the treatment method to be carried out all the time, including: dilating blood vessels and relieving vascular spasm; lowering lipid, lowering fiber, anticoagulation and antiplatelet; Chinese herbal medicine to activate blood circulation and remove blood stasis; and vascular reconstruction surgery.
(4) Improving nerve function: controlling blood sugar is the key, and improving microcirculation and applying neurotrophic agents are the basic principles.
What should be noted in the local treatment of diabetic foot?
A: (1) Dry gangrene: the main focus is to protect the wound surface clean and dry, to prevent injury, wet soaking and infection.
(2) Wet gangrene: The local treatment of wet gangrene is a critical part of the overall treatment of diabetic foot.
Phase I: Local redness, swelling and heat, abscess formation, to create the principle of decompression, the purpose is to make the pus rot out and prevent involution.
Phase II: After anti-inflammatory treatment, local redness, swelling, heat and other inflammatory reactions are controlled, and necrotic tissues are gradually removed by nibbling method by adopting batch debridement.
Phase III: After phase II treatment, necrotic tissue is basically removed and granulation tissue grows at the base, and the principle of improving local blood circulation and promoting granulation growth is adopted.
Phase IV: Granulation growth is good and epithelium starts to crawl, in order to continue to improve the circulation, with the shape of the wound trimmed to help the epithelium crawl and promote the healing of the wound.
What are the specific treatment means for diabetic foot?
A: 1. General treatment
(1) Health education and good care.
(2) Support symptomatic treatment: including restricting activities, reducing weight-bearing and elevating the affected limb to facilitate blood flow return to the lower limb.
(3) Strict control of blood glucose, active correction of hypoproteinemia, edema and other unfavorable factors affecting gangrene healing.
(4) Local debridement, placement of drainage, disinfection, selection of suitable dressings according to the size of the ulcer, the amount of exudation, and whether it is combined with infection, and maintenance of local humidity and temperature of the wound.
2.Treatment of neuropathic foot ulcers: change the pressure on the patient’s foot by special orthopedic shoes or orthoses. Full contact brace.
3.Nutritional nerve treatment: B vitamins, nerve growth factor, etc.
4.Treatment of ischemic lesion: conservative medical treatment (vasodilation, inhibition of platelet aggregation, reduction of fibrinogen and lipids, etc.) if the vascular lesion is not serious and no surgery is indicated. For severe vascular lesions: interventional treatment, arterial reconstruction and amputation on the basis of conservative treatment.
5.Hyperbaric oxygen therapy
6.Anti-infection treatment: For patients with combined infection, bacterial culture should be taken from the secretion before local treatment, and effective antibiotics should be selected according to the results of drug sensitivity test.
7.Surgical treatment: including debridement, suturing, skin grafting and toe amputation (limb), etc.
8.Intracavitary treatment
The advantages of intracavitary treatment are obvious: diabetic foot vasculopathy is characterized by atherosclerosis of the lower limb vessels, often involving several arteries of both lower limbs, among which the tibiofibular artery of the lower leg is the most common (including the anterior tibial, posterior tibial and peroneal arteries). Because of the small diameter of the lower leg vessels and the large number of branches, once the narrowing or occlusion occurs, conventional surgical bypass treatment is often ineffective, and the chance of postoperative restenosis and re-occlusion is high, so the long-term results are not very satisfactory. Interventional treatment is a minimally invasive procedure, and interventional techniques for hemodynamic reconstruction are less invasive, have faster recovery, and have better results. The application of small balloons designed for tibiofibular artery lesions in the treatment of diabetic vascular lesions can achieve more satisfactory results.
The small balloon for the calf vascular lesion is small and long, thick at one end and thin at the other, which is very consistent with the anatomical characteristics of the calf vessels. For patients whose arteries in the lower leg are not completely occluded and who meet the indications for treatment, this small balloon is used to dilate, unblock and shape the arteries as far as the dorsalis pedis artery, so that the ischemic limb can be improved. The effect of this treatment is immediate. After the procedure, the skin temperature increases, the blood supply improves significantly, the pulsation of the dorsalis pedis artery is enhanced, and the symptoms of numbness and pain in the affected limb can be significantly relieved, and it is characterized by no incision, less pain, relative safety, and fewer complications.