Diabetic foot is a disease state in which ulcers and gangrene occur in the lower extremities of diabetic patients due to neuropathy that decreases the protective function of the lower extremities, and macrovascular and microvascular lesions that cause inadequate arterial perfusion resulting in impaired microcirculation. Diabetic foot is a serious complication of diabetes, and is one of the major causes of disability and even death in diabetic patients, which not only causes pain to patients, but also adds a huge economic burden to them.
In addition to routine physical examination, diabetic patients should pay special attention to the signs of the foot.
Such as the patient’s walking gait, the presence of foot deformities such as eagle claw foot and toe exostosis, muscle atrophy, callus; skin temperature, color and sweating, observe the skin for blisters, cracks and ruptures; check the skin sensation of temperature, pressure and vibration (tuning fork vibration sensation); palpate the dorsal foot artery for weakening or loss of pulsation, vascular murmurs can be heard at the arterial stenosis; carefully percussion tendon reflexes such as the knee reflex and ankle reflex, for example, are diminished or absent.
Symptoms.
At the beginning of the disease, patients mostly have itchy skin, cold extremities, dull sensation, edema, followed by persistent numbness in the form of garters in both feet, most of them may have hyperalgesia or loss of pain, a few of them have pinprick-like, knife-like or burning pain in the affected area, which is aggravated at night or in the presence of heat, and the duck walks or leans on a cane. Some elderly patients are accompanied by a history of severe limb ischemia, such as intermittent claudication and resting pain.
Physical signs.
In chronic ulcers of the foot, round penetrating ulcers form on the metatarsal region of the foot, outside the metatarsal heads. Sometimes there are ligament tears, small fractures, bone destruction, and Charcot (Charcot) joints. In dry gangrene, the whole foot and toes are dry and small, the skin is shiny, thin, and pale red, and a variable number of black dots and spots are seen in the marginal area of the toe tips. In wet gangrene, the foot becomes red, swollen, and the skin breaks down, forming ulcers or abscesses of varying size and depth, with necrosis of the skin, blood vessels, nerves, and bone tissue.
Once the diabetic foot has occurred, the condition should be evaluated as clearly as possible before treatment: determine the etiology; determine the type and extent; evaluate vascular patency by physical examination or Doppler; examine secretions and perform bacterial and drug sensitivity tests promptly; evaluate peri-ulcer edema, inflammation and necrosis; X-ray for osteomyelitis and subcutaneous gas; exclude systemic infection, etc. Select appropriate systemic treatment, local treatment or surgery according to the condition.
I. Systemic treatment:
Generally includes metabolic control, vasodilation, blood circulation and blood stasis, and application of antibiotics (if infection is present).
1, metabolic control.
It mainly refers to good control of blood sugar. Poor control of blood sugar is not conducive to the healing of ulcers and control of infection. The occurrence of diabetic foot ulcers, especially the stress caused by combined infections, etc. can further increase blood glucose, and generally need to switch to insulin therapy and keep blood glucose control within the ideal range as much as possible, which is the basis for the treatment of diabetic foot. Blood glucose should be controlled below 11.1mmol/L or as close to normal as possible.
2.Dilate blood vessels and activate blood stasis to improve tissue blood supply.
The following are often used clinically.
①Low-molecular dextrose 500ml or with salvia 10-20ml, intravenous drip, 1 time/d.
②Scopolamine, general dose 0.5~1.5mg/kg, oral in mild cases, intravenous in severe cases.
(iii) Closure of lumbar 2, 3 and 4 sympathetic nerves to relieve vasospasm of the lower limbs.
④Prostaglandin E intravenous injection, which has a good vasodilating effect.
⑤ Anti-platelet drugs such as cilostazol (PEDA) has good peripheral vasodilating effect while anti-platelet, which has good adjuvant effect on diabetic foot ulcers, and other drugs such as Salvia and Chuanxiong can also be used supplementally.
Treatment of neuropathy: vitamin B preparations can be applied and neurotrophic drugs can be applied to improve nerve function.
3.The use of antibiotics.
Diabetic foot ulcers are often prone to secondary infection, and the rapid deterioration of the condition is an important cause of foot gangrene, given that the infection is often a multi-strain mixed infection, and often combined with anaerobic bacterial susceptibility infection, some patients can be clinically asymptomatic and hematological infection features even if there is a serious lower limb infection. In general, broad-spectrum antibiotics and metronidazole should be given in cases where the pathogenic bacteria are unknown, and treatment should be adjusted if necessary after the bacterial and drug sensitivity test results are reported.
Hyperbaric oxygen therapy: It can improve blood circulation and lower limb hypoxia and can be tried.
Local treatment:
It mainly includes local debridement and wound treatment.
1. Debridement.
There are still some controversies, but most advocate adequate debridement, incision and drainage of the infected foci. The debridement should be extended to the healthy tissue with bleeding, and all necrotic tissues should be removed to protect the tendons and ligament tissues with vitality as much as possible; the gangrene with small mouth cavity should be enlarged; multiple incisions should be made for multiple cystic abscesses to keep the drainage unobstructed. Small debridements can be performed bedside, but most cases may require a trip to the operating room under anesthesia.
Local blisters and hemorrhagic blisters should be treated with sterile syringes under strict disinfection, and their contents should be withdrawn from the low level of the blisters and localized with 2.5% iodine to prevent infection, and local pressure should be applied appropriately to dry them out.
2. Trauma treatment.
Adhere to daily drug changes, local application of antibiotics, insulin and scopolamine (654-2) mixture (such as 5% saline 250-500ml and human insulin 40U and gentamicin 240,000 U or other antibiotics and scopolamine (654-2) injection 40mg) for cleaning and wet dressing, where insulin can improve the function of leukocytes, stimulate epithelial cells The local application of insulin can improve the function of leukocytes, stimulate the growth of epithelial cells and fibroblasts and protein synthesis, which is beneficial to the healing of wounds; the local application of antibiotics can enhance the effect of anti-infection; the local application of scopolamine (654-2) can improve blood circulation. Exposure without bandage as much as possible during daytime, bandage is feasible at night to avoid damage; mechanical padding to reduce weight-bearing of ulcer site, bed rest and use of special shoes, etc.; in addition, local irradiation by Chowlin spectrometer or light bulb is helpful to keep the wound dry and improve blood circulation for half an hour each time, 3 to 4 times a day; elevation of the affected limb is helpful to reduce local edema (ulcer of any cause, as long as there is edema, the ulcer is not easy to healing), supplemented with diuretics if necessary. Recently, it has been reported that the application of Kangwyl diabetic foot series of wound care products (debridement gel, exudate absorption paste and ulcer paste, etc.) helps to remove necrotic and decaying tissue from the trauma, enhance exudate absorption of local tissues, promote the growth of granulation tissue and accelerate the absorption of trauma.
Surgical treatment:
1.Arterial reconstruction.
It is an important method for treating ischemia or gangrene of the extremity caused by large vessel obstruction, which can save some patients from amputation. Methods are.
① vascular bypass surgery: vascular patency rate of about 60%, commonly used method is vascular bypass diversion, that is, a section of the normal blood supply artery segment and the distal non-stenotic artery of the diseased vessel between the erection of an autologous or artificial vascular bridge, in order to improve the distal blood supply to the limb.
(ii) Endovascular resection: for large vessels and limited arterial obstruction and stenosis.
(iii) Percutaneous transluminal endovascular angioplasty: better for iliac artery occlusion.
④Endovascular laser treatment.
⑤ Large omental graft with tissues is commonly used for anterior tibial, posterior tibial and peroneal artery occlusions.
2. Amputation.
After conservative treatment is ineffective, in order to save the life of the method of last resort, the best preoperative angiography to determine the amputation plane, without affecting the healing of the amputation plane, should try to preserve the function of the affected limb after surgery and conducive to the installation of prostheses.
3.Bone marrow stem cell transplantation.
Bone marrow stem cells have the function of directional differentiation into various cells needed by human body, and basic and clinical research found that transplanting bone marrow stem cells into ischemic limbs can form vascular endothelial cells locally and produce neovascularization without generating other unwanted tissues. in August 2002, the British Medical Journal first reported the success of autologous bone marrow stem cell transplantation for lower limb ischemia. The method is mainly as follows: bone marrow is obtained under local anesthesia, followed by isolation of bone marrow stem cells, for which mature techniques are available, and finally the isolated bone marrow stem cells are transplanted into the ischemic limb. This method is applicable to all diabetic patients with limb ischemia (equally effective for non-diabetic patients), from early intermittent claudication to late foot ulcers and even limb necrosis, and generally the earlier the course of treatment the better the effect, early treatment can alleviate or completely relieve intermittent claudication and resting pain, and in patients with diabetic foot ulcers can promote ulcer healing or shrinkage, etc. The method is relatively simple to operate, and the efficacy is more certain, which is worthy of further clinical observation and research.