The diabetic foot is one of the most serious and costly chronic complications of diabetes, which can lead to amputation in severe cases, causing serious impact and burden to patients, their families and society. The relative risk of lower limb amputation in diabetic patients is 40 times higher than in non-diabetic patients. About 85% of amputations are caused by foot ulcers, and about 15% of diabetic patients will develop foot ulcers during their lifetime. Therefore, prevention and treatment of foot ulcers can significantly reduce the rate of amputation.
Diabetic foot pathogenesis factors include.
1, neuropathy: sensory, motor and autonomic neuropathy;
2.Vascular lesions of the lower extremities;
3, microcirculatory disorders;
4, immune disorders and infections;
5, reduction of insulin growth factor-1 (IGF-1) in the skin that promotes skin growth. Among them, mainly lower limb vascular lesions and neuropathy.
Clinical manifestations: The signs and symptoms of diabetic foot vary depending on the course of the disease and the severity of the lesion.Wagner’s diabetic foot grading system is divided into grades 0 to 5. Grade 0: refers to the presence of risk factors for ulceration, including: peripheral neuropathy, autonomic neuropathy; lower limb vascular disease; previous history of foot ulceration and/or amputation; foot deformity, such as eagle claw foot, Charcot foot; combined with callus or “corns”; blindness or severely reduced vision; combined smoking, hypertension, hyperlipidemia, high risk factors for renal pathology, especially chronic renal failure; elderly people or people who cannot observe their own feet, especially those who live alone; patients with poor glycemic control; people who lack knowledge of diabetes.
Grade 1: Skin surface ulcers on the feet, but no manifestation of infection. The ulcers tend to occur on prominent parts of the foot, such as the heel, foot or bottom of the foot, and the ulcers are mostly surrounded by calluses.
Grade 2: Exhibits deeper penetrating ulcers, often combined with soft tissue infection, but without osteomyelitis or deep abscesses.
Grade 3: Deep ulcers often affect bone tissue and have deep abscesses or osteomyelitis.
Grade 4: manifests as an ischemic ulcer with gangrene, often combined with neuropathy without severe pain, and the surface of the necrotic tissue may be infected. grade 5: gangrene affects the entire foot, with extensive and severe lesions, some of which develop rapidly.
The main diagnostic methods for diabetic foot are.
1, examination of neuropathy, such as 10 can nylon wire examination, tuning fork examination of vibration sensation, two-point discrimination sensation with a needle, tactile sensation with cotton wool, heel reflex, etc.
2, the easiest way to check the arterial lesions of the lower extremities is to use the hand to touch the pulsation of the dorsal foot or posterior tibial artery to understand the large-vessel lesions of the foot, and the disappearance of fluctuations suggests serious large-vessel lesions, requiring the next step of examination, including: segmental limb blood pressure, ankle/brachial index (ABI) reflects the blood pressure and vascular status of the lower extremities, with normal values of 1.0-1.4, 0.9 for mild ischemia, 0.5~0.7 is moderate ischemia, 0.5~0.5 is severe ischemia; transcutaneous partial pressure of oxygen (TcPO2) measurement reflects the state of microcirculation and also the blood supply of peripheral arteries; vascular ultrasound examination: to clarify whether there is stenosis or occlusion of blood vessels through examination; angiography or vascular CT: to understand the degree and location of lower limb vascular occlusion, to provide a basis for amputation plane or angioplasty surgery.
3, ulcers combined with infection, commonly used probe probe suspected of infected ulcers, such as the discovery of sinus tracts, probe and bone tissue, to consider osteomyelitis; while using the probe to take a specimen of deep ulcers for bacterial culture, to increase the specificity of the culture of infected bacteria. Deep infection or bone lesions can also be identified by X-ray plain film, isotope scan or magnetic resonance examination.
The prevention and treatment of diabetic foot is mainly integrated medical and surgical treatment, including the following aspects.
1, the prevention of diabetic foot
① Wash your feet daily with warm water (<37℃) and warm soap for <5 minutes;
② dry towel dry, especially between the toes;
③Apply moisturizer to dry skin, avoid between the toes; do not use talcum powder;
④Check carefully for skin lesions after washing the feet; seek medical advice promptly; ⑤Do not treat or trim the lesions yourself;
⑥ Wear appropriate shoes and socks, do not walk barefoot, avoid foot trauma;
(7) Do not use hot water bags or electric blankets and other heat sources to warm the feet; use thick towel socks;
(8) Do calf and foot exercises daily;
⑨ Once a year, the foot is examined by a specialist, including sensation and vascular pulsation.
2, the treatment of peripheral neuropathy: commonly used aldose reductase inhibitors, anti-glycosylation agents, antioxidant scavenging free radicals, nerve growth factor and hyperbaric oxygen and special model shoes, etc.
3, the treatment of lower limb vascular lesions: general drug therapy including vasodilator drugs, antiplatelet drugs, anticholinergic drugs, limb hyperbaric oxygen and antithrombotic therapy, for severe stenosis or even occlusion of the blood vessels, minimally invasive interventional angioplasty, vascular bypass surgery or minimally invasive interventional + vascular bypass graft hybrid surgery to restore linear blood flow in the lower limbs.
4.Foot ulcer treatment: local decompression, debridement of the wound and selection of appropriate drug dressing, and selection of effective antibiotics for treatment on the basis of bacterial culture.
5, complete occlusion of blood vessels is difficult to revascularization or serious infection conservative treatment is ineffective and life-threatening, the need for amputation treatment.
6.Stem cell transplantation is a new treatment method for lower limb vascular lesions and diabetic foot developed in recent years, which is still in the research stage and not widely used in clinical practice.