Early discharge without accepting treatment by a young diabetic patient
A 28-year-old man with type 1 diabetes mellitus for 18 years attended the casualty department complaining of a painful foot. He was well known to the hospital and was addicted to crack cocaine. He had severe infection of the left hallux, and deep, infected ulcers over both 1st metatarsal heads Fig. 5.27 . He was admitted to the ward for intravenous antibiotics and possible surgical debridement but walked off the ward 2 h later before treatment was started and was lost to follow-up. Three weeks...
Improper use of a rubber band
A 25-year-old man with type 1 diabetes of 15 years' duration presented with a painful nail sulcus and underwent removal of a spike of nail. The toe was dressed with Fig. 4.12 A ring of superficial necrosis around the toe following use of a tight rubber band to hold a dressing on the toe. Fig. 4.12 A ring of superficial necrosis around the toe following use of a tight rubber band to hold a dressing on the toe. Melolin and Tubegauz and he was advised to attend his practice nurse for dressings and...
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Fig. 8.33 Lisfranc amputation, a Initial presentation with a non-healing wound at the site of prior amputation of the 2nd toe, right foot, b Multiple draining plantar ulcers with sinus tracts, c Completed repair with a long dorsal flap and short plantar flap, d Healed Lisfranc amputation right foot, compared to transmetatarsal amputation of the left foot. Part d from Sanders 1997 with permission from Elsevier Science. underwent a Chopart's amputation of his left foot. In an effort to prevent...
Mobility aids
Before the definitive prosthesis is issued, some patients may be suitable for mobility aids. The amputee mobility aid AMA is suitable for below-knee and through-knee amputees only. The stump is supported and stabilized by an inflatable bag, which also assists in reducing oedema. It is a physical and psychological boost to get the patient on his feet early. It has a knee joint. The pneumatic postamputation mobility aid PPAM aid has an inflatable socket and is suitable for above-knee,...
Advances In Diabetic Foot Care
The diabetic foot has become a major area of interest, and insight has been gained into the reasons why diabetic feet go wrong and the ways in which patients can be helped. Of all the complications of diabetes, the diabetic foot is probably the easiest to prevent and treat. The groundswell of interest in the diabetic foot surged in the 1980s, and developments in foot care included the setting up of multidisciplinary diabetic foot clinics Fig. 6 and the pioneering educational work of Jean...
Wet necrosis Ffb
The microbiological principles of managing wet necrosis are similar to those for the management of infection of the foot with extensive soft tissue infection or the foot with blue discolouration as described in Chapter 5. When the patient initially presents, deep wound swabs and tissue specimens are sent off for microbiology. Deep tissue taken at operative debridement must also go for culture. Intravenous antibiotic therapy Both neuropathic and neuroischaemic patients need parenteral therapy....
Pressure index
The pressure index is widely criticized because, when the arteries are calcified, it may be artificially raised. However, we feel that it is very relevant to the investigation of the diabetic foot as long as the potential difficulties of its interpretation are understood. If the pressure index is 0.5 then it is truly low, and indicates severe ischaemia whether the arteries are calcified or not. Indeed, if the artery is calcified the true pressure index may be even lower and even more urgent...
Management 1
Stage 2 feet require multidisciplinary care. The following components of multidisciplinary care are important at stage 2 Wound control and microbiological control are not needed as the feet have intact skin. To maintain mechanical control, deformity must be accommodated by footwear and callus, dry skin and fissures treated. Common non-diabetic foot problems, already described in stage 1, will also occur in stage 2 feet and need management as described in Chapter 2. Deformities in the...
Prologue
He's both their parent and he is their grave, And gives them what he will, not what they crave. Pericles, Prince of Tyre, II, iii, William Shakespeare Fig. 1 Foot from the UK. This 85-year-old man with type 2 diabetes of 8 years' duration received regular dressings of his ulcerated ischaemic foot for 9 months, but was not referred until extensive gangrene had developed. Fig. 2 Foot from Ukraine. This 48-year-old man with type 2 diabetes of 12 years' duration trod on a nail and developed severe...
Causes of necrosis
Necrosis can be due to infection, when it is usually wet, or to occlusive macrovascular disease of the arteries of the leg, when it is usually dry. Necrosis is not, as previously thought, due to a microangiopathic arteriolar occlusive disease, or so-called small vessel disease. Health-care professionals working with diabetic foot disease should avoid using this term, which is imprecise and may lead to therapeutic nihilism. Digital necrosis is common in patients with renal impairment,...
Historical Background
The last century made great inroads into improving the management of diabetes. The early work of pioneers such as Nicolas Paulesco in Rumania and Georg Zuelzer in Germany culminated in the work of Banting, Best, Collip and Macleod in Canada who produced a pancreatic extract which was used successfully in patients and ended the Fig. 6 International visitors at the King's Diabetic Foot Clinic left to right, Dr Kamenov Bulgaria , the Authors, Dr Harkless USA and Dr Plamen Bulgaria . Fig. 7 The...
CASE STUDY Qft
A 23-year-old woman with type 1 'brittle' diabetes of 12 years' duration, underwent a sural nerve biopsy which failed to heal for 3 months, but healed in 1 week under a tamper-proof dressing. She returned to clinic 3 months later with an ulcer on the dorsum of her foot. Parts of the ulcer bed had unusual morphometry with straight edges as shown in Fig. 4.40. It was thought that she might have an allergy to the dressing used and she was referred to the dermatologists. They did a patch test,...
Gas gangrene diagnosed from culture of tissue
A 65-year-old man with type 2 diabetes of 23 years' duration and chronic ischaemia developed four necrotic toes following an episode of infection which was treated in hospital with intravenous antibiotics. Vascular intervention was not feasible and the toes were treated conservatively, with treatment consisting of pain control with liberal analgesia, oedema control with diuretics, infection control with oral antibiotics, and wound control with Fig. 6.17 a The proximal portion of this necrotic...
Vascular control Gwr
Calle-Pascual AL, Duran A, Diaz A et al Comparison of peripheral arterial reconstruction in diabetic and non-diabetic patients a prospective clinic-based study. Diabetes Res Clin Pract 2001 53 129-36. Cohen MC, Curran PJ, L'Italien Gl et al. Long-term prognostic value of preoperative dipyridamole thallium imaging and clinical indexes in patients with diabetes mellitus undergoing peripheral vascular surgery. Am J Cardiol 1999 83 1038-42. Deery HG, Sangeorzan JA. Saving the diabetic foot with...
Ulcer with local signs of infection
Local signs that an ulcer has become infected include any or all of the following Base of the ulcer changes from healthy pink granulations to yellowish or grey tissue Increased friability of granulation tissue Fig. 5.4 Increased amount of exudate Fig. 5.5 Exudate changes from clear to purulent Fig. 5.6 A deep sinus has appeared in the base of this ulcer. Fig. 5.6 A deep sinus has appeared in the base of this ulcer. Sinuses develop in an ulcer Fig. 5.6 Edges may become undermined so that a probe...
Artefactual ulcers
Some patients cause ulcers by pulling skin off their feet Fig. 4.39 or applying noxious substances, or prevent ulcers from healing. The patients we have seen have been young and mostly female, and have suffered in the past from eating disorders or 'brittle' diabetes. Fig. 4.38 a This patient developed necrosis on the front of the ankle from a bandage which became too tight when her oedema increased, b A close-up view of the iatrogenic lesion shown in a . The conventional bandage was replaced...
Decubitus ulcers
Decubitus ulcers, which develop when the foot is exposed to unrelieved pressure, are common on the diabetic foot and especially on the heel. Patients who have been ill or immobilized are particularly vulnerable. Decubitus ulcers can develop in a short time. Contributing causes include Foreign bodies in the bed biscuit crumbs, etc. Patients attempting to move in the bed by putting excessive pressure on the heels Sliding down the bed so that feet are in contact with bed end.
Mallet toe correctiondistal interphalangeal joint arthroplasty
Mallet toe correction is indicated for lesions that develop at the tip of the toe. In the presence of mallet toe deform Fig. 8.5 Surgical correction of hammer toe deformity, a Preoperative appearance of a rigid hammer toe, 2nd toe, right foot. Notice the very prominent deformity at the proximal interphalangeal joint, b The extensor digitorum longus Fig. 8.5 Surgical correction of hammer toe deformity, a Preoperative appearance of a rigid hammer toe, 2nd toe, right foot. Notice the very...
Case Study On Diabetic Foot Care
A 78-year-old man with type 2 diabetes of 5 years' duration was referred with a discharging subungual ulcer on his right hallux which had been present for 8 years. Pedal pulses were palpable. The footwear was narrow and insufficiently roomy, and he was asked to purchase shoes with a deep toe box which would not cause pressure on the nails. The toe nail was cut back. The patient wore suitable shoes, and the ulcer improved, with less discharge, but Fig. 4.43 This subungual ulcer failed to heal...
Neuroischaemic foot 1
In the neuroischaemic foot, wet necrosis should also be removed when it is associated with severe spreading sepsis. This should be done whether pus is present or not. However, where necrosis is limited to one or two toes in the neuroischaemic foot we avoid surgery where possible until vascular intervention has been achieved. If angioplasty or arterial bypass is not possible, then a decision must be made either to amputate the toes in the presence of ischaemia or allow the toes, if infection is...
Acknowledgements
Ali Foster and Mike Edmonds offer special thanks first to their co-author, Lee Sanders, who contributed the chapter on surgical management of the diabetic foot and also cast a critical and helpful eye over the other chapters giving an American perspective. His advice was invaluable. For sections of the chapter on the management of diabetic major amputees we owe a great deal to Christian Pankhurst and Alan Tanner for details of prosthetic and orthotic management. We are also grateful to Rosalind...
Management
The aim of management is to ensure that Patients do not develop risk factors for diabetic foot ulceration If risk factors do develop, they are detected early and patients placed in stage 2 Common foot problems that can occur in the general population are efficiently treated and do not lead to tissue breakdown even in the absence of neuropathy and vascular disease. The following components of multidisciplinary management are important for stage 1 patients. To encourage the use of suitable...
Wet necrosis with rapid onset
A 73-year-old Afro-Caribbean woman with type 2 diabetes of 30 years' duration, peripheral vascular disease and a previous below-knee amputation attended the diabetic foot clinic with a 2-cm broken blister on her left heel. She was obese and confined to a wheelchair. She did not want to take antibiotics and said she would prefer not to have visits from the district nursing service as her daughter, with whom she lived, would look after the foot. Her daughter was carefully taught to clean and...
th metatarsal head resection
An 80-year-old active man with peripheral neuropathy and loss of protective sensation presented to clinic with a prominent, painful tailor's bunion that could not be satisfactorily accommodated by footwear. The patient had a 5th metatarsal head resection performed 2 years earlier, for correction of a similar condition affecting his right foot. He was very satisfied with the results and returned for surgical correction of his left foot. The surgical procedure and postoperative course were...
Fear of gangrene
Some patients and their families find necrotic feet deeply upsetting. The use of the word 'gangrene' can distress and frighten some patients. It should be explained that just because a small area of the foot has developed necrosis it does not mean that the whole foot will be destroyed or that amputation is inevitable. The health-care practitioner should never express distaste or disgust. If he does not know the patient well, then before the foot is uncovered he should ask whether the patient...
Key points
Angioplasty is the first-line treatment for peripheral Fig. 4.18 The left foot is cold, red and ischaemic at presentation. Fig. 4.18 The left foot is cold, red and ischaemic at presentation. arterial disease in the diabetic limb, where the intention is to obtain straight line arterial flow to the foot Measuring the pressure index may be impossible in patients on haemodialysis with fistulas TcPo2 is a useful alternative method of quantitating ischaemia in these circumstances.
Neuropathic foot 1
In the neuropathic foot, operative debridement is almost always indicated for wet gangrene. The main principle of treatment is surgical removal of the necrotic tissue, which may include toe or ray amputation removal of toe together with part of the metatarsal or, rarely, trans-metatarsal amputation. Although necrosis in the diabetic foot may not be associated with a definite collection of pus, the necrotic tissue still needs to be removed. Fig. 6.13 Wet necrosis of the hallux with cellulitis...
Local signs of infection not noted by patient
A 53-year-old lady with type 1 diabetes of 25 years' duration, proliferative retinopathy with reduced vision, peripheral neuropathy and hallux rigidus developed a neuropathic ulcer under callus on the plantar surface of her right hallux. She was warned of the usual danger signs of deterioration redness, warmth, swelling, pain, purulent discharge but did not return to clinic until her routine appointment. Callus had grown over the ulcer preventing drainage and the toe had become cellulitic Fig....
Open transmetatarsal amputation
Extensive forefoot infection or gangrene that extends on to the plantar skin may preclude a standard forefoot or mid-foot amputation. In these cases, an open or guillotine amputation performed at the mid-metatarsal level may be required. Guillotine amputations have a major disadvantage, in that they require extensive revision. A better alternative is to fashion flaps in the usual manner but to leave the wound open, with the intent to perform a delayed primary closure. The main disadvantage of...
Delayed presentation of infection masked by callus
A 72-year-old woman with type 2 diabetes of 20 years' duration and peripheral neuropathy developed 'a dark spot' on the apex of her right 3rd toe and applied sterile gauze which was replaced at weekly intervals. The toe did not improve and regular dressings were continued for several months until her daughter noticed that the toe had become pink, and brought her up to the diabetic foot clinic. Her pedal pulses were strong and bounding. A plaque of callus covered the entire apex of the pink toe...
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Fig. 5.24 All necrotic tissue has been removed down to healthy pig. 5.25 Wrinkling of skin indicating resolution of oedema, bleeding tissue. Fig. 5.24 All necrotic tissue has been removed down to healthy pig. 5.25 Wrinkling of skin indicating resolution of oedema, bleeding tissue. some cases debridement may need to be accompanied by amputation of a toe or ray. Consent for these procedures should therefore be obtained prior to operation. The anaesthetist should understand that debridement of the...
Acute Charcots osteoarthropathy of the forefoot
A 21-year-old woman with type 1 diabetes of 15 years' duration developed painless swelling of both forefeet Fig. 3.20a . There was no evidence of ulceration. X-ray revealed fragmentation and lucency of the 2nd, 3rd and 4th metatarsal heads of both feet Fig. 3.20b . The patient was supplied with a wheelchair and underwent strict non-weightbearing for 4 weeks. The oedema gradually resolved. Deformity did not develop and the radiological changes stabilized. The radiological changes of...
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Fig. 8.6 Hallux limitus. There is a callus with preulcerative changes on the plantar medial aspect of the great toe. Fig. 8.6 Hallux limitus. There is a callus with preulcerative changes on the plantar medial aspect of the great toe. requires regular debridement and footwear modification. The natural history for hallux interphalangeal joint lesions is for the preulcerative condition to progress to a full-thickness ulcer and eventually to amputation. Correlation between elevated plantar pressure...
Foreign body in foot
A 68-year-old woman with insulin-treated type 2 diabetes of 20 years' duration complained of pain on the back of the left heel and a superficial ulcer surrounded by a halo of erythema Fig. 4.34a . She was unaware of the cause of the ulcer. An X-ray showed two dipped-off insulin needles in the soft tissues of her heel Fig. 4.34b . She had previously Fig. 4.34 a The superficial ulcer of unknown aetiology surrounded by a halo of erythema, b X-ray reveals two clipped-off insulin needles embedded in...
CASE STUDY Ufz
Bacterial discitis of the lumbar spine as a complication of longstanding neuropathic ulceration in a foot with Charcot's osteoarthropathy A 55-year-old man with insulin-treated type 2 diabetes of 15 years' duration, peripheral neuropathy and impaired liver function due to previous hepatitis B infection presented late with acute Charcot's osteoarthropathy of Fig. 5.13 The patient has undergone surgical debridement of his infected foot with rockerbottom deformity and plantar ulceration. Fig. 5.13...
Iatrogenic lesions
Tape applied to atrophic skin and ripped off Tight bandages. We have seen a 53-year-old woman with type 2 diabetes mellitus of 13 years' duration and oedematous feet, who sustained a burn to the dorsum of the foot. She applied a sterile dressing held in place by a bandage which completely encircled the foot and ankle, and made an appointment to be seen at the diabetic foot clinic. When the bandage was removed she had developed superficial necrosis from an over-tight bandage and fluctuant...
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Fig. 8.41 a Lateral radiograph reveals extensive destruction of the left ankle joint with disintegration of the talus and fragmentation of bone, b Postoperative radiograph of the left ankle following tibiocalcaneal fusion with the intramedullary nail and interlocking screws in place, c Long-term follow-up. Clinical appearance of the left foot and ankle 5 years after surgery. over the course of several months, ankle deformity and instability progressed, with disintegration of the talus Fig....
Partial calcanectomy
Partial calcanectomy is indicated for the surgical management of large non-healing wounds located over the heel, with or without osteomyelitis. These wounds are typically chronic decubitus ulcers located on the posterior aspect of the heel, or neuropathic ulcers on the plantar surface of the heel. Regardless of the aetiology, heel ulcers are often unresponsive to conservative therapy and are frustrating to treat. Partial calcanectomy is a viable alternative to below-knee amputation for these...
Hallux amputation Fig ab
Amputation of the great toe invariably results in biomech-anical dysfunction of the foot. The degree to which this occurs depends upon whether or not a portion of the 1st metatarsal has also been removed. The loss of propulsive function is not detrimental to neuropathic patients who already have an apropulsive gait. Of greater concern, however, are the following postoperative sequelae Compensatory flexion contracture of the 2nd toe Ulceration at the tip of the 2nd toe Ulceration beneath the 1st...
Examination
Foot examination should be carried out as described in the introduction. The ulcer should then be examined noting Fig. 4.1 An ischaemic ulcer on the margin of the foot with a halo of erythema. Fig. 4.1 An ischaemic ulcer on the margin of the foot with a halo of erythema. Appearance of the ulcer and surrounding tissues The implications of these are discussed below. Site Ulcers on the plantar surface are usually neuropathic and ulcers on the margins of the foot are usually neuroischaemic. However...
Metatarsal Disarticulations
The 5th ray is amputated through a dorsolateral approach, with a racquet incision encircling the 5th toe. The toe is disarticulated at the metatarsophalangeal joint, and all necrotic tissues are excised. The incision is then extended proximally, in a curvilinear fashion over the 5th metatarsal shaft, to the level of the base. Dissection is kept close to the bone. The soft tissues are retracted using blunt Senn retractors. The exact amount of bone to be removed is determined, at the time of...
Practical Assessment
This can be divided into three parts Every attempt should be made to encourage the patient to be open and non-defensive. The history can be divided into the following sections Be aware that some patients may be asymptomatic due to neuropathy. The presenting complaint is usually one or more of the following For skin breakdown, swelling and colour change or any other presenting complaints, the following questions may be helpful As regards pain, this maybe a specific complaint alone or it may...
Acute Charcots osteoarthropathy with rapid onset of bony destruction and
A 46-year-old man with type 1 diabetes of 33 years' duration, end-stage renal failure treated by renal transplantation and severe neuropathy, received regular foot checks under a renal foot study protocol. Three days before he went on holiday to the Channel Islands his feet were routinely checked and nothing abnormal was discerned. Two weeks later he came to the clinic on his return from holiday to report that his foot was 'a little swollen'. He reported no trauma to the foot, but had been...
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Fig. 5.15 a MRIT1 sequence shows normal uptake in soft tissues under extensor hallucis longus tendon, b Increased uptake on STIR sequence, c A small collection of fluid under E amp flMnBtiairgTCiinnnas gaBKETitaaisffi BfinESRsasM the extensor hallucis longus tendon post gadolinium , d Temperature chart showing resolution of fever. the extensor hallucis longus tendon post gadolinium , d Temperature chart showing resolution of fever. He underwent surgical debridement and 20 mL of pus was drained...
Angioplasty and delayed healing until removal of sequestrum in a neuroischaemic
A 91-year-old lady with type 2 diabetes of 20 years' duration who lived in a nursing home was referred as an emergency with a painful oedematous, ischaemic left foot complicated by severe cellulitis and lymphangitis and a malodorous ulcer on the apex of her 2nd toe. A swab grew mixed coliforms. The 5th toe had a bluish tinge. Her Doppler waveforms were severely damped and her pressure index was 0.3. She was admitted for wide-spectrum intravenous antibiotics and underwent angioplasty of the...
Preparations for transfemoral angiography and angioplasty
Patients taking metformin should stop this 2 days before the procedure and restart 2 days after, or when, renal function returns to normal. Insulin-dependent patients are placed first on the list in outpatient angiography and have their insulin after the procedure is finished. It is important to keep the patient well hydrated. Pre- and perioperative dopamine is no longer used. Further details of MRA are discussed in Chapters 5 and 6. Angioplasty is possible at several levels of the leg arterial...
Foot Callus And Fissures
Fig. 3.8 a Deep fissures before debridement, b The edges of the fissures have been cleared of callus, c The edges of the fissures are held together with Steri-strips. Fig. 3.8 a Deep fissures before debridement, b The edges of the fissures have been cleared of callus, c The edges of the fissures are held together with Steri-strips. Other common foot disorders and their management are described in Chapter 2. The majority of patients will be asymptomatic and ischaemia will be diagnosed on...
Dry necrosis 1
Dry necrosis is secondary to a severe reduction in arterial perfusion and occurs in three circumstances Peripheral arterial disease usually progresses slowly in the diabetic patient, but eventually a severe reduction in Fig. 6.4 a Neuropathic foot with infected plantar ulcer. The 4th toe has turned blue because septic arteritis has led to occlusion of both digital arteries. The 3rd toe is changing colour. Fig. 6.4 a Neuropathic foot with infected plantar ulcer. The 4th toe has turned blue...
Neuroischaemic foot
Ulcers in neuroischaemic feet usually develop around the margins of the foot. Revascularization is the definitive Fig. 4.10 a Bullae over lesser toes caused by footwear, b The bullae are dry and healing well after 2 weeks. Fig. 4.10 a Bullae over lesser toes caused by footwear, b The bullae are dry and healing well after 2 weeks. treatment, although it is still important to off-load the ulcer. A high-street shoe that is sufficiently long, broad and deep, and fastens with a lace or strap high on...