Diabetic Foot - Pathology

Poor Glyaemic Control - updated: 15 March 2008

Wound healing and treatments for people with diabetic foot ulcers

Diabetes Metab Res Rev. 2004 May-Jun;20 Suppl 1:S78-89

Jeffcoate WJ, Price P, Harding KG; International Working Group on Wound Healing and Treatments for People with Diabetic Foot Ulcers.

The factors that delay wound healing are multiple and relate both to diabetes and to the effect of its complications. Diabetic foot ulcers readily become chronic, and chronic ulcers have biological properties that differ substantially from acute ones. Much of the available information on the biology of wound healing relates to acute and experimental wounds and may not be directly relevant. It follows that there is limited evidence currently available to underpin protocols for the management of diabetic foot ulcers, or to guide choice of applications and dressings 1. Nevertheless, it is possible to define certain principles.GLYCAEMIC CONTROL: The first relates to glycaemic control. While chronic complications of diabetes such as peripheral vascular disease and neuropathy may be largely irreversible, aspects of structure and function of connective tissue and cells may be impaired by hyperglycaemia, and their function should be improved if normoglycaemia is achieved. PROMOTION OF HEALING: The second principle concerns attempts at active promotion of wound healing by (1) surgical revascularization, and (2) specific attempts to correct defined biological abnormalities thought to be hindering the healing process. These include the use of a variety of applications, dressings and technologies, which may stimulate healing by applying, or stimulating the release of, growth factors and cytokines. While this approach holds the greatest promise for the future, it will be dependent on defining defects which need correction in specific individuals, and having technologies available to address them. This field is in its infancy. WOUND CARE: The third broad principle concerns the management of the wound and its surrounding tissue in order to promote healing. This includes regular inspection, cleansing and removal of surface debris, elimination of pathogenic bacteria and creation of an appropriate environment to facilitate endogenous tissue regeneration. There are many applications and dressings that may be chosen to promote healing, but, whichever is selected, wound management has to be integrated into an effective programme of multidisciplinary care.

Publication Types:

• Review

Frequency of lower extremity amputation in diabetics with reference to glycemic control and Wagner's grades

J Coll Physicians Surg Pak. 2006 Feb;16(2):124-7

Imran S, Ali R, Mahboob G.

OBJECTIVE: To determine the frequency of minor and major amputations in diabetic patients at different Wagner s grades of severity and to correlate it with the glycaemic control. DESIGN: Cross-sectional analytical study. PLACE AND DURATION OF STUDY: Department of Orthopedic Surgery, Jinnah Postgraduate Medical Centre, Karachi, over a period of 3 years from August 1999 to August 2002. SUBJECTS AND METHODS: The study included 60 patients of diabetic foot disease, who were distributed in to six grades of severity according to the Wagner s method. Glycaemic control was determined by baseline fasting and random blood sugar and HbA1c levels. Patients were treated accordingly and followed-up. Frequencies of minor and major amputations were found and these were correlated with the glycemic control of the patients. RESULTS: There was no patient in grade-0, 6 (10%) patients in grade-I, 13 (21.6%) in grade-II, 14 (23.3%) in grade-III, 18 (30%) in grade-IV and 9 (15%) patients in grade-V respectively. Thirty-seven (61.6%) patients were male. The mean age of the patients was 50.88 +/- 11.06 years. In 40 (66.7%) patients, the duration of diabetes was 8 years or longer. Fifty six (93.3%) were having NIDDM and 35 (58.3%) were smokers. Staphylococcus aureus was the most common pathogen isolated from the wound. Only 1 (16.6%) patient in grade I underwent minor amputation, while 3 (23.7%), 8 (57.14%) and 8 (44.44%) underwent minor amputation in grades II, III and IV respectively. Three (21.42%), 10 (55.55%) and all 9 (100%) underwent major amputation in grade III, IV and V respectively. Below-the-knee amputation was the most commonly performed procedure. Overall frequency of minor and major amputation were 20 (33.3%) and 22 (36.3%) respectively. Patients with poor glycaemic control had higher percentage of minor and major amputation (p-value = 0.001). CONCLUSION: The frequency of minor and major amputation increases with the higher grades of diabetic foot. Poor glycaemic control is a significant risk factor for amputation in diabetic foot patients.

Publication Types:

• Cross-sectional analytical study

Preventing foot ulcers in patients with diabetes

JAMA. 2005 Jan 12;293(2):217-

Singh N, Armstrong DG, Lipsky BA.

CONTEXT: Among persons diagnosed as having diabetes mellitus, the prevalence of foot ulcers is 4% to 10%, the annual population-based incidence is 1.0% to 4.1%, and the lifetime incidence may be as high as 25%. These ulcers frequently become infected, cause great morbidity, engender considerable financial costs, and are the usual first step to lower extremity amputation. OBJECTIVE: To systematically review the evidence on the efficacy of methods advocated for preventing diabetic foot ulcers in the primary care setting. DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION: The EBSCO, MEDLINE, and the National Guideline Clearinghouse databases were searched for articles published between January 1980 and April 2004 using database-specific keywords. Bibliographies of retrieved articles were also searched, along with the Cochrane Library and relevant Web sites. We reviewed the retrieved literature for pertinent information, paying particular attention to prospective cohort studies and randomized clinical trials. DATA SYNTHESIS: Prevention of diabetic foot ulcers begins with screening for loss of protective sensation, which is best accomplished in the primary care setting with a brief history and the Semmes-Weinstein monofilament. Specialist clinics may quantify neuropathy with biothesiometry, measure plantar foot pressure, and assess lower extremity vascular status with Doppler ultrasound and ankle-brachial blood pressure indices. These measurements, in conjunction with other findings from the history and physical examination, enable clinicians to stratify patients based on risk and to determine the type of intervention. Educating patients about proper foot care and periodic foot examinations are effective interventions to prevent ulceration. Other possibly effective clinical interventions include optimizing glycemic control, smoking cessation, intensive podiatric care, debridement of calluses, and certain types of prophylactic foot surgery. The value of various types of prescription footwear for ulcer prevention is not clear. CONCLUSIONS: Substantial evidence supports screening all patients with diabetes to identify those at risk for foot ulceration. These patients might benefit from certain prophylactic interventions, including patient education, prescription footwear, intensive podiatric care, and evaluation for surgical interventions.

Publication Types:

• Review

The management of lower-extremity diabetic ulcers

Manag Care Interface. 2000 Nov;13(11):80-7.

Gonzalez ER, Oley MA.

Lower-extremity ulcers occur in approximately 15% of the estimated 16 million Americans with diabetes. The most important risk factors are neuropathy, ischemia, and poor glycemic control. Early identification of the patient at risk, patient education, and implementation of preventive measures are keys to curtailing morbidity and mortality. Diabetic foot care clinics allow enhanced patient accessibility to health care and improved quality of care. Novel treatment options have expanded the alternatives available to clinicians treating these difficult and prevalent wounds.

Risk factors for complications in the lower extremities in people with diabetes mellitus

Rev Bras Enferm. 2002 Sep-Oct;55(5):514-21

Pace AE, Foss MC, Ochoa-Vigo K, Hayashida M.

This study analyzed risk factors for feet complications on people with diabetes assisted in an outpatient unit. Data were collected by means of semi-structured interviews, feet evaluation and laboratory tests. Risks were analyzed according to Zavala and Braver and the Classification System of the International Consensus on the Diabetic Foot based on descriptive statistics. Results showed that the mean age was 53.3 +/- 13 years old, the duration of the disease was 12.9 +/- 9 and 58% of the patients had incomplete elementary education. Among the risks, the following were identified: microvascular complications, arterial hypertension, inadequate glycemic level, sedentarism and the use of inappropriate shoes in addition to dermatological ad structural alterations. Concerning risks for ulcers, 19.1% were obtained in categories 2 and 3. The results reinforce the need for primary care with emphasis on risk evaluation and patient education.

Publication Types:

• Review

Effect of glycaemic control on apoptosis in diabetic wounds

J Wound Care. 2005 Jun;14(6):277-81

Rai NK, Suryabhan , Ansari M, Kumar M, Shukla VK, Tripathi K.

OBJECTIVE: To study the effect of glycaemic control on apoptosis in chronic ulcers in diabetic patients and the differential roles of insulin and oral hypoglycaemic agents (OHAs). METHOD: Ten non-diabetic (group I) and 20 diabetic patients (groups II and III), with a wound of more than four weeks' duration, who were attending the wound clinic at University Hospital, Varanasi, India were recruited. The 10 patients in group 11 received insulin and the 10 in group III an oral hypoglycaemic agent; all had diabetic foot ulcers. Wound biopsy and other routine investigations were performed. Both DNA fragmentation and morphological changes under light microscopy (apoptotic index) were used as determinants of apoptosis. Different variables, including fasting and post-prandial blood sugar, serum low-density lipoprotein (LDL) and markers of microangiopathy, such as proteinuria and diabetic retinopathy, were compared with apoptosis. RESULTS: DNA fragmentation in groups I, II and III was 40.00 +/- 2.97, 45.26 +/- 3.21 and 60.8 +/- 3.13 respectively (p < 0.01). Near linear correlation was observed with blood sugar level, particularly post-prandial blood sugar (p < 0.05) and DNA fragmentation. DNA fragmentation was significantly correlated with serum LDL and proteinuria, and it was much greater in the OHA group than in the insulin group (p < 0.05). Similarly, in the diabetic patients with background retinopathy the DNA fragmentation was 46.50 +/- 3.42 (n=3) in the insulin group and 66.70 +/- 6.48 (n=4) in the OHA group (p < 0.05). CONCLUSION: There is a significant increase in apoptosis in diabetic wounds with poorly controlled blood sugar and microangiopathy. This increase was greater in patients on OHAs than those on insulin, and it contributes to delayed wound healing. Morphological markers do not appear to be a reliable index of apoptosis in the diabetic wound.

Publication Types:

• Review