Diabetes is fast becoming the epidemic and the developing countries will be bearing the brunt of this epidemic in the 21st century. Currently, more than 70% of people with diabetes live in low- and middle income countries. In 2010, nearly 6.4 % of the world’s adult’s population, an estimated 285 million people, will be suffering from diabetes mellitus. This number is expected to grow to 438 million by 2030, corresponding to 7.8% of the adult population. An estimated 50.8 million Indians are living with diabetes. Diabetes is one of the major causes of premature illness and death worldwide. Non-communicable diseases including diabetes account for 60% of all deaths worldwide.
Every sixth diabetic is predicted to have a foot ulcer or diabetic foot in his lifetime. This figure may even be worse in developing countries like the Indian subcontinent. Approximately 85% of all major amputations in the leg are preceded by an ulcer. There is an amputation happening every thirty seconds throughout the world. Around 50% of all amputations in patients with diabetic foot are either transfemoral or transtibial. Of these patients, around 50% will be back for a second amputation within 5 years. The severe morbidity associated with the diabetic foot and the major amputations results in overall mortality of approximately 50% with 5 years.
Ulcers in diabetic patients occur mostly in feet, especially over the weight bearing areas and the toes. Fifteen percent of diabetic patients will develop foot ulcers in lifetime. Diabetic neuropathy predisposes them for recurrent ulcerations over weight bearing areas and may progress to Charcoat’s joint in severe cases. Fifteen percent of patient with diabetic feet with ulcers will eventually end up with either osteomyelitis or amputation. In patients with diabetes and peripheral vascular disease, the severity of the complications increase many fold and results in rapid destruction of foot and amputation.
Management of diabetic foot patients should start with detailed history and examination. History suggestive of neuropathy and peripheral vascular disease should be elicited. The neurological examination of foot includes Monofilament test, Biothesiometer, Temperature, Vibration perception and motor examination. General examination includes examination for calluses, corns, fissures, ulcers, hammer toes, claw toes, valgus deformity, flat feet and prominent metatarsal heads. Peripheral vascular examination includes checking for pedal pulses, ankle brachial pressure index, toe pressures, transcutaneous pressure measurements and arterial duplex examination.
Risk stratification is must for all diabetic patients. All diabetic patients should undergo annual comprehensive foot examination. The patient should be offered basic education and advised for self management, footcare precautions and lifestyle changes.
Precautions in patients with Diabetic Foot:
Patients with diabetes can have catastrophic complications, even from a small cut in the feet. The general precautions to be taken by all diabetic patients are as follow:
- Inspect the feet daily – Check for cuts, blisters, corns, redness, swelling, or nail problems. Use a hand mirror or accompanying person to look at the bottom of your feet. Call your doctor if you notice anything abnormal.
- Wash the feet in lukewarm (not hot!) water – Keep your feet clean by washing them daily. Use only lukewarm water – the temperature you would use on a newborn baby.
- Be gentle when bathing the feet – Wash them using a soft washcloth or sponge. Dry by blotting or patting. Always dry between the toes.
- Moisturizing the feet – but not between the toes – Use a moisturizer daily to keep dry skin from itching or cracking. But DON’T moisturize between the toes – that could encourage a fungal infection. Using anti-fungal powder between toes is helpful.
- Cut nails carefully – Cut them straight across and file the edges. Don’t cut nails too short, as this could lead to ingrown toe nails. If you have concerns about your nails, consult doctor.
- Never treat corns or calluses yourself – No “bathroom surgery” or medicated pads.
- Wear clean, dry socks – Change them daily.
- Wear socks to bed – If the feet get cold at night, wear socks. NEVER use a heating pad or hot water bottle.
- Shake out your shoes and feel the inside before wearing – Always inspect shoes before putting them on.
- Keep your feet warm and dry – Wear warm socks and shoes in winter.
- Never walk barefoot – Patient are advised to not walk barefoot, even at home.
- Take care of your diabetes – Keep your blood sugar levels under control.
- Stop smoking – Smoking restricts blood flow in the feet.
- Get periodic foot exams – Diabetic patients should get their feet examined regularly by podiatrist, diabetologist or surgeon.
Patients with peripheral vascular disease and diabetes should undergo detailed examination of arterial system. Best medical management should be instituted in all patients. Patients with severe claudication or critical limb ischemia should also undergo angiographic evaluation. Advancement in technologies has made it possible for most of the arterial lesions to be treated by endovascular means. Subintimal angioplasty and intra-luminal angioplasty has made it possible to successfully treat arterial occlusions and stenosis. Surgical bypass has been the gold standard, though more and more lesions are being treated by minimally invasive techniques. Uses of stents, covered stents, long balloons, drug eluting balloons and stents have made it possible to treat difficult and long lesions.
Diabetic foot is one of the most morbid complications of diabetes and results in significant morbidity and mortality. Comprehensive care and management with active participation by patients is the key to success. Multispecialty care is the cornerstone of management and helps to improve the prognosis in patients of diabetic foot.