Diabetic foot
Diabetic foot disease is caused by the complex interaction among peripheral neuropathy (including autonomic neuropathy), macroangiopathy, poor foot hygiene and many other factors. The role of each factor varies from person to person, and may also vary from race to race; For example, in some Asian populations, peripheral vascular diseases may play a less important role. Because its consequence is lower limb amputation, which is one of the most terrible complications of diabetes.
Compared with the general population, the probability of lower limb amputation in diabetic patients is 15-40 times higher. Older people are at higher risk. But if actively handled, most amputations can be avoided.
Peripheral neuropathy with pain disappearing is the most common cause of foot ulcer. Poor foot hygiene is the second reason. This type of neuropathy and ulcer can be completely painless.
Peripheral vascular diseases can also cause foot ulcers. This kind of ulcer hurts easily. Peripheral vascular disease is the main reason why nerve ulcer is difficult to heal. Nerve ulcers occur in places where pressure increases, usually the soles of the feet. The most reported part is the toe dorsal nerve ulcer caused by improper shoes, and the formation of calluses is also the result of this pressure.
In order to heal the ulcer, it is necessary to reduce the local pressure (remove the callus, wear suitable shoes, or use a decompression pad). Vascular ulcers are common in toe tips and heels.
In order to heal the ulcer, it is necessary to improve the blood supply. Infection should be actively controlled. Antibiotic treatment usually takes weeks or months. Attention should be paid to timely debridement of infected and necrotic tissues. Refractory ulcer is the most common cause of amputation.
Routine examination of the sensation or pulse of dorsal artery of foot is the most important method to find the risk of foot ulcer. In the community, it is best to measure the sensation with 5.07/ 10g Semmes Weinstein nylon yarn. Nylon single yarn detection is a simple and cheap sensory detection method. When a force of10g is applied, it will bend.
If the patient does not feel pressure, it can be considered that this foot has sensory loss. The education of foot care for patients who have been identified as at risk should be more detailed and practical than other diabetic patients with good feeling and circulation.
At present, there is no satisfactory method to treat painful neuropathy. Useful methods include strengthening metabolic control and using simple painkillers, tricyclic antidepressants or anticonvulsants to relieve pain. It can convince patients that pain is not the cause of amputation.
If blood sugar control is very poor, foot infections and ulcers can occur due to poor foot hygiene without neuropathy and peripheral vascular diseases. In this case, in addition to strengthening the control of blood sugar, patients should be instructed to wear shoes to reduce the chance of foot trauma. If you wear shoes, you must wear clean socks.
(The above is quoted from Diabetes Guide)
1) definition of diabetic foot: diabetic patients lose their senses due to neuropathy or lose their mobility due to ischemia, combined with foot diseases caused by infection. The most common consequence is chronic ulcer, and the most serious consequence is amputation.
2) Clinical manifestations of diabetic foot: The clinical manifestations of patients with diabetic foot are related to five pathological changes: neuropathy, vascular disease, biomechanical abnormality, ulcer formation and infection of lower limbs.
(1) general manifestations of the foot: due to neuropathy, the skin of the affected limb is dry and sweatless; Tingling, burning, numbness, dullness or loss of sensation in limbs, socks-like changes, and cotton wool on feet; Due to malnutrition of limbs, muscle atrophy, flexors and extensors lose normal traction tension balance, which makes bones sink, leading to joint bending between toes, forming foot deformities such as arch foot, mallet toe and chicken claw toe. When the patient's bone joints and surrounding soft tissues are strained, the patient's continued walking will easily lead to bone joints and ligaments injury, resulting in multiple fractures and ligament rupture, forming Xiake joint. X-ray examination showed bone destruction, and some small bone fragments separated from periosteum, resulting in dead bone and affecting gangrene healing.
(2) The main manifestations of ischemia: common skin malnutrition, muscle atrophy, poor skin dryness and elasticity, hair loss, skin temperature drop, pigmentation, weakening or disappearance of arterial pulsation in limbs, and audible vascular murmur at vascular stenosis. The most typical symptoms are intermittent claudication, pain during rest, squatting and difficulty standing. When the patient's limb skin is damaged or blistered spontaneously, it is infected, forming ulcers, gangrene or necrosis.
(3) Diabetic foot ulcers can be divided into nerve ulcers, ischemic ulcers and mixed ulcers according to the nature of the lesions. Nervous ulcer: The main cause is neuropathy with good blood circulation. This kind of foot is generally warm, numb and dry, with no obvious pain and good foot artery fluctuation. There are two consequences for the foot with neuropathy: nerve ulcer (mainly in the sole of the foot) and neuroarthropathy (Charcot joint). Foot ulcers caused by simple ischemia without neuropathy are rare. Neuroischemic Ulcer These patients have both peripheral neuropathy and peripheral vascular diseases. The fluctuation of dorsal foot artery disappeared. The feet of these patients are cold, which may be accompanied by pain at rest, and ulcers and gangrene appear on the edge of the feet.
Foot ulcers often occur in the forefoot and are often caused by repeated mechanical compression. Because the sense of protection caused by peripheral neuropathy disappears, patients can't feel this abnormal pressure change and can't take some protective measures. After the ulcer occurs, it is complicated with infection, and the ulcer is not easy to heal, and finally gangrene occurs.
3) Classification of diabetic foot: The classic classification method is Wagner classification: Grade 0: Foot has the risk of foot ulcer and no open skin lesions. 1 grade: surface ulcer, no infection in clinic. Grade 2: deep ulcer infection focus, often complicated with soft tissue inflammation, no abscess or bone infection. Grade 3: deep infection, accompanied by bone tissue lesions or abscesses. Grade 4: Bone defect, gangrene of some toes and feet. Grade 5: Most or all foot gangrene.
4) Examination of diabetic foot: Routine examination of the sensation or pulse of the dorsal artery of the foot is the most important method to find the foot at risk of ulcer. In the community, it is best to measure the sensation with 5.07/ 10g Semmes Weinstein nylon yarn. Nylon single yarn detection is a simple and cheap sensory detection method. When a force of 10g is applied, it will bend. If the patient does not feel pressure, it can be considered that there is sensory loss in this leg.
Electrophysiological examination: 90% of diabetic peripheral neuropathy can be detected early by nerve conduction velocity electromyography, and the conduction velocity of motor nerve and sensory nerve of patients is generally slowed down by about 15%-30%.
X-ray examination: osteoporosis or destruction, osteomyelitis and osteoarthropathy can be found.
5) Treatment of diabetic foot:
(1) give priority to prevention, and try to avoid foot injuries, such as wearing soft shoes and socks, to avoid skin abrasion; If you have poor eyesight, don't cut your toenails yourself; Wash your feet with warm water to avoid burns and so on.
(2) General treatment: In addition to strictly controlling blood sugar and improving the general health level, we should also exclude some known risk factors of vascular diseases, such as treating hypertension, lowering blood lipid and avoiding smoking.
(3) Eliminating edema: As long as there is edema, all ulcers are difficult to heal, which has nothing to do with the etiology of ulcers. Diuretics or ACE-I can be used for treatment.
(4) Treatment of neuropathic foot ulcers: 90% of neuropathic foot ulcers can be cured by conservative treatment. The key is to reduce the pressure load on the feet. The definition of relieving load is to avoid all mechanical stress from attaching to the affected limb. This is the basic requirement for curing the affected foot. The patient's foot pressure can be changed by special orthopedic shoes or foot orthosis. In addition, the number of dressing changes and local medication should be determined according to the depth and area of exudate and whether it is complicated with infection. It is important to be able to identify the characteristics of different foot ulcers caused by different reasons, such as neuroischemic ulcers, which generally do not exude in large quantities, and it is not appropriate to use dressings with strong absorption; If there are many infections and exudation, improper dressing selection can soften the wound and aggravate the condition; For foot ulcers that are difficult to cure, some biological agents or growth factors, such as Dermagraft, can be used. Dermagraft is the world's first human skin substitute product, which contains normal skin components such as epidermal growth factor, insulin-like growth factor, keratinocyte growth factor, platelet-derived growth factor, vascular endothelial growth factor, a- and b- transport growth factors, collagen 1 and collagen 2, and fibronectin. Can be used for treating nerve foot ulcer and promoting ulcer healing.
(5) Treatment of ischemic lesions: If the vascular obstruction is not serious or there are no surgical indications, conservative treatment can be taken, and drugs for dilating blood vessels and improving blood circulation can be intravenously dripped. Such as salvia miltiorrhiza, ligustrazine, heparin, 654-2, etc. Recently, it has been reported that intravenous infusion of alprostadil and oral PEDA can improve peripheral blood circulation. Dissolve 40 micrograms of alprostadil (Baodaxin) in 50-250 ml of normal saline, and finish intravenous drip within 2 hours, twice a day; Or dissolve 60 micrograms of alprostadil (Baodaxin) in 50-250 ml of normal saline, and finish intravenous drip within 3 hours, once a day/kloc-0. Patients with renal insufficiency should start with 20 micrograms and drip for 2 hours twice a day. The dosage can be increased to the recommended normal dosage within 2-3 days according to the specific clinical conditions. Patients with renal insufficiency and heart disease should be limited to 50- 100ml/ day, and it is best to drip with infusion pump. Patients with insufficient blood supply to the foot should undergo angiography and revascularization after infection control. Vascular reconstruction can promote ulcer healing, relieve pain, improve lower limb function and improve quality of life. Amputation is also the right choice when the patient is unsuccessful after various treatments, otherwise it will threaten the patient's life. According to the results of angiography or Doppler examination, amputation of lower limbs should be done as much as possible to maintain the function of lower limbs as much as possible. After amputation on one side, there is still the possibility of ulcer or gangrene on the other side, so it is necessary to strengthen the education of foot protection for patients.
(6) Treatment of infection: Patients with foot infection, especially those with osteomyelitis and deep abscess, should strengthen insulin therapy on the basis of monitoring blood sugar to make blood sugar reach or approach normal level. Appropriate antibiotics should be selected according to the results of bacterial culture and drug sensitivity test. The infection of superficial tissues can be treated by local debridement and broad-spectrum antibiotics, such as cephalosporin plus clindamycin (clindamycin can enter tissues well, including diabetic feet that are difficult to enter); Cephalosporins or quinolones should not be used alone, because the antibacterial spectrum of these drugs does not include anaerobic bacteria and some G+ bacteria. Oral treatment can last for several weeks. The above antibiotics can be used for deep infection, but they should be given intravenously at first, and surgical drainage is needed, including excision of infected bone tissue and amputation.
(7) Surgical treatment: Refractory ulcer can be treated by surgery. When the infection or gangrene of diabetic foot affects most and middle part of hind foot, the surgeon must choose whether to let the patient have a large amputation or treat it as conservatively as possible.
(8) Treatment of Charcot Joint Disease: Long-term immobilization is the main method. There are many kinds of braces suitable for diabetic foot ulcer and Charcot joint abroad. Stents can brake diseased joints and change and correct abnormal foot pressure caused by neuropathy. The surgical treatment of Charcot arthropathy is not effective, but it is reported that surgical resection, reconstruction and stabilization of Charcot ankle joint are effective. The contents of the operation include: removing the residue of ankle bone and ankle joint, loosening soft tissue, restoring and fixing the foot. After 6 weeks, the surgical fixation device was taken out and fixed with plaster for 6 weeks. After 3 months, the patient was allowed to wear special shoes with braces instead of plaster braces.
(9) Hyperbaric oxygen therapy can improve the healing rate of diabetic foot ulcer: Kessler of Strasbourg University Hospital in France reported a prospective randomized controlled study, which included 28 patients with diabetic foot chronic ulcer. All patients have no clinical symptoms of arterial disease, but all have signs of neuropathy. After 3 months of standardized treatment, all patients' ulcers did not improve. Randomly divided into control group and treatment group (5 days a week, twice a day, ***2 weeks). After treatment, the ulcer area in the treatment group was significantly smaller than that in the control group, and there was no significant difference in the ulcer area reduction between the two groups on the 30th day. After 4 weeks, 2 patients in the treatment group were completely healed, while no patients in the control group were completely healed. Whether prolonging hyperbaric oxygen treatment time can further improve ulcer healing rate needs further study and determination.
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