Diabetic foot ulcers are of many types and different ulcers require management in different ways. Their optimal management is currently hindered by lack of a useful working classification. Such a classification must be flexible enough to be applied to all lesions likely to be encountered but specific enough to enable clear definition of an individual lesion. It must also be simple enough to ensure that it is understood by all categories of health care workers, whether specialist or not. An attempt has been made to devise a classification--based on the key elements used in describing foot lesions--and it is put forward to act as stimulus for debate. It is based on the clinical definition of infection, ischaemia, and neuropathy. Although two of these, or even all three, may be found in the same foot, they should be considered in the order given because this reflects the sequence of clinical decisions which should be made. The adoption of a classification such as this would aid education, communication, research and audit, and would lead to better management of ulcers.
Experience of conservative management of osteomyelitis in a specialized, multidisciplinary, diabetic foot clinic was reviewed. The records of all patients attending the clinic over a 10‐year period were examined retrospectively, and 22 patients with overt osteomyelitis were identified. Median age was 66 (31–87) years. In 12 cases the bone infection was a complication of a pre‐existing ulcer; the most prevalent organism cultured from swabs was Staphylococcus aureus. The main site of infection was the first toe. The total duration of antibiotic treatment was 12 weeks (median, range 5–72), and clindamycin was the most commonly used oral agent. Four patients did not respond to initial conservative therapy and proceeded to amputation, while 1 patient responded clinically but had a recurrence of osteomyelitis at the same site 6 years later. In the remaining 17 patients resolution of osteomyelitis was achieved with conservative management over a median period of follow‐up of 27 (range 5–73) months. The success of conservative therapy with prolonged courses of oral antibiotics challenges conventional advice that excision of infected bone is essential in the management of osteomyelitis affecting the foot in diabetes. © 1997 by John Wiley & Sons, Ltd.
During a 32-month period 94 foot ulcers in 54 diabetic patients aged 38-90 years (mean 64 years) were managed in a specialist foot clinic. Fifty-six percent were men, and they were significantly younger than women; 46% were taking insulin. Mean duration of diabetes was 13.4 years. Comparison with controls revealed a higher prevalence (p less than 0.01) of retinopathy (60% vs 23%), neuropathy (89% vs 31%), vasculopathy (71% vs 34%), arterial calcification (31% vs 20%) and previous lesions (54% vs 4%). There was no difference in quality of diabetic control, or smoking habit. A simple classification of lesions was used. All types yielded mixed cultures of microorganisms (average 2.1 per swab); the flora obtained was affected by systemic antibiotics. Abnormal pressure was judged to have contributed to all lesions occurring in areas of callus. In addition definable trauma precipitated the event in up to 60% of all other types. Lesions in areas of callus were more likely to have healed by the end of the study period, but average time to healing was significantly longer than other lesions. Despite intensive outpatient support, 33 patients spent a total of 1188 days in hospital during the 974 day period, an average of 36 days per patient and 1.2 beds per day. Further research is urgently required to define optimal methods of prevention and treatment of diabetic foot ulcers.
People with diabetes are liable to suffer potentially disastrous foot problems, including gangrene with subsequent amputation. This article describes the risk factors, management, and ulcer-prevention methods which are essential knowledge for nurses working with this patient group.
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