The diabetic foot in 2015: an overview

Abstract

In 2015, it can be said that the diabetic foot is no longer the Cinderella of diabetic complications. Thirty years ago there was little evidence-based research taking place on the diabetic foot, and there were no international meetings addressing this topic. Since then, the biennial Malvern Diabetic Foot meetings started in 1986, the American Diabetes Association founded their Foot Council in 1987, and the European Association for the Study of Diabetes established a Foot Study Group in 1998. The first International Symposium on the Diabetic Foot in The Netherlands was convened in 1991, and this was soon followed by the establishment of the International Working Group on the Diabetic Foot that has produced useful guidelines in several areas of investigation and the management of diabetic foot problems. There has been an exponential rise in publications on diabetic foot problems in high impact factor journals, and a comprehensive evidence-base now exists for many areas of treatment. Despite the extensive evidence available, it, unfortunately, remains difficult to demonstrate that most types of education are efficient in reducing the incidence of foot ulcers. However, there is evidence that education as part of a multi-disciplinary approach to diabetic foot ulceration plays a pivotal role in incidence reduction. With respect to treatment, strong evidence exists that offloading is the best modality for healing plantar neuropathic foot ulcers, and there is also evidence from two randomized controlled trials to support the use of negative-pressure wound therapy in complex post-surgical diabetic foot wounds. Hyperbaric oxygen therapy exhibits the same evidence level and strength of recommendation. International guidelines exist on the management of infection in the diabetic foot. Many randomized trials have been performed, and these have shown that the agents studied generally produced comparable results, with the exception of one study in which tigecycline was shown to be clinically inferior to ertapenem ± vancomycin. Similarly, there are numerous types of wound dressings that might be used in treatment and which have shown efficacy, but no single type (or brand) has shown superiority over others. Peripheral artery disease is another major contributory factor in the development of ulceration, and its presence is a strong predictor of non-healing and amputation. Despite the proliferation of endovascular procedures in addition to open revascularization, many patients continue to suffer from severely impaired perfusion and exhaust all treatment options. Finally, the question of the true aetiopathogenesis of Charcot neuroarthropathy remains enigmatic, although much work is currently being undertaken in this area. In this area, it is most important to remember that a clinically uninfected, warm, insensate foot in a diabetic patient should be considered as a Charcot foot until proven otherwise, and, as such, treated with offloading, preferably in a cast.

Medial Arterial Calcification

“…[62][63][64] MAC is frequently seen in the pedal arteries of patients with neuropathy-related complications, including foot ulceration and Charcot osteoarthropathy (Charcot foot) in diabetes mellitus patients. 65,66 Indeed, an invariant feature of Charcot foot is the presence of MAC in the arteries, 56 and Charcot foot greatly predisposes to amputation and mortality. The significance of the receptor activator of nuclear factor kappa-B ligand (RANKL)/OPG system in Charcot foot has been demonstrated in vivo as well as in vitro over the past few years.…”

Diabetic foot care within the context of rehabilitation: keeping people with diabetic neuropathy on their feet. A narrative review

“…Typically, the treatment of diabetic neuropathy and its complications, particularly plantar ulceration, should be provided by a multi-disciplinary team 3 . Multi-disciplinary foot clinics are considered the key strategy to optimise diabetic foot care.…”

“…The evidence base for diabetic foot care has been increasing substantially in recent years 3 . Particularly the International Working Group on the Diabetic Foot (IWGDF) has been instrumental in producing a collection of systematic reviews and clinical guidelines covering relevant areas 2 .…”

Retrospective Evaluation of Twenty Seven Patients with Diabetic Foot Infection

“…Antibiyotik tedavisi yanında cerrahi debridman, yara bakımı ve hiperbarik oksijen (HBO) tedavisi gibi, maliyeti yüksek, yönetimi zor ve tedavi şansı düşük yardımcı tedavi yöntemleri de denenmektedir (4,(6)(7)(8). Bu tedavilerle hastane maliyetleri artmakta, yatak işgal süresi uzamakta ve bu konuda deneyimli personel ihtiyacı da ayrı bir problem olarak karşımıza çıkmaktadır.…”