Diabetic foot

The diabetic foot syndrome (DFS ), colloquially known as " diabetic foot ", is a syndrome associated with diabetes mellitus, which occurs most often in patients with type 2 diabetes (known diabetes). The diabetic foot syndrome leads annually in Germany to about 40,000 amputations and is thus the cause of two thirds of all amputations performed.

• 2.1 Nerve damage
• 2.2 circulatory disorders

• 4.1 Therapeutic Methods

Cause

Circulatory disorders and wounds

The cause wounds come on foot or lower leg in question, not spontaneously resolve within two to three weeks. Causes are often circulatory disorders of the extremities or in the context of diabetes-related nerve damage ( polyneuropathy ) decreased sensitivity to pain. The wounds incurred in trivial accidents, by improper foot care, or already bumping the toes in the shoe or to edge.

The risk of suffering from a poorly healing wound, is particularly high in combination with circulatory disturbance. Deep skin ulcers ( ulcers ) can always be further extend into the foot and also colonized with MRSA germs that may prevent normal wound care and healing.

Charcotfuß

Another cause is the destruction of bones and joints in the foot ( Charcotfuß ). A Charcotfuß (also diabetic - neuropathic osteoarthropathy DNOAP = ) arises in the context of polyneuropathy. If it comes to the break, the person does not feel it often through the polyneuropathy. Since no pain is present, many sufferers burden weeks the broken foot. The foot is warm, swollen and red compared to the opposite side. The pain it will be less than expected or may even fail completely despite significant fractures. Lead to the doctor, for example, the conspicuous deformity of the foot, resulting ulcers.

As a first therapy is done the complete discharge ( bed rest ), then the partial relief eg in plaster casts, later special made ​​orthopedic shoes must be worn.

Staging according to Wagner and Armstrong

Source: S3 guidelines DGfW from June 2012

Signs of damage

Signs of damage may indicate nerve damage or circulation problems:

Nerve damage

• Numbness, burning, tingling in the toes and feet.
• The feeling of walking on cotton wool and the feeling of having cold feet, even though they are warm.
• Pain in resting feet, especially at night and pain relief by walking about or cooling.
• Joint swelling and strong tendency to callus and nail fungus.
• Reduction or loss of temperature and pain sensation

Circulatory disorders

• Cold feet
• Thin, parchment-like, bluish pale skin
• Pressure points ( rötl. skin patches, which can not be prune )
• Calf pain or cramps when walking - relief by standing still, colloquially known as intermittent claudication.

Prevention

Preventive measures for prevention of the diabetic foot syndrome affect all people with diabetes and with impaired sensation or circulatory disorders.

General should value on a good skin care - even for observation of vulnerable parts of the body - are laid. To nail and callus care no sharp objects may be used ( not even by podiatrists ), instead, nail files and pumice stones. Skin care ointments should not be applied in the spaces between the toes, but on the sole and dorsum of the foot. Athlete's foot is to be treated consistently and spaces between the toes dried thoroughly after bathing. The shoes must be sufficiently wide and soft and the feet are checked daily for injuries, such as with a shaving mirror.

As measures for prevention are recommended

• Daily View the feet exactly and check for injuries and bruises. Check for swelling by painted by hand over the foot, even after wearing new shoes or after long walks / hikes check feet.
• Daily wash with lukewarm water. Not more than three minutes, dry thoroughly, especially between the toes.
• Apply a skin conditioner with urea-containing creams to avoid cracks ( rhagade / fissures ). The cream must be good move / dry, it may leave any residue between the toes.

• Only use files, do not use rasps, nail clippers or scissors.
• Toenails spade-shaped (straight) shape with files, never cut - due to injury.
• Do not use corns patch or tinctures, they may contain corrosive substances which could lead to injury.
• Wear comfortable, loose and soft shoes, preferably leather, not rubber and sneakers because of perspiration. Daily before using them with your hand to check shoes on bumps or pebbles etc..
• Wear cotton socks without oppressive seam, change socks daily
• Expose feet to excessive heat, as occurs for example in electric blankets or chimneys which cause injury, no direct sunlight
• Be careful when walking barefoot, athlete's foot risk and risk of cuts and scrapes

Especially diabetics should at foot problems professional help from a podiatrist who specializes in the treatment of diabetic foot ulcers, are looking for. This treatment can be prescribed at the expense of the statutory health insurance by the physician under certain conditions.

Treatment

Depending on the severity of injury and the stage, the patient should be properly cared for by a wound care team. Due to the impaired wound healing, the treatment itself can pull over very long periods of time. In some cases, a long-term antibiotics in addition to regular wound care necessary. Stage II: an inpatient care is necessary in individual cases.

The treatment may be related to the guidelines of the German Society for wound healing and wound treatment and the German Diabetes Society.

In wound care team working for optimal support depending on the case, different specialists, including:

• Physicians ( general practitioner / internist / diabetologist / surgeon / vascular surgeon / orthopedist )
• Specialized professionals ( therapists DGfW Wound / Wound Manager ICW)
• Orthotist
• Podiatrists
• Psychosocial care

Therapy orientation:

• National guidelines ( NVL ) Type 2 diabetes: prevention and treatment strategies for foot complications of the German Medical Association, AWMF and KBV ( AWMF guidelines registers NVL 001 / c)
• S3 - Guideline of the German Society for Wound Care ( local therapy of chronic wounds in patients with the risks of peripheral arterial disease, diabetes mellitus, chronic venous insufficiency)
• Diagnosis, treatment, follow-up and prevention of diabetic foot ulcers, Guideline of the German Diabetes Society and the German Society for Vascular Surgery

Even under optimal conditions, there are many people with diabetic foot ulcers in long-term treatment and are often very limited in the activities of daily living.

Therapy methods

Treating the cause: Through vascular surgical measures, such as a revascularization by bypass and by orthopedic surgery for the correction of misalignments in the area of ​​the foot in diabetic osteoarthropathy in order to avoid the pressure points and bony prominences edges

Wound cleaning and debridement: Most surgical removal of devitalized tissue, necrosis, deposits and / or removal of foreign bodies up to intact anatomical structures approach to obtain granulation - mainly active periodic cleaning of the wound as a targeted recurring mechanical debridement in the context of dressing change.

Associations: In a Cochrane review of Palfreyman evident in regard to wound healing, no statistically significant difference between hydrocolloids and gauze or dressings, alginates, foams, hydrocolloids or different manufacturers. Also a vacuum therapy is often used.

Physical Interventions: To supplement the conventional wound treatment are a number of different methods available, the aim is a more effective and faster wound healing, thereby reducing the extremely high rate of amputation. In addition to many case reports, there are few good clinical trials demonstrating scientifically an actual effect of these methods. Many methods need to be evaluated as experimental. An overview of the significance of the different treatment proposals can be found in the aforementioned S3 guideline. The following methods are currently applied:

• Hyperbaric oxygen therapy as a pressure treatment of the whole body, which can be used after attainment of Revascularization as an additional therapeutic option ( After judgment of the Federal Social Court of 7 May 2013 ( PDF, 23 kB) to ensure appropriate compulsory insured patients to receive reimbursement from their health insurance )
• Electro-therapy
• Shock wave therapy ( ESWL)
• A low-energy ( low-level ) laser light therapy
• Heat treatments with infrared radiators
• Ultrasound Therapy