Diabetic foot – the specific anatomo-functional changes of fabrics of foot caused by metabolic violations at patients with dekompensirovanny diabetes. Leg pain, giperkeratoza and cracks of skin, deformation of disteel departments of an extremity, ulcer defects and necroses of soft fabrics, in hard cases - gangrene of foot or a shin are signs of diabetic foot. Diagnostics of a syndrome of diabetic foot includes external survey, definition of different types of sensitivity, doppler sonography and an angiography of vessels, a X-ray analysis of feet, a microbiological research of contents of ulcers etc. Treatment of diabetic foot demands an integrated approach: normalization of level of a glycemia, unloading of the affected extremity, local processing of ulcer defects, performing antibiotic treatment; at severe defeats - surgical methods are applied.
In endocrinology understand a complex of microcirculator and neurotrophic violations in disteel departments of the lower extremities leading to development of ulcer and necrotic processes of skin and soft fabrics, bone and articulate defeats as a syndrome of diabetic foot. The changes characterizing diabetic foot usually develop in 15-20 years after the beginning of diabetes. This complication arises at 10% of patients, another 40-50% of patients with diabetes are included into risk group. At least, 90% of cases of diabetic foot are connected with diabetes 2 types.
Now the organization of the help to patients with diabetic foot is far from perfect: almost in half of cases treatment begins at late stages that results in need of amputation of an extremity, an invalidization of patients, increase in mortality.
Reasons and mechanisms of development of diabetic foot
The main pathogenetic links of a syndrome of diabetic foot are the angiopatiya, neuropathy and an infection. The long nekorrigiruyemy hyperglycemia at diabetes causes specific changes of vessels (a diabetic macrovascular disease and a mikroangiopatiya), and also peripheral nerves (diabetic neuropathy). Angiopatiya lead to decrease in elasticity and passability of blood vessels, increase in viscosity of blood that is followed by violation of an innervation and normal traffic of fabrics, loss of sensitivity of the nervous terminations.
The raised glycosylation of proteins causes decrease in mobility of joints that involves simultaneous deformation of bones of an extremity and violation of normal biomechanical load of foot (a diabetic osteoartropatiya, Sharko's foot). Against the background of the changed blood circulation, the reduced sensitivity and protective function of fabrics, any, even insignificant trauma of foot (a small bruise, attritions, cracks, microcuts) leads to education is long not healing trophic ulcers. Ulcer defects of feet are often infected with stafilokokka, kolibakteriya, streptococci, anaerobic microflora. The bacterial gialuronidaza loosens surrounding fabrics, promoting spread of an infection and necrotic changes which cover hypodermic and fatty cellulose, muscular tissue, the bone and copular device. At infection of ulcers the risk of development of abscess, phlegmon and gangrene of an extremity increases.
In spite of the fact that potential danger of development of diabetic foot exists at all patients with diabetes, the persons with peripheral polyneuropathy, atherosclerosis of vessels, a giperlipidemiya, IBS, arterial hypertension abusing alcohol and smoking treat group of the increased risk.
The risk of deep damages at diabetes is increased by local changes of fabrics - so-called, small problems of feet: the grown nail, fungal damages of nails, mycoses of skin, a natoptysha and callosity, crack of heels, insufficient hygiene of legs. The wrong picked-up footwear can be the reason of emergence of these defects (excessively narrow or close). Decrease in sensitivity of an extremity does not allow the patient to feel that footwear too presses, rubs and injures foot.
Classification of forms of diabetic foot
Taking into account prevalence of this or that pathological component, allocate ischemic (5-10%), neyropatichesky (60-75%) and mixed – neuroischemic (20-30%) a form of diabetic foot. At an ischemic form of diabetic foot violation of blood supply of an extremity due to defeat of large and small vessels is prevailing. The ischemic syndrome proceeds with the expressed persistent hypostasis, the alternating lameness, leg pains, bystry fatigue of legs, pigmentation of skin etc.
Neyropatichesky diabetic foot develops at defeat of the nervous office of disteel departments of extremities. Dryness of skin, a giperkeratoza, extremities, decrease in different types of sensitivity (thermal, painful, tactile etc.) are signs of neyropatichesky foot, to deformation of bones of foot, flat-footedness, spontaneous fractures.
At the mixed form of diabetic foot ischemic and neyropatichesky factors equally are expressed. Depending on weight of manifestations during a syndrome of diabetic foot allocate stages:
0 – high risk of development of diabetic foot: there is a deformation of foot, callosity, , however ulcer defects are absent 1 – a stage of the superficial ulcer limited to limits of skin 2 – a stage of a deep ulcer with involvement of skin, hypodermic and fatty cellulose, muscular tissue, sinews, however without damage of bones 3 – a stage of a deep ulcer with damage of bones 4 – a stage of limited gangrene 5 – a stage of extensive gangrene.
Symptoms of diabetic foot
In a debut the ischemic form of a syndrome of diabetic foot is shown by leg pain when walking, bystry fatigue of legs, the alternating lameness after which persistent hypostasis of foot develops. Foot pale and cold to the touch, a pulsation on arteries of foot is weakened or is absent. Against the background of pale skin sites of a hyperpegmentation are quite often visible.
Existence of callosities is typical, is long not beginning to live cracks on fingers, heels, the side surface of I and V plusnefalangovy joints, an anklebone. Further on their place painful ulcers which bottom is covered with a scab of black-brown color develop. The plentiful ekssudation is atypical (a dry necrosis of skin).
During an ischemic form of diabetic foot distinguish 4 stages: the patient with the first stage can be painless on foot about 1 km; with the second – about 200 m; with the third - less than 200 m, in certain cases pain arises at rest; the fourth stage is characterized by critical ischemia and the necrosis of fingers of feet leading to gangrene of foot or a shin.
The Neyropatichesky form of diabetic foot can proceed as a neyropatichesky ulcer, an osteoartropatiya and neyropatichesky hypostasis. Neyropatichesky defeat develops on the sites of foot subject to the largest pressure – between phalanxes of fingers, on a thumb, etc. Here callosities, dense sites of a giperkeratoz under which the ulcer is formed are formed. At a neyropatichesky ulcer integuments warm and dry; on foot attritions, deep cracks, painful ulcers with hyperemic, edematous edges are found.
Osteoartropatiya or Sharko's joint as a form of diabetic foot, is characterized by destruction of the bone and articulate device that is shown by osteoporosis, spontaneous changes, swelling and deformation of joints (is more often than knee). At neyropatichesky hypostasis there is a congestion of interstitsialny liquid in hypodermic fabrics that even more aggravates pathological changes of feet.
Preservation of a pulsation on arteries, decrease in reflexes and sensitivity, painless ulcer and necrotic defeats of fabrics with a significant amount of exudate, localization of ulcers in places of the raised loading (on fingers, on a sole), specific deformations of foot (the hook-shaped, molotkoobrazny fingers acting heads of bones) is typical for different types of a neyropatichesky form of diabetic foot.
Diagnostics of diabetic foot
Patients with high risk of development of diabetic foot have to be observed not only at the endocrinologist-diabetologa, but also the chiropodist, the vascular surgeon, the orthopedist. An important role in identification of changes it is allocated for self-inspection which purpose – in time to find the signs characteristic of diabetic foot: skin color change, emergence of dryness, puffiness and pain, curvature of fingers, fungal defeats and so forth.
Diagnostics of diabetic foot assumes collecting the anamnesis with specification of duration of a course of diabetes, survey of feet with definition of a lodyzhechno-humeral index and reflexes, assessment of tactile, vibration and temperature sensitivity. Special attention at a syndrome of diabetic foot is paid to data of laboratory diagnostics – to indicators of level of glucose of blood, glikozilirovanny hemoglobin, cholesterol, lipoproteid; to existence in urine of sugar and ketone bodies.
At an ischemic form of diabetic foot UZDG of vessels of the lower extremities, a X-ray contrast angiography, peripheral KT-arteriography is carried out. At suspicion on an osteoartropatiya the foot X-ray analysis in 2 projections, radiological and ultrasonic densitometry is carried out. Existence of ulcer defect demands obtaining results of a bakposev of the separated bottom and edges of an ulcer on microflora.
Treatment of diabetic foot
Serve as the main approaches to treatment of diabetic foot: correction of carbohydrate exchange and HELL, unloading of the affected extremity, local processing of wounds, system medicamentous therapy, at inefficiency - surgical treatment. For the purpose of optimization of level of a glycemia at diabetes of 1 type correction of a dose of insulin is made; at diabetes 2 types – transfer of the patient to insulin therapy. HELL β-blockers, APF inhibitors, antagonists of calcium, diuretics are applied to normalization.
It is in the presence purulent - necrotic defeats (especially at a neyropatichesky form of diabetic foot) it is necessary to provide the mode of unloading of the affected extremity by means of restriction of movements, use of crutches or the wheelchair special orthopedic adaptation, insoles or footwear. Existence of ulcer defects at a syndrome of diabetic foot demands carrying out systematic processing of a wound – excision of nekrotizirovanny fabrics, bandagings with use antibacterial and antiseptics. Also around an ulcer it is necessary to delete callosities, natoptysh, sites of giperkeratoz to lower load of an affected area.
System antibiotic treatment at a syndrome of diabetic foot is carried out by medicines of a wide range of antimicrobic action. Within conservative therapy of diabetic foot medicines of a-lipoic acid, a spazmolitika (, a papaverine), haemo dialyzate of serum of calfs, infusions of solutions are appointed.
The severe damages of the lower extremities which are not giving in to conservative treatment demand surgical intervention. At an ischemic form of diabetic foot endovascular dilatation and stenting of peripheral arteries, a tromboembolektomiya, popliteal and-foot shunting, an arterialization of veins of foot, etc. is applied. For the purpose of plastic closing of big wound defects the autodermoplastika is made. According to indications drainage of the deep purulent centers is carried out (abscess, phlegmon). At gangrene and osteomyelitis the risk of an amputation/exarticulation of fingers or foot is high.
Forecast and prevention of diabetic foot
Wound defects at diabetic foot badly give in to conservative therapy, demand long-term local and system treatment. At development of an ulcer of foot amputation is required to 10-24% of patients that is followed by an invalidization and increase in mortality from the developing complications. The problem of diabetic foot dictates need of improvement of level of diagnostics, treatment and medical examination of patients with diabetes.
Prevention of a syndrome of diabetic foot provides obligatory control of level of glucose in blood in house conditions, regular observation at a diabetolog, observance of the required diet and the scheme of drug intake. It is necessary to refuse wearing close footwear in favor of special orthopedic insoles and footwear, to carry out careful hygienic care of feet, to carry out special exercises for feet, to avoid traumatizing the lower extremities.
Observation of patients with diabetic foot has to be carried out in specialized offices or offices. Special care of feet, atraumatic manipulations and local treatment will be organized by the narrow expert - podiatry.