The Diabetic Foot Ulcer: A Multidisciplinary Approach
Saturday, February 04, 2012
Diabetic foot ulcers, also referred to as mal perforans or neurotrophic ulcerations, are the leading cause of hospitalization in patients with diabetes.
Lower extremity ulceration is also the leading cause of partial foot and leg amputations. Treatment of the neurotrophic ulcer is often problem focused and does not address the complex underlying etiologies. Incorporating a multidisciplinary approach is essential to achieve rapid closure of the wound, prevent recurrence, and ultimately reduce the incidence amputation.
The underlying etiology of the diabetic foot ulcer includes peripheral neuropathy, increased plantar pressures, and peripheral arterial disease. Complicating factors often include inadequate glycemic control, infection, and poor nutritional status.
Successful treatment requires a comprehensive medical evaluation to assess and manage the multiple co-morbidities that frequently present with these patients.
Surgical debridement, mechanical off-loading, and infection management are principle modalities for treating the neurotrophic ulcer. Extrinsic off-loading, which includes pressure relief shoes, total contact casting, and non weight-bearing status are often successful. Recalcitrant cases may require surgical intervention. Achilles tendon lengthening and resection/correction of osseous deformities have been used successfully to decrease plantar pressures.
Vascular intervention in the diabetic patient with peripheral arterial disease is often indicated. Noninvasive vascular studies, such as Pulse Volume Recordings, ABI, and segmental pressures, are used to assess the degree of PAD. Recent advances in the field of endovascular surgery may offer a less invasive alternative to traditional revascularization procedures.
Case Study
A 51-year-old female patient with 20+ year history of poorly controlled IDDM presents with an infected neurotrophic ulcer on the plantar aspect of the right foot. She relates a several-month history of progressively worsening symptoms with increased redness, swelling and drainage over the past week. Her history includes chronic renal failure, CABG, retinopathy, peripheral neuropathy, and Charcot osteoarthropathy of the right foot with ulcer.
Physical exam demonstrates diminished vascular status with DP and PT pulse biphasic on doppler. Complete loss of protective sensation was noted throughout both lower extremities. An extensive ulcer is noted on the plantar lateral aspect of the right foot. There is gross collapse of the midfoot with rocker-bottom deformity and rigid Charcot changes. The 4.5cm diameter wound had a mixed fibrotic and necrotic base with surrounding hyperkeratotic tissue. Surrounding erythema and malodor were present. No purulent drainage or focal abscess was noted. The wound probed to the level of bone.
The patient has mild leukocytosis, HgA1c 8.6, Albumin 2.6, Sed Rate >100. Wound cultures: Methicillin Sensitive Staph aureus. X-rays showed extensive degenerative changes throughout the midfoot. Rocker bottom deformity noted. Findings were consistent with consolidated Charcot arthropathy. Tc99 Three phase bone scan was highly suspicious for osteomyelitis of the right foot.
The following assessment was made: limb threatening neurotrophic ulcer of the right foot; uncontrolled diabetes with vascular and renal manifestations; peripheral neuropathy; and diabetic Charcot osteoarthropathy.
The patient was hospitalized and immediately started on broad spectrum IV antibiotics. Endocrinology and Infectious Disease consultations were obtained to control rampant blood sugars and infection management, respectively. Noninvasive vascular studies revealed adequate perfusion to the right foot. Podiatric surgical consult was ordered for management of the wound.
Surgical debridement of the right foot wound was performed. There was extension into the deep fascia and plantar ligaments as well as osseous involvement. Aggressive debridement of necrotic, fibrotic, and non-viable tissue is indicated to obtain a healthy, granular wound base. Once the wound was stabilized, negative pressure wound therapy (Wound VAC) was initiated.
The patient was placed in a custom CRO (Charcot Restraint Orthotic) walker to achieve offloading of the wound. The patient underwent long-term IV antibiotics and was followed as an outpatient. Serial debridements, progression to advanced topical wound therapies, and continuous education were successful to achieve closure of the wound.
In conclusion, a comprehensive, multidisciplinary approach for treatment of the neurotrophic ulcer is critical to achieve long-term success and thereby reduce the incidence of lower extremity amputations.
Dr. Joseph Bartal is a board-certified foot and ankle surgeon with expertise in foot and ankle trauma, diabetic limb salvage and wound care. He is a member of the Southwest General Medical Staff.
MD News January/February 2012, Cleveland/Akron/Canton
Congratulations on presenting the issues of the diabetic foot with a relevant case presentation.
Great article!!!!