(First published in THE HINDUSTAN TIMES on Tuesday, 6th August 2013)Diabetes has proved itself a silent killer disease. Today in the world maximum numbers of the patients are suffering from this disease, and moreover they are passing through the complications too. The World Health Organisation estimated that in the year 2000, 150 million people had diabetes mellitus, and it is predicted that this number will rise to 366 million by the year 2030.The life style, diet and addictions are adding fuel to fire. Evidence prove that the patho-physiological process of diabetes have put the foot at increased risk for tissue damage. As soon as tissue damage has occurred,the foot is at risk for end stage complication including gangrene and amputations.
50% of all lower extremity amputations are diabetes related. 70% of these are preceded by a foot ulcer.3-10% of those with diabetes have a foot ulcer.15% of all those with diabetes will, during their life time develop an ulcer. The international working group on the diabetic foot proposed the PEDIS classification: It grades the wound on the basis of 5 feautures1. i.e. perfusion,Extent (area) ,Depth, Infection and sensation this actually helps in planning and deciding the treatment.
Patient with diabetes because of various grades of eye involvement, they have difficulty in seeing well and thus more prone to injuries, loss of sensations in feet due to neuropathy also has same effect and many of them may be old and left alone by the family thus it is very important to understand that such patients may slip easily in wet floors, the dirty water can cause serious infections in their ulcers/cracks in the feet due to dryness. The moisture in environment also encourages bacterial growth and chances of insect bites ranging from small insects to even scorpions become easier and commoner, as these can hide in the shoes.Therefore all such patients must check the shoes inside for any foreign body including insects and even rats.
CAUSATION
To date no treatment which prevents or reverses development and progression of neuropathy(loss of sensations) has been identified. Neuropathy is the most significant risk factor for diabetic foot ulcers and is present in over 80% of patients with diabetes and foot lesions. It is quite evident that in the majority of cases (56%), infection was the sole predominant feature while others had associated vascular disease /neuropathy.
The polymicrobial infection has to be treated with proper wide spectrum antibiotics in adequate dose for adequate time. The use of routine antibiotics also is one factor for such high number of dreaded complications.Local antibiotics infiltration and topical usage has an off label use. We have sufficient experience to advise its use.
TREATMENT
Precise diabetic control , proper broad spectrum antibiotics, vascular interventions, endovascular stents where indicated, vasodilators, treatment for neuropathy and aggressive debridement excising all dead and dying tissues and only leaving healthy tissue which must be profusely bleeding needing elastocrepe bandage and several feeding tubes can be left in the wound over tulle grass gauzes and the outer end is out of dressing. As soon as the granulation tissue is healthy free use of growth factors, skin grafts, pedicles or even free graft leads to gratifying results. All efforts can be totally crashed by allowing the patients of neuropathy, to move on deformed foot with pressure points leading to reulcerations and failure of the efforts to salvage the limb. Tow things need to be emphasized that all patient with diabetes must put on seamless socks of cotton, but these are expensive and just reversing a normal cotton sock and using this can save money as now seam will not come in direct contact of the feet. Secondly most of the patients of Diabetic foot will need modified shoes to off load the pressure points. Without such shoes the problem will occur recurrently and the limb may be lost. Rainy season comes with warning that all must be careful so that patients may not catch serious infection, may not slip and must only consult an expert.Delay leads to very serious consequences in this dreaded disease.
Remember a dictum, 'you give an inch to diabetes, it will take the whole limb'. Today poor vascularity and neuropathy two problems are confronting with the medical science and so colour dopplar study and Neuroptahy must be investigated and finally Pedography which will analyse and indicate the pressure points which have to be offloaded with modified shoes.When patient knows these facts ,they ask the doctors concerned to get these done and thus a better state is created for avoiding complications.
Recent alterations in overall treatment specially of surgical and endovascular advances have drastically changed the gloomy scenario, morbidities and results in management of Diabetic foot-The curse of present lifestyle. But taking proper precautions and treatment, all may remain safe.
(First published in THE HINDUSTAN TIMES on Tuesday, 6th August 2013)
Professor (Dr) Rama Kant, Citizen News Service - CNS
August 2013
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