Definition and Terminology
Diabetic foot disease refers to:
foot pathology involving the ankle and distal segments,
associated with peripheral neuropathy,
variable degrees of ischemia,
and/or infection,
most commonly presenting with foot ulceration.
The term “Diabetic Foot Syndrome” was introduced by:
the International Working Group on the Diabetic Foot (IWGDF) in 1993.
In the 2023 update:
the use of the term “syndrome” is no longer encouraged,
as the condition represents a disease entity rather than a syndrome.
The preferred terminology is:
Diabetes-related Foot Disease.
The condition may involve one or more of the following:
peripheral neuropathy,
peripheral arterial disease,
infection,
foot ulcer(s),
neuro-osteoarthropathy,
gangrene,
amputation.
Clinical Importance
Diabetic foot disease is:
among the most severe,
and most costly complications of diabetes mellitus.
Compared with other long-term diabetic complications:
it results in higher rates of hospital admission.
Responsible for:
approximately 50% of all diabetes-related hospitalizations.
Five-year mortality:
approximately 50%,
exceeding that of breast and prostate cancer.
It is the leading cause of non-traumatic lower extremity amputations.
Represents a major global public health problem.
Metabolic Derangements
Insulin resistance and chronic hyperglycemia.
Formation of advanced glycation end products (AGEs):
glycosylated proteins and lipids.
Neuropathy
Motor Neuropathy
Muscle imbalance.
Foot deformities.
Altered biomechanics.
Sensory Neuropathy
Loss of protective sensation.
Inability to perceive pain or pressure.
Autonomic Neuropathy
Reduced sweating.
Dry, fragile skin.
Angiopathy
Peripheral arterial disease.
Combination of:
microvascular,
and macrovascular involvement.
Mechanical and External Factors
Repetitive microtrauma.
Inappropriate footwear:
ill-fitting,
excessively tight or loose.
Walking barefoot.
Thermal injuries.
Penetrating foreign bodies.
Disease Progression
Diabetic foot disease is:
not limited to the presence of a wound.
It represents a multifactorial process involving:
neuropathy,
angiopathy,
mechanical overload.
Ulceration:
is the most common clinical finding,
often serves as the initiating lesion in the pathway toward amputation.
Diabetic Foot Disease in the Geriatric Population
Elderly patients are at increased risk for diabetic foot disease.
Contributing factors include:
visual impairment,
reduced mobility,
particularly involving the hip joint.
Additional Risk Factors in Geriatric Patients
Difficulty with foot care.
Increased duration of diabetes.
Poor metabolic control.
Insulin therapy.
Peripheral edema.
Skin atrophy.
Low socioeconomic status.
History of foot ulceration or amputation.
Epidemiologic Considerations
Prevalence of diabetes increases with age.
Among individuals aged ≥65 years:
prevalence reaches 29.2%.
Diabetes and its complications are largely diseases of the geriatric population.
Data derived from U.S. population studies (2017–2020).
Preventive Approaches in Diabetic Foot Disease
Prevention represents the most effective strategy,
although implementation is often challenging.
Optimal glycemic control:
reduces microvascular and macrovascular complications,
including peripheral arterial disease and cardiovascular disease.
Preventive Strategies: Core Elements
Identification of ulceration risk factors:
sensory neuropathy,
loss of protective sensation,
motor neuropathy,
foot deformities,
bony prominences,
peripheral arterial disease.
Assessment of Sensory Neuropathy
Semmes–Weinstein monofilament testing:
assesses tactile sensation.
Standard test:
5.07 monofilament applying 10 g pressure.
Characteristics:
low cost,
reliable,
easy to perform.
Used for:
detection of diabetic polyneuropathy,
identification of patients at risk for ulceration.
Evaluation of Foot Deformities
Common deformities:
pes cavus,
pes planus,
Charcot foot,
claw toes,
hammer toes.
High-risk pressure points:
metatarsal heads,
heel,
toe tips.
Callus and ulcer-prone areas require careful inspection.
Clinical Forms of Diabetic Foot Ulcers
Superficial ulcer.
Deep ulcer.
Infected deep ulcer.
Acute spreading infection.
Sepsis.
Foot gangrene.
General Treatment Approach for Diabetic Foot Ulcers
Management requires a multidisciplinary approach, involving:
endocrinology (glycemic control),
cardiology,
cardiovascular surgery (revascularization),
interventional radiology,
infectious diseases,
hyperbaric medicine and wound care,
geriatrics and nutrition.
Core components:
infection control,
advanced wound care techniques,
off-loading strategies,
serial debridement and local wound care.
Initial Evaluation of Diabetic Foot Ulcers
First step:
clinical examination and ulcer staging.
Determination of:
presence of complications.
Infection assessment:
based on clinical findings.
Probe-to-bone test:
considered optimal.
Superficial swab cultures are not recommended.
Ischemia assessment:
arterial Doppler,
handheld Doppler,
ankle–brachial index (ABI > 0.9),
CT angiography when indicated.
Management of Superficial and Uncomplicated Deep Ulcers
Assessment of ulcer location:
e.g., hallux plantar callus.
Evaluation for infection:
clinical assessment often sufficient.
Imaging:
plain radiographs to exclude osteomyelitis,
MRI when necessary.
Off-Loading Strategies
Non-Surgical
Custom footwear.
Removable orthoses.
Surgical
First-line procedures may include:
first MTP joint resection arthroplasty,
interphalangeal joint resection,
metatarsal osteotomies,
metatarsal head resections.
Off-Loading Modalities
Braces.
Half-shoes.
Casting techniques.
Total contact cast:
considered the gold standard.
Management of Infected Deep Ulcers
May require:
primary-level amputation.
Deep tissue cultures:
guide antibiotic therapy.
Associated findings:
deep abscess,
osteomyelitis,
necrotic tissue.
Management includes:
radical debridement,
antibiotic-impregnated spacers when indicated.
Acute Spreading Infections
Infection may spread along:
tendon sheaths,
poorly vascularized compartmental structures.
Common pathways:
central compartment via interdigital ulcers,
peroneal tendons proximally,
FHL and FDL tendon sheaths toward the leg.
Infected tendons:
must be excised.
Adjunctive Therapies
Hyperbaric oxygen therapy.
Vacuum-assisted closure systems:
demonstrated progressive wound improvement over time.
Gangrene and Sepsis
Represent advanced stages of diabetic foot disease.
Require urgent and aggressive management.