Foot complications are among the most serious and costly complications of diabetes mellitus. Amputation of the lower extremity or part of it is usually preceded by a foot ulcer. A strategy that includes prevention, patient and staff education, multidisciplinary treatment of foot ulcers, and close monitoring can reduce amputation rates by 49–85%. Therefore, several countries and organizations, such as the World Health Organization and the International Diabetes Federation, have set goals to reduce the rate of amputations by up to 50%. The basic principles of prevention and treatment described in these guidelines are based on the International Consensus on the Diabetic Foot. Depending on local circumstances, these principles have to be translated for local use, taking into account regional differences in socio-economics, accessibility to health care, and cultural factors. These practical guidelines are aimed at healthcare workers involved in the care of people with diabetes. For more details and information on treatment by specialists in foot care, the reader is referred to the International Consensus document. Although the spectrum of foot lesions varies in different regions of the world, the pathways to ulceration are probably identical in most patients. Diabetic foot lesions frequently result from two or more risk factors occurring together. In the majority of patients, diabetic peripheral neuropathy plays a central role: up to 50% of people with diabetes with type 2 diabetes have neuropathy and at-risk feet. Neuropathy leads to an insensitive and sometimes deformed foot, often with an abnormal walking pattern. In people with neuropathy, minor trauma – caused, for example, by ill-fitting shoes, walking barefoot, or an acute injury – can precipitate a chronic ulcer. Loss of sensation, foot deformities, and limited joint mobility can result in abnormal biomechanical loading of the foot. Thickened skin (callus) forms as a result. This leads to a further increase of the abnormal loading and, often, subcutaneous haemorrhage. Whatever the primary cause, the patient continues walking on the insensitive foot, impairing subsequent healing (Figure 1). Peripheral vascular disease, usually in conjunction with minor trauma, may result in a painful, purely ischaemic foot ulcer. However, in patients with both neuropathy and ischaemia (neuro-ischaemic ulcer), symptoms may be absent, despite severe peripheral ischaemia. Microangiopathy should not be accepted as a primary cause of an ulcer. All people with diabetes should be examined at least once a year for potential foot problems. Patients with demonstrated risk factor(s) should be examined more often – every 1–6 months. The absence of symptoms does not mean that the feet are healthy; the patient might have neuropathy, peripheral vascular disease, or even an ulcer without any complaints. The patient's feet should be examined with the patient lying down and standing up, and their shoes and socks should also be inspected. After examination of the foot, each patient can be assigned to a risk category, which should guide the subsequent management (Figure 2). Education, presented in a structured and organized manner, plays an important role in the prevention of foot problems. The aim is to enhance motivation and skills. People with diabetes should learn how to recognize potential foot problems and be aware of the steps they need to take in response. The educator must demonstrate the skills, such as how to cut nails appropriately. Education should be provided in several sessions over time, preferably using a mixture of methods. It is essential to evaluate whether the person with diabetes has understood the messages, is motivated to act, and has sufficient self-care skills. An example of instructions for the high-risk patient and family is given in the succeeding part of this article. Furthermore, physicians and other healthcare professionals should receive periodic education to improve care for high-risk individuals. Inappropriate footwear is a major cause of ulceration. Appropriate footwear should be used both indoors and outdoors and should be adapted to the altered biomechanics and deformities – essential for prevention. Patients without loss of protective sensation can select off-the-shelf footwear by themselves. In patients with neuropathy and/or ischaemia, extra care must be taken when fitting footwear – particularly when foot deformities are also present. The shoe should not be too tight or too loose (Figure 4). The inside of the shoe should be 1–2 cm longer than the foot itself. The internal width should be equal to the width of the foot at the site of the metatarsal phalangeal joints, and the height should allow enough room for the toes. The fit must be evaluated with the patient in standing position, preferably at the end of the day. If the fit is too tight because of deformities or if there are signs of abnormal loading of the foot (e.g. hyperaemia, callus, ulceration), patients should be referred for special footwear (advice and/or construction), including insoles and orthoses. In a high-risk patient, callus and nail and skin pathology should be treated regularly, preferably by a trained foot care specialist. If possible, foot deformities should be treated nonsurgically (e.g. with an orthosis). A standardized and consistent strategy for evaluating wounds is essential and will guide further therapy. The following items must be addressed. Ill-fitting shoes are the most frequent cause of ulceration, even in patients with ‘pure’ ischaemic ulcers. Therefore, shoes should be examined meticulously in all patients. Most ulcers can be classified as neuropathic, ischaemic, or neuro-ischaemic. This will guide further therapy. Assessment of the vascular tree is essential in the management of a foot ulcer. If one or more pedal pulses are absent, or if an ulcer does not improve despite optimal treatment, more extensive vascular evaluation should be performed. As a first step, the ankle brachial pressure can be measured. An ankle brachial pressure index less than 0.9 is a sign of peripheral arterial disease. However, ankle pressure might be falsely elevated because of calcification of the arteries. Preferably, other tests, such as measurements of toe pressure or transcutaneous pressure of oxygen (TcPo2), should be used. Figure 5 gives an estimate of the chance of healing using the tests. If a major amputation is being contemplated, the option of revascularization should be considered first. Noninvasive evaluation and estimate of probability of healing: Neuropathic ulcers frequently occur on the plantar surface of the foot or in areas overlying a bony deformity. Ischaemic and neuro-ischaemic ulcers are more common on the tips of the toes or the lateral border of the foot. The depth of an ulcer can be difficult to determine because of the presence of overlying callus or necrosis. Therefore, neuropathic ulcers with callus and necrosis should be debrided as soon as possible. This debridement should not be performed in ischaemic or neuro-ischaemic ulcers without signs of infection. In neuropathic ulcers, debridement can usually be performed without (general) anaesthesia. Infection of the foot in a person with diabetes presents a serious threat to the affected limb and should be evaluated and treated promptly. Infection is diagnosed by the presence of signs and/or symptoms of inflammation, but these may be blunted by neuropathy or ischemia, and systemic findings (e.g. fever, increased white blood count) are often absent. Infections should be classified as mild (superficial with minimal cellulitis), moderate (deeper or more extensive), or severe (accompanied by systemic signs of sepsis). If not properly treated, infection can spread to underlying tissues, including the bone. Patients with a diabetic foot infection should be assessed for the presence of osteomyelitis. When there is a deep wound overlying the bone, especially if it is longstanding and it is possible to touch the bone with a sterile probe, osteomyelitis is likely. Properly obtained specimens for Gram stain and culture of deep tissue are advised; avoid superficial swabs. Mild (superficial and limited) infection is usually caused by aerobic Gram-positive cocci, especially Staphylococcus aureus. Chronic infections and infections that are more severe are often polymicrobial with aerobic Gram-negative rods and anaerobes. If treatment is based on the principles outlined in the succeeding part of this article, healing can be achieved in the majority of patients. Optimum wound care cannot compensate for continuing trauma to the wound bed or for ischaemia or infection. Patients with an ulcer deeper than the subcutaneous tissues should be treated intensively, and, depending on local resources and infrastructure, hospitalization must be considered. In all countries, at least three levels of foot care management are needed: Setting up a multidisciplinary foot care team has been found to be accompanied by a drop in the number of amputations. If it is not possible to create a full team from the outset, this should be built up step by step, introducing the various different disciplines at different stages. This team must work in both primary and secondary care settings. Ideally, a foot care team would consist of a diabetologist, surgeon, podiatrist, orthotist, educator, and plaster technician, in close collaboration with an orthopaedic, podiatric and/or vascular surgeon, and dermatologist. Neuropathy can be detected using the 10-g (5.07 Semmes–Weinstein) monofilament, tuning fork (128 Hz), and/or cotton wisp. Easy-to-use foot screening assessment sheet for clinical examination None declared.
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Bakker et al. (2012) studied this question.