How to treat a Diabetic Foot and save a limb

Diabetic foot problems are a major cause of hospitalization and prolonged hospital stay. 15 % of
all diabetics will develop foot ulcer during their life time. Diabetic foot complications is greater than all the other complications of diabetes combined, CAD, VD, retinopathy & nephropathy. Throughout the world this is the scenario. So, every effort should be made to prevent the development of neuropathy to prevent diabetic foot complications. In this article every effort was made to explain the development of ulcer, its pathogenesis and how manage it in a primary care set up so that we can arrest the further leading complications and to prevent amputation. Indian diabetic foot problems are mainly neuropathic and not critical ischemic as is seen in western countries. So, if we identify early and manage early the diabetic foot ulcer we can prevent amputation.

Normally we have seen many of the Indian people walking bare foot day in and day out. But they don’t cause any foot problems because of intricate mechanism of the foot. The human foot is a complex structure composed of 26 bones and 33 joints. It has more than 100 muscles, tendons and ligaments and a network of blood vessels and nerves, skin and soft tissues. It is also soft but rigid. It is elastic and flexible and serves the purpose of shock absorber and propulsion engine. It took nearly 4 million years of evolution to perfect the human foot. Human foot is an engineering & architectural marvel. It cannot be compared to any structure. All these structures work together to provide the body support, balance and mobility. A structural flaw or malfunction as it occurs in diabetes or leprosy will result in the development of foot problems like hammer toe, in growing nail, charcot’s arthropathy and pathophysiological alterations like autonomic neuropathy and peripheral neuropathy causes the development of fissures, corn, Callus, dry skin etc. which predisposes the development of foot and super added infection.

Such an engineering marvel should be protected and saved.. Even if it is suffering from Diabetic
complications foot ulcer the foot must be saved at any cost. Deformed diabetic foot is better than
absent foot. Nowadays incidence of diabetic is rising. It is estimated that in 2030 the number of
diabetics in India are estimated to be around 79.4 million. Among these about 15- 20 % will have
diabetic foot problems.

For a diabetic foot ulcer amputation is not the answer.. 50 % of the amputated person will
loose their life in about 5 years. In 50 % of the amputees they will loose the other leg in about 5 years.

So It is the beginning of the end. So, in diabetes the affected limb must be saved at any cost. Deformed limb is better than absence of limb.

Today we are seeing more number of lower leg amputations. Even for minor ulcer of a toe
infection amputations is carried out. Reason being poor knowledge of diabetic foot problems among
the public and poor knowledge of diabetic foot management among the clinicians, be it a general
practitioner, physician or a surgeon.

Proper repeated, patient education about the foot problems to the diabetic persons and proper
knowledge about the diabetic foot ulcers to the clinicians will reduce the incidence of lower limb

Tight control of the blood sugar in diabetic individual protects a person from neuropathy and
getting foot ulcer as has been proved by UKPDS study.

Pathogenesis of diabetic foot ulcer:

Anatomical basis of diabetic foot infection: Arches of the foot helps in the equal distribution of
body weight. In diabetes this equal distribution is affected resulting in new pressure points. This is the starting point of foot ulcer in diabetes. Majority of the diabetic foot ulcer are in the region of 1st meta torso phalangeal joint.

High pressure points with dry and brittle skin leads to callus formation in the foot which acts as
a foreign body which causes tissue damage and ulceration of the foot.

Normally,while standing the plantar tissue becomes ischemic. Every time the foot is lifted from the
ground the pressure is released and the capillaries open and the blood supply is restored. When a
normal individual stands he feels uncomfortable and changes his position, the blood supply is restored.But in a diabetic individual due to neuropathy he don’t feel uncomfortable, due to lack of sensation sand stands still continuously resulting in ischemia and tissue injury.

In diabetes due to neuropathy the foot becomes insensitive foot. The insensitive foot is vulnerable to repeated minor injury or thorn or nail prick. Nail or thorn may be present in the foot wear causing
repeated injury for days together getting it deeper ulcer, later infection aggravates the condition.

Due to autonomic neuropathy there is decreased sweating in the diabetic foot. Dry skin causes
fissure and cracks in the sole. Super added injury and infection causes an ulcer.

Increased susceptibility to infection is multi factorial. There is wide range of impaired poly morpho
nuclear function. There is impairment of chemotaxis, phagocytosis, and bactericidal activity. There is
reduced T lymphocytes, reduced CD/CD8 ratio, reduction of IgG & Igm and reduction in functional
activity of complement components. Increased blood viscosity leads to incidence of thrombosis. Poor blood supply leads to poor supply of antibiotics to the affected areas.

Tendons of lower limb connect the foot to the leg. Tendons are avascular. So, tendons spread the
infection from the tip of the toe to the leg very quickly

Precipitating Causes of foot ulcer: Repetitive trauma due to thorn/nail, walking, foreign body, self
surgery, barber surgery, insect bite like ants rats, etc. massage, chemical injury, pressure injury etc.

Off loading the foot: First to do in the management of diabetic foot ulcer is giving rest to the
affected foot. It is called off loading the foot. The patient must be advised strict bed rest till the
ulcer heals. Because above the person’s weight is on the foot and below the earth is giving
thrust to the foot. In between the foot is getting jammed. To remove this pressure the foot is
offloaded for quick healing of the ulcer.

Oedema: In diabetic foot ulcer edema leg causes accumulation of protein rich fluid in the foot which is an ideal environment for bacterial colonization. Infection spreads through tendons to the distant leg.

Decompression: By just doing the surgical decompression i.e. making an incision over the edematous
region, the tension in the leg or foot is relieved. By relieving the tension blood supply to the distal
affected region is improved. By improving the blood supply the nutrients to the affected part is
improved. Venous return improves. Antibiotic supply to the ulcer area improves. With good glycemic
control and suitable antibiotics administration and with the improvements in nutrient and blood supply the ulcer heals as early as possible. While making an incision one must take utmost care not to injure vital neurovascular structures.

The management of diabetic foot problems is complicated and requires lot of patience and

The presenting ulcer may be of various stages.
1. Simple ulcer
2. Infected ulcer with infection and edema foot
3. Deep ulcer requiring toe amputation
4. Large ulcer with infection and septicemia requiring vigorous treatment
5. Severe infection with gangrene requiring amputation.

How to manage a simple ulcer: Examine the foot of every diabetic patient because of it is of
paramount importance. Since most of the diabetic foot problems are painless and the patients are
unaware of it because of insensitive foot.

The presenting ulcer may be simple but non healing for months together. The small ulcer which
appears to be a small and superficial may be only the tip of the iceberg. It may be a penetration deep
into the deeper tissues.

If it is contaminated ask the patient to wash the ulcer and its surroundings in running water. By
washing in running water most of the foreign materials are removed. Clean the surrounding areas of the ulcer with savlon or iodine solution. After cleaning the wound apply a saline gauze, pad and apply a tight bandage.

Scrapping: Sometime the ulcer may be superficial, no edema. Make the chronic non healing ulcer in to an active bleeding ulcer by scrapping with the back of the blade handle. By scrapping the ulcer bed, the blood supply to the affected part is improved and healing process is initiated resulting in good healthy granulation tissue. The ulcer heals very quickly with good glycemic control.

Scooping: Scooping out all the purulent material from the ulcer bed. By just scooping the dead tissue
and pus the wound gets cleaned.

Callus: If the person present with callus, cut away all the callus tissue and clean the ulcer. Underneath the callus it harbors the foreign bodies like small stone, sand, hair etc. These foreign bodies will irritate the underlying healthy tissue and erode and lead to deeper ulcer involving the muscle, deep tissue and even bone. So, callus has to be excised for early healing of a foot ulcer.

Discharging sinus: If a diabetic foot ulcer present with discharging sinus i.e. serous or purulent
discharge, probe the wound with the help of a probe i.e. sterile artery forceps and assess the depth of
the wound and where it goes ( to find any important structure like nerve of vessel) Explore the wound to find any dead tissue like tendon or any bone, and remove all the necrotic material , cut and remove as long as you can till there is dead tissue. Once the dead tissue hidden in the discharging wound is removed the ulcer will heal automatically with suitable antibiotics and good glycemic control.

Debridement: Early healing of a diabetic foot ulcer depends upon early removal of all the devitalized
tissue. Surgical debridement should be adequate. Deride all the devitalized structures like skin, deep
sub cutaneous tissues, muscle, tendons, bone etc.

Drainage: All the pus pockets should be explored and drained. Drainage must be adequate otherwise
purulent material will accumulate and it will become good culture media for the organisms to multiply in millions in a short time. With poor glycemic control the infection will spread rapidly to the deeper compartments and ascend up to the leg through the tendons. While doing surgical debridement the doctor should aware of the vital structures like the feeding vessels and the important nerves supplying that area. (Surgical anatomy) Aggressive and adequate debridement if indicated.

Abscess: Abscess should be drained adequately with generous incision. Incision should extend the
length breath of the abscess. Don’t put small incision. The drainage will not be adequate with very small incision. It will not heal easily. If the incision is generous the drainage will be adequate and should be deroofed. The wound will heal very quickly.

The single most important factor in preventing amputation is elaborate, detailed repeated education of the patient in diabetic foot care. If each one of the reader treat a diabetic foot ulcer early we can prevent thousands of limb every year.

Even though diverse no. of dressing materials are used over the times like antiseptic cream,
betadine, dilute acetic acid solution, acriflavin, mercurochrome,silversulphadiazine, honey, animal tissue & fat, amniotic membrane, placental bits, etc. normal saline dressing stood the test time. Because normal saline mimics physiological body fluid, and organism will never grow in normal saline. It also keeps the wound surface wet. Acts as a good absorbent of secretions.

Epidermal growth factors of immense value once the infection is controlled. It is of no use in the
presence of infection. They accelerate the growth of epidermis to cover the wound.

The dressing should consist of three layers. First, saline gauze to cover the wound surface. Wound area should be packed with sterile saline gauze. Second, gauze cotton gamgee pad to absorb the purulent or serious collection over which the third layer, bandage roll is rolled to keep the dressing in place.

The dressing should be changed daily or twice daily if there is more collection in the pad.

Once the healing process has started, by the appearance of pink red granulation tissue dressing can be done once in two days.

Throughout the course of the treatment blood sugar should be kept less than 150 mg/dl. Regular
shout acting insulin is the insulin of choice administered 6th hourly. Blood sugar estimation should be done 6th hourly before giving insulin injection and dosage titrated according to the blood sugar value.

At the start of the treatment urine should be analyzed for ketone bodies. Wound swab taken from the deeper structure should be sent for pus culture and sensitivity. Accordingly antibiotics should be
administered once the culture result is known.

Diabetic foot ulcer is an emergency. It should be dealt with immediately. Otherwise we may have
to lose the limb.

My own experience
Total no. of diabetic foot ulcer... 262
Toe disarticulation...10
Gangrene ... 08
Amputation.. 03

In my experience the duration of the ulcer ranges from 10 days to 18 months. 99 % of the ulcers healed well in quick time. The treatment ranges from scrapping of the wound, decompression, and
debridement. At the end if necessary skin grafting was done. With good glycemic control, off loading of the foot with adequate regular debridement of all dead tissues. Debridement of decompression should be done as early as possible as the patient is admitted. If it is delayed we will end up amputation. Pus should be sent for culture and sensitivity. Accordingly antibiotics should be administered. In severe infection parenteral antibiotics is advised. Blood sugar should be kept under control i.e. less than 150mg/dl. Regular human insulin (short acting) is the insulin of choice. Without debridement the wound will not heal and the blood sugar will not fall. Once we start debridement the infection gets controlled with antibiotics and the blood sugar also begins to fall.

Doctor Dr. Vijayarathinam P, 2012102113:24:08

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