What is the management and treatment of diabetic foot?

Management and Treatment of Diabetic Foot

Diabetic foot management requires immediate multidisciplinary team coordination with aggressive surgical debridement, pressure offloading, vascular assessment with urgent revascularization when indicated, and infection control—all delivered systematically to prevent amputation and death. 1, 2

Immediate Assessment and Risk Stratification

Vascular Evaluation

• Measure ankle-brachial index (ABI) and ankle systolic pressure immediately in every patient with a diabetic foot ulcer 3, 2
• If ankle pressure <50 mmHg or ABI <0.5, pursue urgent vascular imaging and revascularization 1, 3
• If toe pressure <30 mmHg or transcutaneous oxygen pressure (TcPO2) <25 mmHg, consider urgent revascularization 1, 3
• The aim of revascularization is to restore direct flow to at least one foot artery, preferably the artery supplying the anatomical region of the wound 1

Neuropathy Assessment

• Test for loss of protective sensation using 10g (5.07 Semmes-Weinstein) monofilament at three plantar sites, 128 Hz tuning fork, or cotton wisp 1
• Peripheral motor neuropathy causes foot deformities (claw toes, high arch, subluxed metatarsophalangeal joints) leading to excess pressure and ulceration 1
• Peripheral sensory neuropathy results in lack of protective sensation, allowing unattended injuries 1

Infection Classification

Mild infection (superficial skin involvement):

• Cleanse and debride all necrotic tissue and surrounding callus 1
• Start empiric oral antibiotic therapy targeting S. aureus and streptococci (cephalexin, flucloxacillin, or clindamycin) 1, 3, 2

Moderate to severe infection (deep, potentially limb-threatening):

• Urgently evaluate for surgical intervention to remove necrotic tissue, including infected bone, and drain abscesses 1
• Assess for peripheral arterial disease; if present, consider urgent revascularization 1
• Initiate empiric parenteral broad-spectrum antibiotic therapy targeting gram-positive and gram-negative bacteria, including anaerobes 1
• Adjust antibiotic regimen based on clinical response and culture/sensitivity results 1

Surgical Debridement

Sharp debridement with scalpel is the cornerstone of treatment and must be repeated as frequently as clinically needed (often weekly or more). 1, 2

• Remove all necrotic tissue and surrounding callus at each debridement session 1, 2
• Obtain tissue specimens by biopsy, ulcer curettage, or aspiration (not swabs) for culture before starting antibiotics 1, 4
• Seek surgical consultation for deep abscess, extensive bone/joint involvement, crepitus, substantial necrosis/gangrene, or necrotizing fasciitis 1, 4

Pressure Offloading

For neuropathic plantar ulcers, use a non-removable knee-high offloading device (total contact cast or removable walker rendered irremovable) as the preferred treatment. 1

• When non-removable devices are contraindicated, use removable offloading devices 1
• For non-plantar ulcers (including heel ulcers), consider shoe modifications, temporary footwear, toe-spacers, or orthoses 1, 3, 2
• Instruct patients to limit standing and walking; use crutches if necessary 1, 3
• If other biomechanical relief is unavailable, consider felted foam with appropriate footwear 1

Local Wound Care

Wound Management Protocol

• Inspect the ulcer frequently 1
• Select dressings to control excess exudation and maintain a moist environment 1, 2
• Consider negative pressure therapy to help heal post-operative wounds 1
• Do not use footbaths where feet are soaked, as they induce skin maceration 1

Treatments NOT Well-Supported

• Biologically active products (collagen, growth factors, bio-engineered tissue) in neuropathic ulcers 1
• Silver or other antimicrobial-containing dressings 1

Adjunctive Therapies

When Standard Care Fails

• Consider systemic hyperbaric oxygen treatment in poorly healing wounds; this may hasten wound healing and help prevent amputations 1, 3, 2, 4
• Granulocyte colony-stimulating factors may help prevent amputations in severe infections 1, 4
• Consider sucrose-octasulfate impregnated dressing for non-infected neuro-ischemic ulcers that haven't improved after 2+ weeks of optimal care 2

Revascularization Triggers

• If ulcer shows no signs of healing within 6 weeks despite optimal management, consider revascularization irrespective of initial test results 1
• If contemplating major (above ankle) amputation, first consider revascularization 1

Antibiotic Duration

• Mild infections: 1-2 weeks usually suffices, some require additional 1-2 weeks 4
• Moderate to severe infections: 2-4 weeks is typically sufficient, depending on structures involved, adequacy of debridement, and wound vascularity 4
• Osteomyelitis: Generally at least 4-6 weeks required, but shorter duration sufficient if entire infected bone is removed 4

Multidisciplinary Team Organization

Establish a multidisciplinary foot-care team, as this approach is associated with significant reductions in diabetes-related lower extremity amputations. 1, 2, 4, 5

Three-Level Care System

Level 1: General practitioner, podiatrist, and diabetes nurse 1

Level 2: Diabetologist, surgeon (general, orthopedic, or foot), vascular surgeon, endovascular interventionist, podiatrist, diabetes nurse, in collaboration with shoe-maker, orthotist, or prosthetist 1

Level 3: Specialized diabetic foot center with multiple experts from several disciplines working together as a tertiary reference center 1

• The team should include or have ready access to an infectious diseases specialist or medical microbiologist 1, 4

Prevention of Recurrence

• Once healed, include patient in integrated foot-care program with lifelong observation, professional foot treatment, adequate footwear, and education 1
• The foot should never return in the same shoe that caused the ulcer 1
• Provide pressure-relieving footwear to reduce ulcer risk (13.3% vs 25.4% with usual care) 5
• Use foot skin temperature measurements with offloading when hot spots (>2°C difference between feet) are found (18.7% vs 30.8% with usual care) 5

Cardiovascular Risk Reduction

• Emphasize smoking cessation, control of hypertension and dyslipidemia, and use of aspirin or clopidogrel 1, 3
• Pharmacological treatments to improve perfusion beyond antiplatelet therapy have not been proven beneficial 1

Common Pitfalls to Avoid

• Do not treat clinically uninfected ulcers with antibiotics 4
• Do not rely on wound swabs; obtain tissue specimens by biopsy, curettage, or aspiration 1, 4
• If infection fails to respond to 1 antibiotic course in a stable patient, discontinue all antimicrobials, wait a few days, then obtain optimal culture specimens 4
• Plain radiography may be adequate for many cases, but MRI is more sensitive and specific for detecting soft-tissue lesions and osteomyelitis 4

Patient Education

• Instruct patients and relatives on appropriate self-care and how to recognize signs of new or worsening infection (fever, changes in wound conditions, worsening hyperglycemia) 1
• During bed rest, instruct on preventing ulcers on the contralateral foot 1
• Annual foot review by general practitioner or podiatrist for all patients with diabetes 6
• Three-monthly foot review for any patient with history of diabetic foot infection 6