Diabetic foot - treatment
Many people are involved in the overall care of diabetic foot problems:
 | Diabetologist and diabetes specialist nurse |
| Vascular surgeon |
| Orthopaedic surgeon |
| Nurse |
| Podiatrist |
| Orthotist |
The management of the diabetic foot ulcer depends on the primary cause of the ulcer. Management may therefore be channeled to a specialist once the foot has been assessed and the main underlying cause determined. Initial referral is usually to a diabetologist or a vascular surgeon.
Infection and gangrene
This requires rapid treatment with antibiotics. Cultures swabs are taken to identify the bacteria involved so that appropriate antibiotics can be used. Bed rest and elevation of the infected area to prevent swelling is needed. Accurate control of blood sugars may need the use of insulin in patients normally on tablets.
If the infection is severe, with the formation of pus, urgent surgery may be needed. Often the infection is worse than it may appear. The picture shows a foot once infected/dead tissue has been removed:
Neuropathic ulcer
In this case the ulcer is due to loss of sensation in the foot allowing pressure to cause ulceration over a longer time than infection.
Treatment involves redistributing the weight off the ulcerated area. The orthopaedic surgeon and the orthotist are mainly involved in this. Methods used include total contact plaster casting (light-weight scotch-cast is used), extra foam padding, moulded insoles and the wearing of semi-rigid shoes with a hole for the ulcer.
Once the ulcer has healed, redistribution of weight must continue with the use of moulded insoles to prevent recurrence of ulceration.
Ischaemic ulcer
This is due to arterial disease causing a lack of blood supply to the foot. An angiogram will be necessary to assess the exact extent of the disease.
Treatment involves a bypass operation to improve the blood supply to the foot (see critical ischaemia). As the bypass graft has to be taken to small arteries below the knee and sometime the foot, vein grafts are used. These grafts are taken from the patient's own leg or arm. Any gangrenous areas on the foot have to be removed.
Because the bypass graft is onto very small arteries, the chances of success are slightly less than the bypasses considered in critical ischaemia .
In addition to bypass grafting a careful assessment of neuropathy has to be undertaken and appropriate shoes made.
Amputation
Sometimes the situation is beyond salvage and an amputation is the only choice. Usually this is below the knee, sometimes above. In this example bones making up the ankle joint have been destroyed by infection - pain was not felt because of diabetic nerve damage. This is known as a 'Charcot joint'.
