The topic of the day is diabetic foot complications!
What does it mean when podiatrists say ‘diabetic foot complications?’
A cohort study done in 2015 in California by Al-Rubeean et al describe diabetic foot complications as a serious consequence of diabetes mellitus and can threaten medical and economic sectors alike. Complications such as Diabetic Foot Ulcerations, Diabetic Foot Infections and Gangrene. However, identifying its risk factors and the extent to which diabetic foot complications can impact different sectors, can enable practitioners to build effective prevention programs such as diabetes registries that are currently set up in countries such as Denmark, Sweden, Singapore, Malaysia, Saudi Arabia and Thailand (Al-Rubeean, et al., 2015).
A study done by Al-Maskari et al., 2015 found that peripheral neuropathy (PN) and peripheral vascular disease (PVD) are quite well-known risk factors for diabetes and patients who have both PN and PVD, even those that are asymptomatic, are at risk of diabetic foot complications such as ulceration and infection, leading to non-traumatic amputations (Al-Maskari & El-Sadig, 2007).
Complications that involve the lower limb tend to be the most common manifestations of diabetes (Al-Maskari & El-Sadig, 2007). It was interesting to note that in the Al-Rubeean et al study, even though a majority of the participants were diabetes type 2 patients, the prevalence of diabetic foot complications were reportedly higher amongst the type 1 diabetic patients (Al-Rubeean, et al., 2015). In conclusion, it was noted that the reason for such results could be the duration of diabetes the patient had experienced. The study gleaned that the relationship between poor glycemic control and diabetic foot conditions were consistent with their findings and that there was a clear association between poor glycemic control and higher rates of diabetic foot lesions (Al-Rubeean, et al., 2015).
Diabetic retinopathy and nephropathy were contributing players amongst the diabetic population. Microangiopathic changes and renal impairment could explain the delayed healing pathways and retinopathy, affecting vision, could increase the diabetic patients' chances of foot trauma (Al-Rubeean, et al., 2015).
An article from Armstrong et al, from 1998 is really quite fascinating. The article discusses management in terms of preventative measures, and how family physicians play an important role in diagnostics of diabetes thereby preventing diabetic complications. Since this article is from an American journal, the medical terminology in terms of primary and secondary care may be a little different however, the discussion of preventative measures and outlining the risk factors seems to be relevant in current practice and seems little has changed in the school of thought (Armstrong & Lavery, 1998).
Armstrong et al, outline 3 major points that are currently in practice with diabetic care. Patient education on risk factors, routine evaluation and preventative maintenance, i.e annual diabetic assessments as is currently called (Armstrong & Lavery, 1998).
Peripheral Arterial Occlusive Disease:
This disease is higher in patients with diabetes than in patients that do not suffer from diabetes. Smoking, hypertension and hyperlipidemia increase the chances of peripheral arterial occlusive disease in diabetic patients. Clinical signs and symptoms of lower limb ischemia include claudication, pain in the arch or forefoot during rest or at night, absent popliteal or posterior tibial pulses, thinned or shiny skin, absence of hair on legs or big toe, thickened nails, redness when legs are dependent and pallor when legs are elevated. Non-invasive vascular tests are helpful and include the ankle-brachial pressure index (ABPI) and absolute toe systolic pressure (Armstrong & Lavery, 1998).
Armstrong et al., 1998, discuss the importance of tissue perfusion for wound healing, therefore if there are any signs that arterial insufficiency could be present then that increases the chances of wound healing failure. Adequate control of concomitant hypertension and hyperlipidemia can help reduce the chances of peripheral arterial occlusion disease (Armstrong & Lavery, 1998).
Sensory and Autonomic Neuropathy:
Distal symmetric polyneuropathy is stated as a common complication affecting diabetic patients. In fact, neuropathy is an etiologic component to a diabetic foot ulcer and is clinically seen in 82% of diabetic foot cases (Al-Rubeean, et al., 2015). Autonomic neuropathy has several common manifestations in the diabetic foot such as denervation of dermal structures leading to a decrease in sweat gland function leading to anhidrotic skin which becomes a breeding ground for fissures and infection portholes (Armstrong & Lavery, 1998).
An interesting factor, as presented in the article by Armstrong et al., 1998, was also witnessed by myself in the clinic. Which was the confusing outcome of patients that have vascular competency (termed as ‘autosympathectomy’), leading to an increase in blood flow, this being the primary etiological factor in the pathogenesis of Charcot’s joint and several foot complications (Armstrong & Lavery, 1998).
Structural Deformity and Limited Joint Mobility:
A majority of diabetic foot ulcers form over bony prominences, this is quite common in diabetic patients with neuropathy. Bunions, hammer-toes and calluses can lead to abnormal bony prominences, this is seen more in diabetic patients as is hypothesized that the atrophy of intrinsic musculature that helps stabilize the foot. Rigid deformities and limited ranges of motion at the subtalar joint or metatarsophalangeal joints have been linked to foot ulceration in diabetic patients. Other injuries include hot water bottle/soaks leading to thermal trauma, and puncture wounds (Armstrong & Lavery, 1998) (Al-Rubeean, et al., 2015).
References
Al-Maskari, F. & El-Sadig, M., 2007. Prevalence of risk factors for diabetic foot complications. BMC Family Practice, 8(59).
Al-Rubeean, K. et al., 2015. Diabetic Foot Complications and Their Risk Factors from a Large Retrospective Cohort Study. [Online] Available at: https://journals.plos.org/plosone/article/citation?id=10.1371/journal.pone.0124446 [Accessed 21 June 2021].
Armstrong, D. G. & Lavery, L. A., 1998. Diabetic Foot Ulcers: Prevention, Diagnosis and Classification. American Family Physician, 57(6), pp. 1325-1332.
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