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Diabetic foot disorders

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Many new therapies that may accelerate wound healing in treatment of ulcers are currently being studied. Growth factor therapy uses various growth factors such as platelet derived growth factors, vascular endothelial growth factors, fibroblast growth factors, and keratinocyte growth factors to stimulate chemotaxis of cells that promote wound healing. Patient’s own platelet rich plasma are being used on wounds to assist with new tissue formation. Bioengineered tissue grafts in some instances have been shown to increase facilitate complete wound closure and currently two of them are approved for treatment of diabetic ulcers. Hyperbaric oxygen therapy, ultrasonic therapy, negative pressure wound therapy, and electric stimulation are all being tested for treatment of diabetic foot ulcers.

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Diabetic foot ulcers if left untreated can lead to gangrene, abscesses, osteomyelitis, and necrotizing fasciitis ultimately requiring amputation of the lower extremitiesextremity. Several amputation options exist, ranging from hallux amputation to below-the-knee amputations, and special considerations must be taken into account for each procedure. More information on the various types of amputations can be found here (http://www.orthopaedicsone.com/display/Main/Diabetic+foot+ulcer). Even with advances in the medical and surgical management of diabetes, the 5-year mortality rate remains poor at approximately 66% after the amputation of a leg.

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Charcot arthropathy is a particularly frustrating and debilitating condition because it can take 6-12 months or more for the involved joints to resolvestablize.  Furthermore, when it does get better, the foot may have collapsed and changed shape. The resulting deformity can put the patient at risk to develop an ulcer over new prominent bony areas.

Additionally, some Some studies suggest that using bisphosphonates (inhibitors of osteoclasts often used to treat osteoporosis) may be helpful in treating Charcot arthropathy by trying to limit osteolysis. Most studies have shown a reduction in markers indicating bone turnover.  However, however, there have been no significant differences in clinical or radiographic outcomes have been reported. Electrical bone growth stimulation to promote rapid healing of fractures has been suggested as a supplement to the treatment of acute Charcot arthropathy. Similar to bisphosphonate therapy, there is no conclusive data for its efficacy.

Surgery may be recommended as a treatment if a severe deformity has occurred or the foot or ankle has become unstable and cannot be corrected through immobilization and off-loading. Surgery ranges from exostectomy (removal of prominent bone) to reconstruction of the foot with including fusion of the bones unstable joints after the deformity is has been corrected. This can involve the use of screws and plates, or rods that go inside the bone, or pins that come out of the bone and skin and attach to a frame on the outside of the foot and ankle. The goal of surgery is to end up with a foot that is stable, can bear weight, and can fit in a shoe or brace and not have problems with ulcers developing over prominent areas of bone. Most surgical procedures that involve fusion will typically require a long period of not putting any weight on the foot or leg for , often 3 months or more. The average time from surgery to therapeutic shoes is approximately 7 months. Surgery for Charcot arthropathy is associated with significant risks including increased risks of infection, problems with wound healing, and non-union.

Figure 7. Surgery using a tensioned thin wire external fixator to treat an unstable Charcot arthropathy

Risk factors and prevention

Cigarette smoking and poor glycemic control increases the risks for diabetic foot ulcerations by worsening diabetic neuropathy and , peripheral artery disease, and the associated wound healing capacity. Previous ulcerations or amputations increase the risk of developing another ulcer. Another risk factor for developing an ulcer is a tight calf muscle (equinus contracture), which increases the lever force of the foot driving the forefoot into the ground with more force.  

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Distinguish infection from Charcot arthropathy

Provide basic patient education information to diabetic patients