Notice: The most important measures are metabolic optimization and treatment of internal diseases and infection control. The following measures should be performed/observed in the presence of diabetic foot:
- Local wound treatment: wound debridement of avital tissue (wound toilet, i.e., removal of dead tissue); in this context, the so-called “moist wound treatment” has been established as a fundamental principle of the treatment of chronic wounds.
- Preparatory measures (here: rehabilitation of the wound bed):
- After debridement, a deep smear is performed as standard for microbiological diagnosis.
- Therapeutic measures
- Local wound treatment according to the wound situation:
- No signs of infection → moist wound treatment;
- Hydrocolloid dressings for bradytrophic tissue (tissue with slow metabolism) and low wound secretion.
- Alginate and polyurethane foam dressings in early stage wound and environmental edema (= abundant secretions).
- Wound infected→ debridement and antiseptic (wound disinfectant).
- If necessary, local therapy with an antibiotic (according to the result of a resistogram); cephalexin, clindamycin (first-line agent); combination of amoxicillin/clavulanic acid or clindamycin with ciprofloxacin in severe infections (if necessary, also as parenteral therapy).
- No signs of infection → moist wound treatment;
- Local wound treatment according to the wound situation:
- Pressure relief through relief shoes (therapeutic shoes; orthoses with soft padding, plaster technique), if necessary also crutches or wheelchair (see also under “Further therapy“).
- Infection control
- For patients in stage Wagner > 3, the use of hyperbaric oxygen therapy (synonym: HBO therapy; English : hyperbaric oxygen therapy; HBO2, HBOT; form of therapy in which oxygen – usually 100 percent in the inhaled air – is used) or stem cell therapy to prevent amputation may be considered
- If necessary, also pedal interventional or surgical vascular reconstruction (goal: foot preservation).
Operations
- Therapy of vascular diseases: In severe circulatory disorders, catheter intervention with balloon dilatation (widening of the narrowed section of the vessel with the aid of a liquid- or air-fillable balloon catheter) and/or stent (vascular support) is the primary treatment. For further treatment, open bypass surgery is available.
- Foot surgical correction of (toe) deformities.
- Amputation – if unavoidable, restriction to a part of the forefoot; Note: Always seek a second opinion!Note: A particularly high risk of amputation exists in patients who suffer from both gout and diabetes. (Approximately 25-fold increased risk of peripheral limb amputation).
- Bariatric surgery/Bariatic surgery – In severely obese patients, gastric bypass (artificially reduced stomach size) may be indicated in terms of metabolic surgery. According to a study by Schauer et al, 42 percent of diabetics have a normal HbA1c after surgery (laboratory parameter for determining blood glucose over the past days or weeks/HbA1c is, so to speak, the “blood glucose long-term memory“). In another study by Mingrone even 75% of patients achieved remission of diabetes mellitus.
Further notes
