The Long and Winding Road of Foot Disease in Patients With Diabetes

Foot disease is one of the most devastating complications of diabetes mellitus. The appearance of a foot ulcer transforms a subject with diabetes into a high-risk patient for the rest of life. This patient will have acute episodes characterized for re-ulceration that is commonly complicated by infection, limb ischemia, or they may develop acute neuroarthropathy. The outcomes of the treatment of these acute episodes may be healing (sometimes), amputation (unfortunately), longstanding nonhealing ulcers, and, sometimes, the demise of the patient. When outcomes of acute episodes are favorable, the patient is considered “in remission,” that is, the chronic state of the disease. The chronic state may be defined by the persistence of the factors that lead to the development of the ulcer without frank ulceration. Chronic and acute states are both challenging. Clinicians in charge must be well informed about the complexity of diabetic foot disease and accept that successful management of the patient, as a whole, is a team effort. Clinical management of foot disease is best achieved treating the patients in a multidisciplinary setting as exemplified by the success of the Kings College Hospital Diabetic Foot Clinic pioneered by Michael Edmonds. Learning from experienced multidisciplinary centers is of primary importance for doctors who want to develop new experiences in their regions. The acute state is defined by the presence of a foot ulcer. The priority is to accurately diagnose the etiology of the ulcer in order to determine the appropriate treatment pathway. Foot ulcers may be classified into 3 main types: neuropathic, ischemic, and neuroischemic. Infection is common in every ulcer type; this complicates treatments and worsens outcomes. In cases of neuropathic ulcers, offloading, debridement, and removal of surrounding hyperkeratosis are among the mainstays of standardized care, others being controlling diabetes and so on. Standard care works variably; it is difficult to precisely define the reasons for such variability; however, adjuvant therapies exist with the potential to help wound healing: topical PDGF is one example of such advanced adjuvant methods. A range of adjuvant methods exist and are used variably even though high-quality evidence of their wound healing efficacy is lacking. This notwithstanding advanced adjuvant therapies must not be used in isolation but only with appropriate offloading and debridement. When treating neuroischemic and ischemic ulcers, it is important to ensure appropriate blood perfusion into the foot. Vascular surgeons and interventional radiologists have important roles in the management of such patients. Patients with diabetes develop infrapopliteal disease, which may go onto critical limb ischemia. Endovascular revascularization or distal bypasses are offered as treatment, which requires expertly trained surgeons and knowing all the technical pearls in order to succeed. Local and/or general conditions of the patients may limit the use of revascularization. Medical management of these patients is required to maintain quality of life while trying to achieve healing using several treatments. Infection is a dramatic complication of the patient with a foot ulcer especially when infection complicates an ischemic foot. It is possible to save limbs in such difficult conditions; some centers are very experienced managing this acute problem following an aggressive approach. There are several types of infection that may complicate a foot ulcer. A worrying concern is the appearance of multidrug-resistant organisms. This confers additional complexity to the case, and the opinion of infectious diseases specialist is of primary importance. One of the most frequent infections in the diabetic foot is osteomyelitis. New evidence supports the treatment of diabetic foot osteomyelitis exclusively with antibiotics. Taking a bone biopsy for culture is a modern approach to an old problem. However, surgery should not be considered old-fashioned and still has an important role on the treatment of diabetic foot osteomyelitis. Surgery of diabetic foot osteomyelitis does not mean amputation. It has been reported 557231 IJLXXX10.1177/1534734614557231The International Journal of Lower Extremity WoundsAragón-Sanchez and Mani research-article2014