Pyptiuk Alexander Vladimirovich doctor honey Sciences,
1. What is a "diabetic foot"?
The diabetes is one of the most important pandemic non-infectious diseases. The list of late complications of diabetes leads to diabetic foot syndrome (SDS), which develops in 30-60% of patients. Each year more than 1 million people with diabetes lose part of the lower limb, every 20 seconds in the world. Amputation is carried out, in which 85% is preceded by ulcers.
Diabetic foot syndrome, as defined by the World Health Organization, is a "foot ulcer (distally from the ankle joint and the ankles) associated with neuropathy, various degrees of ischemia and infection."
Bakker K. InternationalWorkingGroupontheDiabeticFoot. The 2015 WGDF guidancedocumentsonpreventionandmanagementoffootproblemsindiabetes: developmentofanevidence-basedglobalconsensus / Bakker K., Apelqvist J., Lipsky B.A., VanNetten J.J. //DiabetesMetabResRev.- 2016.- 32 (Suppl 1) .- P. 2-6
Hofman A. TheRotterdamStudy: 2016 objectivesanddesignupdate / Hofman A., Brusselle G. G., Darwish M. S., vanDuijn C. M., Franco O. H. et. below. // Eur J Epidemiol .- 2015 No. 30 (8) .- P. - 661-708.
2. What classification and what stages of the pathological process exist?
One of the most common SDS classifications is the classification proposed by MeggittWagner:
0 items - intact skin, possible hyperemia, pre-ulcer changes in the skin, bone deformities;
1 item - superficial ulcer defect;
2 items - Deep ulcer (in the days of ulcers subcutaneous fat, tendon, joint capsule);
3 items - a deep ulcer that penetrates into the bone structures, the cavity of the joints, with signs of infection; 4 items - Limited gangrene (fingers, heel, or gangrene to transmetatarial level);
5 centuries - a common gangrene.
3. What is the symptom of the disease?
Increasing the level of sugar in the blood leads to a violation of various types of exchanges, which in turn leads to the development of peripheral polyneuropathy. It causes diabetic osteoarthropathy (OAP, Charko's foot, Sharko's joint). The prevalence of this complication among patients with diabetes occurs in 0.1-55%. The final stage is the disruption of blood supply, due to damage to the vessels and purulent-necrotic processes.
Thus, we deal with a patient who has in the first place a violation of the inertia, which increases the risk of injury and infection. Asymptomatic period represents a serious problem, since there arcane necrosis, the cause of which is often a traumatic foot injury or injury, obtained during the treatment of nail plates. Progression of the process is expressed in the spread of gangrene to transmetatarsal level, damage to the hemic region, which in most cases leads to the execution of primary amputation.
Hump is defined as pain syndrome, represented by convulsive pain in the muscles of the legs or muscles of
the femur, developing in response to muscular ischemia against the background of walking or physical activity. The patient is forced to stop the movement, the pain is in a calm condition, after which the patient can continue to walk until there is again pain. this is the case with "pure" ischemia against the background of obliterative atherosclerosis. Atherosclerosis, which arose on the basis of diabetes leads to a disruption of blood supply, and polyneuropathy does not give a "true" clinical picture, and as a consequence, patients are appealing for help in the later stages, when there are ischemic ulcers. They are localized in the apical parts of the limbs: in the area of the heel, the lateral edge of the foot, the tips of the fingers, often - in the interdigital intervals. Pulmonary defects are painful. Gradual mummification of affected areas is possible.
4. Tell us about the methods of diabetic foot diagnosis and treatment.
Unfortunately, diabetes affects not only the vessels of the limbs, but also the vessels of the retina of the eye. The first sign is a deterioration of vision, while the condition is probably already a violation of blood supply and tissue limbs. It is necessary to constantly monitor the level of sugar in the blood, and this is a prerequisite for all patients with diabetes. Daily careful care of the feet and phalanges of the fingers. A prerequisite is wearing insoles and protective shoe that unloads the foot and prevents the formation of scrubs, corns. Correct care of nail plates, correct pedicure.
Patients should learn how to walk correctly - to determine for themselves the pace and distance of painless desire. Stop before the pain begins, to pause to start in a state of comfort.
Regarding the organization of medical care, this should be a clear strategy for assisting this category of patients, a proper stage treatment at the links endocrinologist - therapist-surgeon - rehabilitation. Unfortunately, the diagnosis of diabetes has been delayed, it is only detected at the stage of manifestation of later purulent-necrotic complications , which often lead to fatal consequences.
Tactics in the eruption of purulent-necrotic complications of SDS is produced by many community of counterparts, surgeons and is divided into three components.
1. Liquidation of the acuity of the purulent necrotic process (Wide section of the destruction center with the simultaneous formation of soft tissue clumps, for the subsequent closure of the wound, revision and adequate drainage of purulent pockets and swings).
2. Endotoxin control. Degree 1B.
3. Treatment of diabetes mellitus in order to prevent the progression, aggravation and, eventually, stabilization of carbohydrate metabolism. Degree 1B. The introduction of an interdisciplinary team coordinated by an endocrinologist is associated with a decrease in the frequency of serious amputations in patients with diabetes mellitus.
4. Prevention of postprandial hyperglycemia.
5. Normalization of protein, fat and water-electrolyte exchanges. Degree 1B.
6. Removal of vascular spasm and stimulation of collateral blood circulation. Degree 1B
7. Improvement of central and regional hemodynamics. Degree 1B
8. Creation of moderate hypocoagulation and improvement of rheological properties of blood. Stage II - Restoration or improvement of revascularization.
Stage III closure of the tissue defect after necrotic anemia and restoration of the limb function. In the absence of a positive dynamics of treatment - high amputation at the level of the middle third of the thigh.
Only a comprehensive approach can save the limb and turn the patient into a social sphere. Ivano-Frankivsk, street. Halytska 2, 76000, IFNMU +380505346152
Pyptiuk Alexander Vladimirovich doctor honey Sciences, professor, head Department of Surgery
, Ivano-Frankivsk National Medical University.