糖尿病足病外科治疗应注意三点

糖尿病足是指因糖尿病神经病变（周围神经感觉障碍、运动神经病变所致局部畸形及自主神经损害）、下肢血管病变（如动脉硬化引起的周围小动脉闭塞症,或皮肤微血管病变）以及细菌感染所致的足部疼痛、溃疡及足坏疽等,常常由于缺血、神经病变和感染三种因素协同发生作用。糖尿病足是常见的糖尿病慢性并发症之一,     

老年糖尿病患者足病变的诊断与防治

糖尿病足的定义是发生于糖尿病患者的与局部神经异常和下肢远端外周血管病变相关的足部感染、溃疡和／或深层组织破坏。国外的资料说明，所有的因糖尿病有关问题的住院中，糖尿病足占到47％。糖尿病足溃疡和截肢所带来的医疗耗费巨大，在美国此项费用几乎相当于其余糖尿病并发症的医疗花费的总和。     

传统医药有效治疗糖尿病足

糖尿病足是指糖尿病患者由于合并神经，血管病变以及感染导致肢体发生溃疡或深部组织破坏，是周围神经病变，缺氧，足部畸形和感染共同作用的结果。西医治疗本病，在控制血糖、血压基础上，疏通血管、改善微循环、抗感染等均是重要治疗手段；外科治疗也是主要的治疗方式之一，如血管旁路术、外科血管重建手术，介入治疗、局部清创等，病情严重时需截肢处理。但是目前糖尿病是坏疽的截肢率、病死率、复发率均很高，严重影响糖尿病足患者的生命、健康和生活质量。     

糖尿病足的综合治疗

1背景资料 “糖尿病足”的诊断名词1956年由Oakley提出。1999年,世界卫生组织（WHO）对糖尿病足（diabeticfoot,DF）的定义是：糖尿病患者由于合并神经病变及各种不同程度末梢血管病变而导致下肢感染、溃疡形成和（或）深部组织的破坏。其中包含了三种病变因素,即血管因素、神经因素、感染因素,临床表现常常侧重于某一方面,所以临床诊断上病名很多,如“糖尿病下肢血管病变”、“糖尿病性动脉硬化闭塞症（DAO）”、“糖尿病周围神经病变”、“糖尿病坏疽（DG）”等,实际上都归属于糖尿病足。     

糖尿病足部溃疡的治疗

出于改善治疗结果的期望，现将内外科糖尿病足的治疗方法在此作一综述。 1 评估 1．1病因分析 临床上常将糖尿病足部溃疡分为：神经性；缺血性；神经缺血性。神经性溃疡的主要原因是感觉神经病变而致感觉缺失的足部承受组织破坏性机械负荷所致。单纯缺血性溃疡无神经病变少见，占糖尿病足溃疡的10％～15％，一般发生在严重的周围血管病变并有创伤为诱因的情况下。     

糖尿病足的治疗与护理

糖尿病足是糖尿病患者因神经病变而失去感觉，因缺血而失去活动能力，和（或）合并感染所致的足部疾患。由于足部的解剖生理特点，糖尿病患者一旦发生足部感染，可能导致截肢或死亡，若早期给予重视和干预，积极进行足部护理和治疗，可提高患者的生存质量，减少家庭和社会负担。我科近年来应用全身治疗与局部处理相结合的综合治疗措施，取得了较好的治疗效果，现将护理体会报告如下。     

中西医结合治疗糖尿病足溃疡

糖尿病足是一种慢性、进行性、全身性疾病。它既有糖尿病内科的临床表现，又有局部溃烂、感染等外科症状和体征，常在发生坏疽之前或同时伴有血管病变，神经病变，局部感染及其他相关心、脑、肾、眼底病变，肺部感染，酮症等急、慢性并发症。因此，涉及到多学科检查、诊断与治疗。在治疗上，要强调和重视“三个结合”，即“内外科综合治疗的结合、中西医方法的结合和整体与局部处理的结合”。     

糖尿病足病变诊断和治疗

糖尿病足是糖尿病患者足或下肢组织破坏的一种病理状态，如溃疡、骨及关节病变乃至所引起的坏疽等，往往是下肢血管病变、神经病变和感染共同作用的结果。引致糖尿病截肢的首位原因是足溃疡的不愈合及其并发症。近年来，我国糖尿病足发病率明显增加。笔者检索到国内发表的糖尿病足的文献为：１９９６年６篇，１９９７年１４篇，１９９８年２８篇，１９９９年则增加至７０篇。这从一个侧面说明糖尿病足已受到国内学者的重视［１］。 一、糖尿病足病变的分类和分级 根据病因，糖尿病足溃疡和坏疽可分为神经性、缺血性和混合性。根据病情严重程…     

足部的需要

糖尿病足是指因糖尿病血管病变和（或）神经病变和感染等因素，糖尿病患者足或下肢组织破坏的一种病变，是糖尿病患者截肢、致残的主要原因之一。通过对糖尿病足部溃疡的预防，对糖尿病足病的早期诊断和积极管理，90％以上的截肢是可以预防的，减轻患者经济负担，提高生活质量。     

糖尿病足36例临床分析

糖尿病足是糖尿病患者足或下肢组织破坏的一种病理状态，是下肢血管病变、神经病变和感染共同作用的结果。近年来，我们收治糖尿病足患者36例，现分析如下。     

Peripheral Neuropathy as a Presenting Feature of Type 2 Diabetes: A Case-Controlled Study

The characteristics and outcome of 68 newly diagnosed Type 2 diabetic patients who presented with clinically evident peripheral neuropathy were compared with matched controls who had no neuropathy at diagnosis. All subjects (34 male) whose median age was 68 (range 47–89) yr were identified from a computerized diabetes register and presented in 1982–1990. The groups were compared at diagnosis for haemoglobin A₁, body mass index, blood pressure, smoking, and alcohol consumption, and for co-existent coronary and peripheral vascular disease. Mortality and morbidity were recorded to March 1991. Significantly more patients with neuropathy had co-existent peripheral vascular disease: 24(35%) compared to 6(9%) controls (p = 0.0021). Twenty (30%) of those with neuropathy and no controls had retinopathy at diagnosis, which was sight-threatening in 10. Seven (10%) with neuropathy but no controls presented with foot ulcers, one requiring limited amputation. Two more patients with neuropathy and one control subsequently developed foot ulcers resulting in one or more amputation in each group. Twenty-one (31%) of those with neuropathy and 14 (21%) controls died (p = 0.2109). In conclusion more diabetic patients with clinically evident peripheral neuropathy at diagnosis have peripheral vascular disease than matched patients without neuropathy. It is likely that macrovascular disease either exacerbates or causes the neuropathy in this group of patients. They are at high risk of developing foot ulceration and high priority should be given to foot care in planning their management.     

Pie diabético

Diabetic foot includes a group of syndromes in which the interaction among loss of protective sensation due to sensory peripheral neuropathy, a change in pressure spots due to motor neuropathy, autonomic dysfunction, and decreased blood supply due to peripheral vascular disease can lead to the occurrence of wounds or ulcers usually related to minimal injuries that are usually unnoticed. Diabetic foot is associated with higher morbidity and a high risk of amputation of the foot or limb. These situations can be avoided with an appropriate prevention program, based on the early detection of diabetic neuropathy and assessment of the associated risk factors in addition to structured patient education. Also important are optimal treatment of the acute injury, with specific antibiotics and foot care measures that encourage early and effective healing.     

Diabetic foot disease in the elderly

Elderly diabetic patients are particularly burdened by foot disease. The main causes for foot disease are peripheral neuropathy, foot deformities and peripheral arterial disease (PAD). Other risk factors include poor vision, gait abnormalities, reduced mobility an medical co-morbidities. The risk of major amputations increases with age, along with the increased prevalence of these risk factors. Th true risk of amputation and other burdens of foot disease in the elderly are likely underestimated by current epidemiological data. Th prevalence of neuropathy, foot deformities and PAD as well as the risk of amputation all increase with age even in non-diabetic patients. The principles of prevention and management of diabetic foot disease may also apply to large segments of the elderly non-diabetic population. Foot ulcer prevention relies on the identification of high risk patients and avoidance of triggering events, such as ill-fitting shoes, walking barefoot or poor self-care. PAD is a major cause of amputation and should be prevented by lifelong attention to glycaemic control, treatment of hypertension and dyslipidemia, and avoidance of smoking. The treatment of foot ulcers relies on pressure relief (off-loading), wound debridement, and treatment of infection and ischemia. It requires an individualized approach considering the patient's co-morbidities and functional status. Off-loading remains essential, but devices such as total contact casts or crutches can only rarely be implemented. However, providing adapted standard foot-wear and insisting on its consistent use even at home is often effective. The benefits of aggressive vascular or orthopaedic surgery should be weighed against the risks of prolonged hospitalisation and resulting functional decline. Greater attention to prevention and individualized care are needed to reduce the burden of diabetic foot disease in the elderly.     

Comparison of Risk Factors for Foot Problems in Diabetic Patients Attending Teaching Hospital Outpatient Clinics in Four Different European States

Although the St Vincent declaration calls for common European action in order to reduce major amputations, the differences in the incidence of foot problems and the prevalence of risk factors has not been fully investigated. We have examined the risk factors for foot ulceration and amputation in 278 consecutive patients (mean age 50.4 years, range 18–79 years) attending outpatient clinics of four teaching hospitals: Athens, Manchester, Rome, and Antwerp. There were no differences in age, weight or sex among the four groups but the percentage of patients with Type 1 diabetes was higher in Rome and Antwerp. Patients in Rome and Antwerp also had a longer duration of diabetes compared to Athens and Manchester. Mean vibration perception threshold was similar in all groups. No differences were found in the number of patients with moderate or severe clinical neuropathy (neuropathy disability score > 5), severe sensory loss (VPT > 25 V), and limited joint mobility. Symptomatic peripheral vascular disease was more frequent in Antwerp (p < 0.05) compared to the other three centres and foot ulceration in Rome compared to Manchester (p < 0.05). The number of smokers or ex-smokers and the average alcohol consumption were similar in all centres. We conclude that, despite a few differences mainly in Type 1 diabetic patients, there are no major differences in the risk factors for foot ulceration and that, therefore, similar strategies for the prevention of foot problems may be equally successful in different European countries.     

Reducing the incidence of foot ulceration and amputation in diabetes

Diabetes is a common disease that is associated with numerous complications, including foot ulceration and amputation. In diabetic patients, the incidence of foot ulcers ranges from 1.0% to 4.1%, and the incidence of lower-extremity amputations ranges from 2.1 to 13.7 per 1000. Risk factors for developing foot ulcers and subsequent amputation include neuropathy, peripheral vascular disease, and trauma. To reduce these complications, several preventive strategies have been devised, from reducing risk factors to improving treatment and management.     

The Prevalence of Foot Ulceration and its Correlates in Type 2 Diabetic Patients: a Population-based Study

The prevalence of peripheral neuropathy, peripheral vascular disease, and foot ulceration in Type 2 diabetic patients in the community were determined in a community-based study. Eight hundred and eleven subjects (404 male, 407 female, mean age 65.4 (range 34–90) years, diabetes duration 7.4 (0–50) years) from 37 general practices in three UK cities were studied. Neuropathy was diagnosed clinically using modified neuropathy disability scores which were ascertained using structured interviews and clinical examinations by one observer in each city. Peripheral vascular disease was diagnosed if a history of revascularization was present or ≥ 2 foot pulses were absent. History of current or previous foot ulceration was recorded. The prevalence of neuropathy was 41.6% (95% confidence limits 38.3–44.9%) and the prevalence of PVD, 11% (9.1–13.7%). Forty-eight percent of neuropathic patients reported significant neuropathic symptoms. Forty-three patients (5.3% (3.8-6.8%)) had current or past foot ulcers; 20 of these were pure neuropathic ulcers, 13 neuroischaemic, 5 pure vascular, and 5 were unclassified. Multiple logistic regression showed history of amputation, neuropathy disability score, and peripheral vascular disease to be significantly associated with foot ulceration after adjusting for age and diabetes duration. A substantial proportion of Type 2 diabetic patients, often elderly patients who do not attend hospitals, suffered from peripheral neuropathy and peripheral vascular disease. These patients are at risk of foot ulceration and may benefit from preventive footcare.     

Physiopathology of the diabetic foot

Diabetic foot ulcerations result from different physiopathological mechanisms; a clear understanding of them is crucial to reduce their incidence, provide early care, and finally delay the amputation risk. The three main diabetes complications involved in foot ulcerations are neuropathy, peripheral arterial disease, and infection. The most common pathway to ulceration is peripheral sensorimotor and autonomic neuropathy, leading to loss of sensitivity, foot deformities, high foot pressure, and dry skin. Peripheral arterial disease is more frequent and more serious in the diabetic population. It delays cicatrization and causes gangrene and finally amputation. Infection is also a major complication of ulceration because of its risk of spreading into deep tissue and bone, which increases the risk of amputation. Infection may also generalize and become life-threatening. These complications preferentially affect the foot because it is exposed to hyper pressure, neuropathy, and peripheral arterial disease, which cause distal lesions, and the foot is exposed to a closed atmosphere, a source of soaking and skin frailty. Diabetes itself may enhance the risk of complications stemming from the disease's long-term progression and poor glucose control, thereby affecting ocular and renal functions. Finally, some psychosocial situations such as depression syndrome or poor hygiene possibly enhance diabetic foot occurrence.     

Change in amputation predictors in diabetic foot disease: effect of multidisciplinary approach

Diabetic foot disease causes important morbidity in diabetic population, and amputation due to diabetic foot disease occurs more often than in general population. We have been evaluating patients with diabetic foot disease in a multidisciplinary approach since year 2000. In the current study, we sought to investigate the change in amputation rate and its predictors in diabetic foot with a multidisciplinary team approach. Seventy-four patients (52 male, 22 female) hospitalised between January 2002 and December 2007 were retrospectively analysed. Sixteen out of 74 have undergone amputation. We found overall amputation rate as 21.6%, which is lower than previously reported from our institution (36.7 and 39.4%, respectively). Major amputations (syme, below-knee, above-knee) were applied to 11 patients (14.9%). A logistic regression model including osteomyelitis, peripheral neuropathy, peripheral vascular disease, hypertension, gangrene and age revealed that gangrene is now the only significant predictor for amputation. Our observations confirm that amputation rate has declined after implementation of a multidisciplinary team work, and risk factors apart from presence of gangrene are no longer amputation predictors in our centre.     

Magnitude of foot problems in diabetes in the developing world: a study of 1044 patients

Aim To gain insight into the prevalence of peripheral neuropathy, foot care practices, foot at risk and foot ulcers in patients with diabetes mellitus at a tertiary care centre. Methods A prospective case study involving 1044 patients with diabetes mellitus attending the diabetes clinic of a tertiary care centre in north India from January 2007 to May 2008. All subjects underwent a detailed clinical assessment including vibration perception threshold (VPT) and ankle brachial pressure index (ABI), along with metabolic parameters, and were categorized into ulcer, foot at risk and patients with no risk factors. Foot care practices were assessed with a questionnaire. Peripheral neuropathy was defined as VPT score ≥ 25 V. Peripheral vascular disease (PVD) was defined as ABI < 0.9. One hundred and forty‐nine patients with foot at risk were followed up for 9.0 ± 2.3 months (range 5–13 months). Results The prevalence of peripheral neuropathy was 34.9% and of PVD 12.6%. Two thirds of the patients were at risk for foot ulceration; 9% had an ulcer and 20.2% of them required amputation. Correct foot care practices were followed by 214 (20.5%) subjects of the whole study population and by only 135 (19.3%) of the patients with foot at risk. Improvement in glycaemic control in the patients on follow‐up was associated with improvement or stabilization of VPT score. Five (3.4%) patients developed new ulcers on follow‐up. Conclusion The high prevalence of neuropathy and PVD, coexisting with poor adherence to foot care practices predisposes to foot problems in people with diabetes in our study population.     

How Effective is Cushioned Therapeutic Footwear in Protecting Diabetic Feet? A Clinical Study

Therapeutic footwear with cushioned insoles was supplied to 50 diabetic patients with severe peripheral neuropathy and/or peripheral vascular disease (age 59(SD 12) years, known duration of diabetes 17(7) years), 36 of whom had a history of foot ulceration. A follow-up examination was carried out 25(14) months later, except in 8 patients who died from conditions unrelated to their foot lesions, and 1 patient who died from sepsis due to upper limb amputation. Among the surviving 41 patients, intercurrent foot lesions during follow-up occurred in significantly fewer (42%) of the 26 who had worn the shoes regularly than of the 15 who had worn the shoes irregularly (87%, p less than 0.01). At follow-up, only 15% of the 41 patients were being treated for foot-lesions, compared with 78% of these 41 patients before cushioned shoes were provided. It is concluded that the availability of therapeutic shoes with cushioned insoles for diabetic patients at risk of foot lesions decreases the morbidity due to the diabetic foot syndrome.