Diabetic foot syndrome

from Wikipedia, the free encyclopedia
Skin ulcer on the diabetic foot
Diabetic foot syndrome
Classification according to ICD-10-GM
E14.74 + Unspecified diabetes mellitus with diabetic foot syndrome, not designated as derailed
E14.75 + Unspecified diabetes mellitus with diabetic foot syndrome, referred to as derailed
G63.2 * Diabetic polyneuropathy
I79.2 * Peripheral angiopathy in diseases classified elsewhere
ICD-10 online (GM version 2020)

The diabetic foot syndrome (DFS) mentioned, commonly known as "diabetic foot" is a syndrome of pathological changes on the basis of a painless sensory neuropathy and / or peripheral arterial disease (PAD) in diabetes mellitus . It is most commonly found in patients with type 2 diabetes mellitus and is associated with a high risk of poorly healing wounds on the foot.

Epidemiology

Around 15% of diabetics develop painless, poorly healing wounds on their feet as a result of their illness. This risk affects one million people with diabetes in Germany. It is estimated that 250,000 diabetics in Germany currently have a foot wound. Every year, 4% of diabetics develop a new wound, and 0.1% develop a Charcot foot due to the collapse of the arch of the foot .

root cause

In the context of inadequately controlled diabetes mellitus with permanently high blood sugar levels ( hyperglycemia ), chronic damage occurs in a hitherto unexplained manner, in particular to the eyes, kidneys and nerves, with two types of damage being decisive for the diabetic foot:

  • Diabetic neuropathy : in the context of diabetes-related nerve damage ( polyneuropathy ), the pain sensation is often greatly reduced or absent entirely, so that even large and deep wounds are not perceived. The wounds often occur - unnoticed - in banal accidents, after improper foot care, with stones in the shoe, with excessive stress, especially with foot misalignments or even when the tips of the toes in the shoe or against edges. In order to be able to clearly determine the patient's need for protection, the early detection of neuropathy is of great clinical importance; to be Rydel-Seiffer tuning fork , monofilament - pinprick test, Temperaturdiskrimination, tendon reflex - and used other tests. The foot often has a characteristic appearance:
    • Skin is rosy, warm and dry
    • Numbness, burning, tingling in the toes and feet.
    • The feeling of walking on cotton wool and the feeling of having cold feet even though they are warm.
    • Pain with resting feet, especially at night, and pain relief from walking around
    • Feet are prone to cornification and nail fungus.
    • Reduction or loss of vibration, temperature and pain perception ( perception thresholds are increased!)
  • Diabetic angiopathy : Damage to large and small vessels and regulation of the vascular tone result in circulatory disorders in the extremities . Here, too, there is a characteristic appearance in the pure form (although mixed images are often present):
    • cold feet, thickened nails
    • Thin, parchment-like, bluish pale skin, especially on the forefoot
    • Pressure points (reddish skin spots that cannot be brushed away)
    • Calf pain or cramps while walking - relief by standing still, colloquially claudication (lat .: intermittent claudication) called.

For the most part, diabetic foot syndrome (in 40 to 60%) is triggered by polyneuropathy alone . Wounds that arise as a result of polyneuropathy occur in particular in areas that are exposed to particular pressure, usually on the ball of the foot or the underside of the foot. 15% of the cases are due to peripheral arterial occlusive disease (PAD). Such wounds are often on the toes and tips of the toes, where the blood circulation situation is worst. About one third of the causes of the wound is a combination of neuropathy and PAD. If both risk factors come together, the ulcer risk is significantly higher and the chances of recovery are significantly lower.

The malum perforans is a typical, purely neuropathic wound on the foot . Without adequate treatment, the skin ulcers ( ulcerations ) can reach deeper and deeper into the foot and can also be colonized with MRSA germs, which can prevent normal wound care and healing. In addition, there is a risk of infection and the spread of infection via the lymph vessels ( lymphangitis ) or the bloodstream ( septicemia ) up to sepsis (blood poisoning), which is associated with high mortality .

Charcot foot

Classification according to ICD-10
E14.6 + Unspecified diabetes mellitus with other specified complications
M14.6 * Neuropathic Arthropathy
ICD-10 online (WHO version 2019)

Another cause of the destruction of bones and joints on the foot is diabetic neuropathic osteoarthropathy ( DNOAP , also known as Charcot's foot ). It arises in the context of polyneuropathy. Due to the misalignment and the overload, which is not painful due to the polyneuropathy, as well as a frequently present osteopenia , individual foot bones can break due to fatigue . Since the pain threshold is extremely high and there is no longer any pain sensation, many sufferers continue to strain the broken foot for weeks. The foot becomes warm, swollen, and red compared to the opposite side. The pain turns out to be less than expected or may even not occur despite significant bone fractures. At this stage, magnetic resonance imaging (MRI) shows bone marrow edema , which, at best, can be completely cured by immediate, strict relief treatment. Unfortunately, the noticeable deformation of the foot in the late stages of the disease often leads to the doctor. The diagnosis is then based on an X-ray examination and includes the so-called " 5 D of the radiological manifestation of DNOAP ".

  • Distension of the joints
  • Dislocation of bones and joints
  • Debris of the bone
  • Disorganization of the bones and joints
  • Increase in density in the bones

As a therapy for osteoarthropathy, first complete relief (bed rest), then partial relief, e.g. B. in plaster casts, later special orthopedic custom-made shoes must be worn. Orthopedic interventions may be necessary to correct the deformity surgically and to compensate for local overloads.

Diagnosis

The diagnosis consists, on the one hand, of the diagnosis of the diabetic foot wound, but on the other hand it can and should be broader and include the causes. In order to assess both, in addition to many other classifications, two have established themselves in German-speaking countries:

Wagner-Armstrong Classification of Diabetic Foot Wounds

The depth of a wound that has arisen on the foot as a result of diabetic foot syndrome is recorded using the Wagner graduation. Only the wound and not the foot deformities are assessed, i.e. only one aspect of the syndrome is assessed, which is seen as a problem in the Wagner classification. Nevertheless, this classification is widespread. In combination with the University of Texas Diabetic Foot Classification System , or “Armstrong staging” for short (left: A to D), the Wagner grades (above: 0 to 5) are related to the factors ischemia and infection, whereby the Wagner-Armstrong classification commonly used in German-speaking countries emerges.

0 1 2 3 4th 5
A. no lesion is present A superficial wound is The wound extends to the tendon and / or joint capsule Bones and / or joints are damaged partial necrosis of the foot Necrosis all over the foot
B. With infection With infection With infection With infection With infection With infection
C. With ischemia With ischemia With ischemia With ischemia With ischemia With ischemia
D. With infection and ischemia With infection and ischemia With infection and ischemia With infection and ischemia With infection and ischemia With infection and ischemia

based on: D. Hochlenert, G. Engels, S. Morbach: The diabetic foot syndrome - About the entity to therapy. (2014) and K. Hodeck, A. Bahrmann (Ed.): Pflegewissen Diabetes. (2014)

PEDIS classification

The PEDIS classification developed by the International Working Group on the Diabetic Foot (IWGDF) is used internationally. This classification was presented in 2004 by the Maastricht internist Nicolaas Schaper. The acronym PEDIS ( Latin : Genetic Singular to pes = foot) is made up of the first letters of the five factors considered here:

  • P erfusion: The blood flow situation in the affected extremity is divided into three degrees of severity.
  • E xtent: The wound size is recorded following debridement and given in cm².
  • D epth: The wound depth and extent is based on the damaged body tissue and comprises three degrees
  • I nfektion: The presence and severity of an infection is detected in four grades.
  • S ensation: The feeling for the foot is divided into two grades, which records whether the patient perceives his foot unrestrictedly (grade 1) or restricted (grade 2).

Body island shrinkage

The affected person's reduced perception of pain in the lower extremities is characteristic of diabetic foot syndrome. Carelessness towards the condition of one's own feet can lead to minor injuries and considerable damage without being noticed. The carelessness of those affected, which sometimes seems unusual, could be explained by the so-called body island shrinkage . The concept of body islands describes our body, which cannot be perceived as a whole, but only in its individual regions, as an accumulation, e.g. gastric, oral or anal "islands". The system of the body islands was researched after the First World War on patients who had to be amputated as a result of a war injury, but who continued to notice their lost limbs. The distinction made for this concept between the existing body and the perceived body was derived from this. As a result of their diabetic polyneuropathy in diabetic foot syndrome, patients feel their lower limbs less or not at all, which in their perception leads to the disappearance of the affected regions: to shrinkage of the body island. The affected foot is no longer counted as part of one's own body, but perceived as part of the environment and as a “doctor's problem”.

prevention

Preventive measures to avoid diabetic foot syndrome affect all people with diabetes and with impaired sensation or circulatory disorders.

Skin care

In general, people with diabetes should value good skin care. Regular skin care measures also serve to observe the skin areas where damage can occur unnoticed due to the reduced pain sensation caused by diabetes. Sharp objects must not be used to care for nails and calluses (not even by pedicurists), instead nail files and pumice stones. Suitable skin care products contain moisturizing factors such as glycerin , lactic acid and urea . Creams or care foams based on water-in-oil are used. In order to prevent unobserved fungal infestation or maceration , these products are not applied between the toes, but rather on the soles and dorsum of the feet. Athlete's foot should be treated consistently and the spaces between the toes should be carefully dried after bathing. The shoes must be sufficiently wide and soft and the feet must be checked daily for injuries, e.g. B. with a shaving mirror.

Further measures

As measures to prevent diabetic foot ulcer are recommended

  • Take a close look at your feet every day and check for injuries and pressure points. Check for swelling by running your hand over the foot, even after wearing new shoes or after long walks / hikes.
  • Wash daily with lukewarm water. No longer than three minutes, dry well, especially between the toes.
  • Apply cream to the skin with urea-containing creams to avoid cracks ( fissures / fissures). The cream must be absorbed / dry well, no residue must remain between the toes.
  • Use files only, do not use rasps, nail clippers or scissors.
  • Shape toenails into a spade (straight) shape with files, never cut - because of the risk of injury.
  • Do not use corn plasters or tinctures, they may contain corrosive substances that can cause injury.
  • Wear comfortable, wide and soft shoes, if possible made of leather, no rubber or gym shoes because of perspiration. Check shoes by hand for bumps or stones etc. every day before use.
  • Wear cotton stockings without pressing seams, change stockings daily
  • Do not expose feet to extreme heat, such as those caused by electric blankets or chimneys, there is a risk of injury, no direct sunlight
  • Be careful when walking barefoot, risk of athlete's foot and the risk of cuts and abrasions

Diabetics in particular should seek professional help from a podiatrist who specializes in the treatment of diabetic foot syndrome if they have foot problems . This treatment can be prescribed by the doctor under certain conditions at the expense of the statutory health insurance.

treatment

Depending on the severity of the damage and the stage, the patient should be properly cared for by a wound treatment team . Due to the wound healing disorder, the treatment can drag on over very long periods of time. A fundamental requirement for the successful treatment of diabetic foot syndrome is the pressure relief of the affected area, especially the wound. Only when the relief of the foot is guaranteed can further therapeutic measures take effect. In some cases, long-term antibiotic therapy is necessary in addition to regular wound care. From stage II, inpatient care is necessary in individual cases. Treatment can be based on the guidelines of the German Society for Wound Healing and Wound Treatment or the German Diabetes Society . In wound care team different specialists work together for optimal care depending on the case, u. Doctors (general practitioner, internist, diabetologist, surgeon, vascular surgeon, orthopedist), nurses specializing in wound care, orthopedic shoemakers and podiatrists .

IRAS rule

The so-called IRA principle provides an orientation for the treatment of diabetic foot syndrome . This acronym is made up of the first letters of the terms infection control, revascularization and amputation . Supplemented by the aspect of S Chulung of patients and relatives, this principle extends to IRAS rule .

  • Infection clean-up: The infection is one of the decisive factors for tissue damage in DFS. A diagnosis is made clinically and is based on IDSA or PEDIS, the two common classifications of foot infections in connection with diabetes.
  • Revascularization: Based on the ankle-arm index and the measurement of the occlusive pressures of the foot arteries, conclusions can be drawn about the status of the blood vessels. Their rehabilitation is a fundamental part of the therapy and the prerequisite for the healing of diabetic foot ulcers.

Prompt infection control and immediate revascularization are the prerequisites for preventing further tissue loss. If these measures are delayed, the risk of amputation increases.

  • Amputation: Diabetics are three to ten times more likely to have a leg amputation than non-diabetics. Between 50 and 70% of all amputations on the lower extremities are due to a diabetic metabolic disorder. 85% of foot amputations in diabetics can be traced back to DFS, as a result of which an infection developed or gangrene developed.
  • training

Relief and immobilization

Total Contact Cast with bandage shoe

Another essential aspect of the care of foot wounds in diabetics is the adequate pressure relief of the damaged tissue. A wound on which pressure is repeatedly or constantly exerted by the patient's clothing, movement and the patient's own weight cannot heal smoothly and threatens to become a chronic wound . The method that has been best studied for everyday pressure relief is relieving the foot with a so-called Total Contact Cast . This is a full-contact plaster cast that is modeled so that the damaged tissue is not stressed when walking. The non-removable Total Contact Cast is considered the gold standard for treating diabetic foot ulcers. Total Contact Casts , which are sawed open and consist of two shells for putting on and taking off, which are attached with a single plaster bandage or with Velcro straps, enable wound control and do not hinder those affected with personal hygiene. In addition to such TCC, plastic orthoses , forearm crutches or a wheelchair can be used. In some cases, complete immobilization of the affected person may be advisable initially. Such total immobilization increases the risk of developing thrombosis and pneumonia, especially in older patients .

Even under optimal conditions, many people with diabetic foot syndrome are in permanent treatment and are sometimes very limited in their daily activities .

Therapy methods

Fighting causes: The blood circulation can be improved by vascular surgical measures such as revascularization through a bypass . Orthopedic interventions can correct malpositions in the area of ​​the foot and reduce local overloads with pressure load peaks on protruding bones. For this purpose, corrective joint stiffening ( arthrodesis ), corrective bone changes ( corrective osteotomies ), partial bone resections and tendon displacements are particularly suitable for osteoarthropathy .

Wound cleaning and debridement : Mostly surgical removal of non-vital tissue, necrosis, plaque or removal of foreign bodies up to intact anatomical structures while preserving granulation tissue - mainly active periodic wound cleaning as targeted, recurring mechanical wound cleaning as part of the dressing change.

Associations : In a Cochrane review in 2015, there was no statistically significant difference between hydrocolloids and gauzes or compresses, alginates, foams or hydrocolloids from different manufacturers with regard to wound healing in patients with the underlying disease diabetes mellitus. It was stated that the decision for a certain wound dressing should be based on the specifications of the care facility, the economic requirements and the individual preferences of the patient. An effective form of care is also vacuum therapy , in which the wound is treated with negative pressure.

Physical interventions : To complement conventional wound treatment, a whole range of different procedures are offered, the aim of which is more effective and faster wound healing in order to reduce the extremely high amputation rate. In addition to many case reports, there are only a few good clinical studies that scientifically prove the actual effect of these procedures. Many processes can still be assessed as experimental. An overview of the value of the different treatment proposals can be found according to a guideline of the German Society for Wound Treatment (DGfW). The procedures mentioned there include hyperbaric oxygen therapy , electrical stimulation therapy , ultrasound therapy or plasma therapy , among many others .

Check-ups The German Diabetes Society recommends check - ups at least once a year if there is no sensory neuropathy , otherwise every six months. If there is arterial occlusive disease or a foot deformity, the check-up should be carried out every three months, as well as in the early stages of an ulcer. Doppler ultrasound checks are generally recommended once a year.

literature

  • Dirk Hochlenert, Gerald Engels, Stephan Morbach: The diabetic foot syndrome - About the entity to therapy. Springer Verlag, Berlin / Heidelberg 2014, ISBN 978-3-662-43943-2
  • Franz X. Köck, Bernhard Koester (ed.): Diabetic foot syndrome. Georg Thieme Verlag, Stuttgart / New York 2007, ISBN 978-3-13-140821-1
  • Kerstin Protz: Modern wound care. 8th edition. Elsevier Urban & Fischer Verlag, Munich 2016, ISBN 978-3-437-27885-3

Web links

Commons : Diabetic foot  - collection of images, videos and audio files

Individual evidence

  1. ↑ a b D. Hochlenert, G. Engels, S. Morbach: The diabetic foot syndrome - About the entity for therapy. Springer Verlag, Berlin / Heidelberg 2014, p. 7
  2. ↑ Holger Lawall: Diabetic foot syndrome on polyneuropathy, circulatory disorders and second opinions . In: German Diabetes Health Report 2017 The inventory , German Diabetes Society (DDG) and Diabetes DE - German Diabetes Aid. Kirchheim, Mainz 2017
  3. ↑ D. Hochlenert, G. Engels, G. Rümenapf, S. Morbach: Diabetic foot syndrome. In: The Diabetologist. Volume 11, 2015, pp. 151-163, doi: 10.1007 / s11428-014-1328-z
  4. ↑ a b K. Protz: Modern wound care. 8th edition. Elsevier Urban & Fischer Verlag, Munich 2016, pp. 146–149.
  5. ↑ a b c Matthias Augustin , Eike Sebastian Debus u. A .: Optimized wound therapy and care "UKE wound primer" standards in the diagnosis and therapy of wounds , University Medical Center Hamburg-Eppendorf , 3rd edition 2015, page 22
  6. ↑ a b Alphabetical directory for the ICD-10-WHO version 2019, volume 3. German Institute for Medical Documentation and Information (DIMDI), Cologne, 2019, p. 149.
  7. ↑ a b Hans Lippert : Wundatlas. Compendium of complex wound treatment . Georg Thieme Verlag, Stuttgart 2006, ISBN 3-13-140832-4 , pp. 222-233
  8. ↑ National Health Care Guideline Type 2 Diabetes: Prevention and Treatment Strategies for Foot Complications Status: November 30, 2006 (in revision)
  9. ↑ a b D. Hochlenert, G. Engels, S. Morbach: The diabetic foot syndrome - About the entity for therapy. Springer Verlag, Berlin / Heidelberg 2014, pp. 5–7
  10. ↑ K. Hodeck, A. Bahrmann (Ed.): Pflegewissen Diabetes . Springer Verlag 2014, p. 77
  11. ↑ Neuropathically infected foot (62%).
  12. ↑ Macroangiopathic-ischemic foot (13%).
  13. ↑ Neuropathic-ischemic foot (25%).
  14. ↑ Richard Daikeler, idols Use, Sylke Waibel: diabetes. Evidence-based diagnosis and therapy. 10th edition. Kitteltaschenbuch, Sinsheim 2015, ISBN 978-3-00-050903-2 , p. 150.
  15. ↑ NC Schaper: Diabetic foot ulcer classification system for research purposes: a progress report on criteria for including patients in research studies . In: Diabetes Metab Res Rev , 2004, 20 (Suppl 1), pp. S90-S95. International Working Group on the Diabetic Foot (IWGDP) (PDF)
  16. ↑ D. Hochlenert, G. Engels, S. Morbach: The diabetic foot syndrome - About the entity for therapy. Springer Verlag, Berlin Heidelberg 2014, ISBN 978-3-662-43943-2 , p. 2
  17. ↑ K. Hodeck, A. Bahrmann: Pflegewissen Diabetes . Springer Verlag, Berlin Heidelberg 2014, ISBN 978-3-642-38408-0 , p. 79
  18. ↑ K. Protz: Modern wound care. 8th edition. Elsevier Urban & Fischer Verlag, Munich 2016, page 162
  19. ↑ Kerstin Protz: Modern wound care. 8th edition. Elsevier Urban & Fischer Verlag, Munich 2016, page 260
  20. ↑ D. Hochlenert, G. Engels, S. Morbach: The diabetic foot syndrome - About the entity for therapy. Springer Verlag, Berlin Heidelberg 2014, ISBN 978-3-662-43943-2 , page 60
  21. ↑ Holger Lawall: Diabetic foot syndrome about polyneuropathy, circulatory disorders and second opinions , in German Diabetes Health Report 2017 Die Aufstandaufnahme , German Diabetes Society (DDG) and Diabetes DE - German Diabetes Aid, Kirchheim, Mainz 2017
  22. ↑ D. Hochlehnert, G. Engels, S. Morbach: The diabetic foot syndrome - About the entity for therapy, Springer Verlag, Heidelberg 2014, ISBN 978-3-662-43943-2 , page 128
  23. ^ L. Wu, G. Norman, JC Dumville, S. O'Meara, SE Bell-Syer: Dressings for treating foot ulcers in people with diabetes: an overview of systematic reviews. The Cochrane Database of systematic Reviews, 2015, Art. No .: CD010471
  24. ↑ D. Seidel, EAM Neugebauer, R. Liefering, T. Mathes, W. Eglmeier, A. Hörster, S. Banaoglu, V. Jakob, A. Staß, S, Ashoori, U. Schwanke, P. Krüger, F. Schwarzkopf: way out of the evidence trap. Randomized, controlled study on negative pressure wound therapy for diabetic foot wounds on behalf of statutory health insurance companies . In: Zeitschrift für Wundheilung , 1/2013, pp. 15-21, ISSN  1439-670X
  25. ↑ According to the judgment of the Federal Social Court of May 7, 2013 (PDF; 23 kB) in Germany, suitable legally insured patients can receive the reimbursement of costs from their health insurance company if the diagnosis is made
  26. ↑ German Diabetes Society criticizes IQWiG's assessment of HBO in diabetic foot syndrome: Faster wound closure through hyperbaric oxygen therapy (HBO) has not been adequately documented. German Diabetes Society, accessed on November 16, 2016 .
  27. ↑ Stephanie Arndt, Anke Schmidt, Sigrid Karrer, Thomas von Woedtke: Comparing two different plasma devices kINPen and Adtec SteriPlas regarding their molecular and cellular effects on wound healing . In: Clinical Plasma Medicine . tape 9 , March 2018, p. 24–33 , doi : 10.1016 / j.cpme.2018.01.002 ( elsevier.com [accessed April 15, 2020]).
  28. ↑ F. Brehmer, HA Haenssle, G. Daeschlein, R. Ahmed, S. Pfeiffer: Alleviation of chronic venous leg ulcers with a hand-held dielectric barrier discharge plasma generator (PlasmaDerm ® VU-2010): results of a monocentric, two -armed, open, prospective, randomized and controlled trial (NCT01415622) . In: Journal of the European Academy of Dermatology and Venereology . tape 29 , no. 1 , January 2015, p. 148–155 , doi : 10.1111 / jdv.12490 ( wiley.com [accessed April 15, 2020]).
  29. ↑ Thoralf Bernhardt, Marie Luise Semmler, Mirijam Schäfer, Sander Bekeschus, Steffen Emmert: Plasma Medicine: Applications of Cold Atmospheric Pressure Plasma in Dermatology. 2019, accessed on April 15, 2020 .
  30. ↑ Holger Lawall: Diabetic foot syndrome about polyneuropathy, circulatory disorders and second opinions , in German Diabetes Health Report 2017 Die Aufstandaufnahme , German Diabetes Society (DDG) and Diabetes DE - German Diabetes Aid, Kirchheim, Mainz 2017