Diabetes mellitus is a chronic disease of the carbohydrate metabolism and it reaches almost epidemic dimensions worldwide. Currently, in Bulgaria, there are around 600,000 people, suffering from diabetes, and around 300,000 are still not aware of their disease or are about to get diabetes…!  Around 75% of the people, diagnosed with diabetes, have poor metabolic control, which leads to the development of complications – myocardial infarction, apoplexy, blindness, amputations and chronic renal failure. Among the complications of diabetes – the diabetic foot syndrome (DFS) takes the leading position.

Diabetic foot

Definition – the diabetic foot is a combination of pathological changes of the lower appendages and the feet, which is due to the developing vascular degenerative syndrome and the changes of the peripheral nervous system that are typical of the patients with diabetes mellitus.

According to epidemiological studies, we can assume that around 15 % of patients with diabetes mellitus, in the progress of their disease, suffer from lesions of the foot with various severity, and characteristics, which often end in amputations. Unfortunately, this statistics is rather cruel – once every 30 seconds one amputation of a patient with diabetes mellitus.

In our country, there is no precise statistics about the frequency of amputations, but we can safely say that over 50% of non-traumatic amputations of lower appendices in Bulgaria come from people with diabetes.

The DFS is a severe complication of the diabetes mellitus, but with appropriate treatment and timely precention of these wounds, the amputation will be avoided in over 80 per cent of patients with diabetes.

Prerequisites for the occurrence of pathological changes of the diabetic foot

The main prerequisite for the occurrence of lesions with diabetic foot is the presence of a diabetic (poli)neuropathy and/or peripheral arterial disruptions of circulation. Although, statistical data somewhat differs, one can assume that the following distribution is true:

• in around 45 % of the cases, the cause is diabetic neuropathy;
• in other 45 %, the etiology is mixed – neuropathy and blood circulation disorder;
• and in the other 10 %, the cause is an insulated instances of peripheral blood circulation disorders;

Diabetic neuropathy

Diabetic neuropathy – it is characterised with increased ischemia of neural cells and progressive damage of the neural tissue.  It affects equally autonomous, sensory and motor fibers.

From a clinical point of view, these injuries lead, both separately and jointly, to typical changes of the foot in patients with diabetes:

• The injuries of autonomous threads causes a reduction of sweat secretion with resulting atrophic, dry and warm skin;
• The injured sensory functions lead to reduced sensation of pain and loss of the feeling of pain;
• The reduced activity of the motor neurons leads to atrophy of the supporting muscles and reduced regulation of the motor function;
• With first type diabetes, the affecting of nerves usually appears many years after the increased level of blood sugar. On the other hand, with the second type of diabetes, it can develop only after a few years of bad control or even be discovered upon diagnosing the patient with diabetes mellitus.
• With diabetic neuropathy a number of serious complications can occur, some of which can even be life-threatening.
• The first signs of neuropathological disorders in the legs are darkened dry skin, which acquired “marble-like” appearance, stinging sensation, twitches and pain while resting, especially at night. The feeling of pain from injuries, however, is almost non-existent.
• The lack of sensitivity in extremities becomes a precondition for accidental injury of the feet and wounds, which are very hard to heal. They become infected, and as a consequence, lead to disintegration of tissues and gangrene, which is only treated by amputation.

Diabetic neuropathy and DFS

• A specific configuration of the foot develops, which is characterised with typical orthpedic deformities and hyperkeratosis /blisters/ as a result of plantarly developed atypical loads.
•         With foor neuropathology, predominantly a typical ulcer forms in the points of greatest pressure, which is lined with hyperkeratosis, which is most often infected.
•         Frequently, due to the increased pressure and cutting forces, in the hyperkeratotically changed skin occurs separation between the skin and the subcutaneous area with the formation of fissures, hemorrhages and hematomas, which are later colonised by bacteria.

Depending on the depth of the ulcer, we differentiate 4 clinical stages:

• superficial ulcer;
• ulcer, with depth reacing the joint capsule and/or the tendon;
• ulcer with an abscess, pyogenic arthritis, osteomielitis;
• necrosis and gangrene of the foot;
• A typical feature are the fungal infections between the toes, which are a consequence of the reduced immune protection of the organism, micro injuries and wounds, caused pressure due to uncomfortable shoes, points of pressure, caused by ingrown toe-nails, cutting with sharp utensils for clipping of the nails, or by thermal injuries, e.g. a foot bath that is too warm.

All, even the most insignificant injuries represent an entrance for the mostly commonplace infections, which, in combination with uncontrolled diabetes, lead to life-threatening infections of the foot.

Patients with diabetes often allow a dangerous DELAY in time, which leads to the a general reduction in the protection of the organism. An infection, although localised at first, can quickly spread in depth, and endanger basic anatomic structures – tendons, muscles and bones.

The inflammation of the bone can also lead to the complete destruction of the foot skeleton. The result is the appearance of a Charcot foot, or a deep inflammation of the foot tissues (foot phlegmon), which poses a risk to the circulation of the fingers and a risk of diabetic gangrene.

Diabetic angiopathy

The macroangiopathy is related to the effects of diabetes and with atherosclerosis – there are layered stenoses to complete obliteration of the peripheral vessels of medium size. The macroangopathy of patients with diabetes can be characterised as advanced, especially severe form of atherosclerosis.

Microangiopathies are diseases of the final blood vessels and are grouped like micro-circulation disorders.  After a pathoanatomic examination, a specific thickening of the basal membrane at the level of arterioles, capillary and pre-capillary vessels is found in patients with diabetes, where in most cases complete obliteration of vessels is not found.

The deteriorated circulation in the tissues, caused by micro- or macroangiopathy, presents a serious risk for the development of diabetic ulcer on the foot, and it impedes the healing of existing ulcers.

The predilection spots for the development of ischemic diabetic ulcers are similar to those of artherial ulcers:

•      the end phalanxes of toes;
•      the nails, the nail beds;
•      the heads of the first and second metatarsal bone;

Necroses, caused by the most severe circulation deficiency, are usually located along the lateral edge of the goot, the heel, in the spaces between the fingers and along the extension surface of the shin.

Treatment and prevention

• The main goal is:

•    reduction of amputations;
•    preservation of the function of limbs;
•    preservation of the quality of life of patients with diabetes;

•  The treatment is an interdisciplinary task and success is possible only using wide range of measures. For this experts in internal diseases, orthopedics, neurology, dermatology and trained experts in health care must be engaged.

The main measure in the treatment of all diabetic lesions is the optimum regulation of diabetes (normoglycemia), which is also the best therapy of neuropathy.

The conservative treatment is concentrated onto the improvement of the central hemodynamics (treatment of cardiac or respiratory failure, regulation of blood pressure), hemorheology and vasodynamics, as well as anticoagulation.

The most important problem of the treatment of diabetic ulcers is the unusuallu serious risk of infections. The mixed forms of neuropathologic and angiopathologic ulcers, and the purely neuropathologic ulcers can in principle be considered to be infected.

The possibility of spreading an infection are particularly good due to the differentiated structure of the connecting tissue, so that the respective antibiotic treatment is always justified. 

Activities of health care extpers, related to the treatment and prevention of the DIABETIC FOOT SYNDROME 

The inform and train patients about the principles of correct prevention:

• selection of the right shoes (if possible, custom-made orthopedic shoes);
• daily inspection of the condition of the feet, respectively for any changes in the shoes (appearance of points of pressure);
• observance of strict foot hygiene (frequent short bath of the feet with lukewarm water, good soaking of the spaces between the fingers without the use of any creams);
• ban in barefoot walking;
• blisters must be treated only by an expert;
• use of different types of orthopedic pads and insoles;

• use of cotton socks;
• warming procedures for the toes are not recommended (warmers, etc.);
• correct maintenance of nails (filing in a straight line, not using metal files, any nails that are ingrown in soft tissues must be treated by a doctor);
• if any changes in the foot are found, medical assistance must be sought immediately;
• Advice and encouragement of patients regarding coping with risk factors like: smoking tobacco and extra weight.
• Constant reminders that the normalisation of the carbohydrate, fat and protein metabolism deters the development of any vascular complications of this disease, and this allows a human to lead a complete life.
• They must assist surgeons and take part in the performance of a number of surgical procedures and putting of bandages in strict observance of septics and antiseptics.
• They keep track of the appearance of any symptoms of ketoacidosis, whereby they strictly control the values of the blood sugar, urinalysis for keto bodies and ionogramme.
• They follow the condition of wounds (bleeding, secretions, pain).
• The follow the general condition of the limb (temperature, colour, edemas, etc.).
• With their positive attitude, they strive to provide, both physical and emotional comfort to the patients.

The orthopedic shoes, designed for diabetic foot by Dr.Orthopedic are made of a natural healthy and soft leather, which does not cause any wounds and lesions of the feet of patients with diabetes. It is extremely important that there is no seam along the shoe lining, which guarantees comfort of use for patients with diabetic foot. The natural leather and latex provide softness of the cuffs and the shoe. The presence of a breathing system ensures the necessary microclimate for the healthy use of orthopedic shoes. The special, anatomically designed, lightened, absorbing sole with breathing orthopedic insole are made of natural leather, and are the necessary prerequisite for the prevention of diabetic foot.