Diabetic Neuropathy & Foot Ulcers

A patient loses a toe or a foot every single minute somewhere in India. So get yourself checked without delay!
  • Diabetic neuropathy

    Increased blood sugar levels in Diabetes, leads to nerve damage due to toxic products called aldoses and aldehydes. Nerve damage is called diabetic peripheral neuropathy. Nerve damage leads to loss of sensation of touch and pain causing pins & needles sensation, numbness and burning. Neuropathy makes diabetic feet unable to protect itself from injury. This is a well-known complication of diabetes which makes feet prone for foot ulcers. Once ulcers form, they become infected and diabetes itself makes the healing process slow.

    Testing for neuropathy

    Testing a patient for neuropathy involves testing for vibration, touch, temperature and blood flow.

    Over a period of time, diabetics loose these modalities of sensation on the foot.

    Bioesthesiometry

    This test helps to determine vibration and touch sensation in the feet which are affected early in diabetic neuropathy. This testing is important not only to diagnose early changes in the diabetic feet, but also to monitor the response to treatment. It is recommended to have this testing once a year for all diabetics. Early loss of sensation is a precise indicator of impending ulceration.

    Testing for sensation in the foot
    Testing for sensation in the foot
    A test result
    A test result

    Computerized foot pressure testing

    Computerized foot pressure testing is done to give an idea of pressure distribution in the feet and thereby allow design of effective footwear.

    Normal foot pressures are distributed across the whole foot. In diabetics and also especially in people over the age of 50, foot pressures increase and are unevenly distributed, pre-disposing to ulcer formation.

    The foot scan is not only useful to know pressure distribution but also useful in diagnosing flat feet, and thereby advising corrective footwear.

    Foot Imprint scan
    Foot Imprint scan

    Vascular studies

    Latest blood flow studies of the feet are done to understand severity of blood flow reduction on progression of disease.

    Blood flow studies are important in diabetics as the very small blood vessels are involved early in the disease and are responsible for ulcer formation. All diabetic foot testing should involve not only foot testing but also pressure measurement of the arm as well.

    ABPI and vascular studies indicate not only the severity of vascular compromise in diabetic feet, but also in allowing one to predict gangrene level and the level of amputation.

    Blood flow studies
    Blood flow studies
    A test result

    Treatment

    AT HAPPY FEET we have got LEDs (Light emitting diodes) to increase blood flow and improve symptoms of tingling & numbness and burning. Together with a combination of proven medicines we have got a good success rate for treatment of diabetic neuropathy.


    Diabetic foot ulcer

    Diabetics are more prone for foot ulcers due to reduced skin sensation in the feet and narrowing of blood vessels in the feet. If you have diabetes you have an increased risk of developing narrowing of the arteries (peripheral vascular disease). This can cause a reduced blood supply (poor circulation) to the feet. A combination of vascular disease and neuropathy makes diabetics prone for ulceration and infection.

What can I do to prevent foot ulcers?

Care of your feet

Dont's

  • Do not cut your nails curved at the edges. Curved nail cutting at the edges causes in-growing toe nails. It can lead to infection, and before one realizes loss of a toe!

    Right & wrong way of cutting nails

    Right & wrong way of cutting nails
  • Using excessive soap on the feet can cause dryness and cracking, leading to infection.
  • NEVER BE BAREFOOT AT HOME, EVER! Because diabetic patients have lessened sensation on their feet, they are more prone for ulceration.
  • Avoid footwear with protruding knobs. These are widely advertised in the market as giving one's feet, an acupuncture effect. They are harmful to a neuropathic, especially diabetic foot.
  • If you wear shoes, use only cotton socks which allow feet to breath.
  • Avoid using open sandals with thongs, as thongs can cause ulcers especially if not padded well.
  • Repeatedly washing your feet several times a day can lead to drying and cracking, leading to infection.
  • Do not use hot water to wash or immerse your feet in.
  • Using narrow fronted shoes can give rise to a variety of problems like fungal infections between toes, and corns and ulcers on adjacent toes.

    Correct & incorrect footwear

    Correct & incorrect footwear

Do's : Consult your Podiatrist if you have a cut or redness or boil on the foot.

  • Inspect your feet and toes at least once a day, preferably at bedtime. Look for corns, reddish areas, ulcers and deep cracks.
  • Use a mild soap and water at room temperature for cleaning your feet.
  • Use moisturizing cream (not oil or ointment) after bath in the morning and at bedtime.
  • A clean soft cloth should be used to remove excessive water between toes.
  • Soft footwear made of special microcellular polymer is recommended for use.

    MCP footwear
    MCP footwear
    MCP footwear
    MCP footwear

  • Use cotton or silicone socks if you wear shoes.

Treatment of ulcers on the feet

In whichever stage, early, small or badly infected and gangrenous, requires planning and an established approach. Goals are to maximize healing, early coverage and minimize loss of toes or feet.

Foot ulceration in diabetics is common. The cause is poor blood flow and lack of sensation due to neuropathy (or loss of normal sensory function of the nerves).

Early and thorough debridement

This is the cornerstone to success in diabetic foot surgery. All dead and decaying tissue is removed including involved bony infection for healing to take place.

Maggots

Medical maggots are very helpful to remove dead and necrotic tissue from the foot.

Diabetic Foot UlcerDiabetic Foot Ulcer

Diabetic ulcers- are not only common but occur at pressure areas

Antibiotics

They have to be used based on organism isolated and sensitivity to the particular antibiotic.

VAC therapy

Vacuum is applied using a continuous negative pressure with VAC machine. Negative pressure removes inflammatory exudate and promotes healing. Existing, large non-healing, chronic and infective wounds shrink to a small and manageable size. This can help closure of wounds using split skin graft or full thickness local or distant flap.

VAC therapy
A wound without and with VAC therapy
VAC therapy
VAC machine


Off-loading

One of the most neglected but important aspects of ulcer treatment is the need for customized footwear. As the name implies, taking the weight off the involved area, lets healing to progress rapidly and is used as a routine in our centre. Depending on the location of the ulcer, a front off-loading or a back off-loading is available. Success usually hinges on using a combination of above.

Off-loading
Front off-loading foot wear
Off-loading
Back off-loading for ulcers on heel


Growth factor-based applications

Growth factors are normally present in tissues which help wounds to heal normally after injury. In diabetes several cellular changes lead to abnormal growth factor function on the cells, leading to delay in healing. Growth factors based on platelet cell and epidermis (normal top layer of skin) have been proven to work on diabetic wound healing. These have to be applied only on non-infected wounds with granulation tissue.

Growth factor-based applicationsGrowth factor-based applications

Special dressings will accelerate healing & reduce oozing

Hyperbaric oxygen

Bacteria thrive in wounds due to lack of oxygen. In chronic wounds oxygen given at a higher concentration, called hyperbaric oxygen accelerates wound healing.

Hyperbaric oxygen
Oxygen chamber
Hyperbaric oxygen
Before & after oxygen therapy

At higher concentrations oxygen causes free radical damage to bacteria. Also healing is delayed in oxygen-scarce wounds. Generally several sessions may be required for the wound to granulate and become normal skin.

Foot skin cover and Plastic surgery for large wound defects

Diabetic foot ulcers develop due to neuropathy and lack of microcirculation to the parts. They become chronic, infected and could lead to amputation.

The best way to treat these is to clear the infected matter in wound with an operation called debridement. Once there is red granulation tissue and wound is no longer infected, then a secondary split skin graft or either local or regional full thickness graft is used.

LOCAL FLAPS

Here skin is taken from the surrounding areas, and not from a distant site. The skin closure after harvest is in such a way that there is no requirement for split skin grafts.

V-Y Plasty

Local healthy skin is used to cover the defect on the ulcer. The incision is made like a V and then closed like a Y. No additional skin is required to cover the

Example of V-Y flap

Example of V-Y flap

Rotation flaps

  • Rotation flaps
  • Rotation flaps
  • Rotation flaps
  • Rotation flaps

Local healthy skin is used to cover the defect on the ulcer. Rotation of the skin is done to achieve closure, as shown. Results are good as long as rigid plastic surgery principles are adhered to. The donor area that is rotated is usually taken from non-weight bearing area. Rarely the donor area will require split skin graft.

Supramalleolar island flap

  • Supramalleolar island flap
  • Supramalleolar island flap
  • Supramalleolar island flap

Using blood vessels in a reverse technique due to a existence of perforators connecting superficial and deep vessels, a large 'flap'-meaning skin with fat, fascia and blood vessels is transported to the ulcer area. The donor area is usually closed on it's own, or wound sometimes require a split skin graft taken from the thigh. Both heal well.

Reverse sural flap for heel ulcers

  • Reverse sural flap for heel ulcers
  • Reverse sural flap for heel ulcers
  • Reverse sural flap for heel ulcers

Similarly, a large 'island flap' is taken from calf, and reversed to treat heel ulcers. The advantage compared to supra-malleolar is that a relatively large distance is covered with the flap, mitigating flap loss due to tension on the flap.