Current concepts for the evaluation and management of diabetic foot ulcers

Abstract

The lifetime risk for diabetic patients to develop a diabetic foot ulcer (DFU) is 25%. In these patients, the risk of amputation is increased and the outcome deteriorates.More than 50% of non-traumatic lower-extremity amputations are related to DFU infections and 85% of all lower-extremity amputations in patients with diabetes are preceded by an ulcer; up to 70% of diabetic patients with a DFU-related amputation die within five years of their amputation.Optimal management of patients with DFUs must include clinical awareness, adequate blood glucose control, periodic foot inspection, custom therapeutic footwear, off-loading in high-risk patients, local wound care, diagnosis and control of osteomyelitis and ischaemia. Cite this article: EFORT Open Rev 2018;3:513-525. DOI: 10.1302/2058-5241.3.180010.

Keywords: diabetic foot ulcers; infection; osteomyelitis; revascularization; wound dressings.

Fig. 1

a, b) Photographs of the right foot of a 69-year-old diabetic woman with a heel and a medial malleolus purulent DFU. c) Anteroposterior and d) lateral radiographs of the right leg show complete distortion of the ankle and talar joints and osteolysis at the distal tibia and fibula. She was treated with a below-knee amputation, intravenous antibiotics and blood glucose control.

Fig. 2

a) Photograph of the right foot of a 72-year-old diabetic man shows a DFU at the heel with soft-tissue necrosis. b) Surgical debridement in healthy viable tissue was done and tissue cultures were obtained. Post-operatively, he was administered per os antibiotics for three months and was educated for blood glucose control and wound dressing changes once per day with silver-impregnated dressings. c) Photograph of the foot five months post-operatively showing wound healing with granulation tissue, without evidence of infection.

Fig. 3

Photograph of the right foot of a 53-year-old diabetic woman shows a DFU at the dorsum of the foot and dry gangrene of the second and third toes. She was treated with third ray amputation, wound debridement, intravenous antibiotics and blood glucose control.

Fig. 4

Photograph of the right foot of a 74-year-old diabetic man shows a DFU at the lateral side of the surface of the foot with wet gangrene and gas accumulation at the soft tissue. He was treated with multiple surgical debridements, intravenous antibiotics and blood glucose control; however, because of PAD he ended up with a below-knee amputation.

Fig. 5

Photograph of the right foot of a 68-year-old diabetic woman shows a DFU at the heel of the foot with dry gangrene. She was treated with multiple surgical debridements, intravenous antibiotics and blood glucose control; however, because of persistent infection, osteomyelitis and PAD she ended up with a below-knee amputation. Post-operatively, she experienced acute heart and renal failure; she was admitted to the intensive care unit and died seven days later.