Etiology and Treatment of Pedal Wounds in the Diabetic Patient

摘要

Wounds related to diabetes mellitus are multifactorial in etiology. Primary factors contributing to chronic diabetic foot ulceration include peripheral neuropathy and peripheral vascular disease. Secondary factors including limited joint mobility, neuropathic osteoarthropathy (Charcot foot), and a depressed immune response to infection further complicate treatment. Prompt treatment of diabetic foot wounds with a multidisciplinary approach, coordinating the primary care physician, endocrinologist, vascular surgeon, and podiatrist, can achieve healing, and reduce the chance of amputation. 1 In the United States, approximately 50% of all nontrau- matic lower extremity amputations occur in patients with diabetes mellitus. Limb amputation is not an inevitable fact of diabetes with a controlled, organized approach to wound care. Long-term glycemic control is the goal. Identifying the etiology of the wound and then intervening with techniques to allow for an optimal wound climate for healing must be instituted. This includes optimizing arterial perfusion to the wound site. Removal of unhealthy tissue, thereby reducing bacterial bioburden, via debridement is important for wound bed preparation. Depending upon the depth of the wound, other deeper structures such as tendon, muscle, and bone (in osteomyelitis), may require excisional debridement. In addition, evaluation for a neuropathic component or struc- tural defor mity of the foot ie hallux valgus, hammertoes, or pes planus is also necessary to properly remove pressure or offload the wound to optimize healing potential. In cer- tain instances, wounds cannot heal due to structural defor- mity of the foot and surgical correction of the underlying deformity is required.