Diabetes pp 123-138 | Cite as

Diabetic Foot

A Continuing Challenge
Part of the Advances in Experimental Medicine and Biology book series (AEMB)


Diabetes is rapidly emerging as the new global epidemic. The prevalence of diabetes is expected to double in the next three decades. Diabetic foot (DF) is a major complication of long standing diabetes, accounting for nearly 35% of all hospital admissions in diabetic climcs. It also accounts for nearly 80% of all nonlraumatic amputations of the lower limb. Due to its significant morbidity and mortality, DF has a staggering economic impact not only on the individual and his family but also the society. The aetiopathogenesis of DF is multifactorial and is related to peripheral neuropathy leading to the insensate foot with foot deformities, peripheral vascular disease and infection in addition to the reduced immunity seen in these patients. The clinical evaluation of the DF in addition to the detailed examination of foot deformities and the ulcers should focus on identifying loss of protective sensation using simple clinical tests as well as an examination of the vascular integrity by a simple hand held Doppler device. Patients of DF should be managed by a multidisciplinary team which in addition to clinical specialists should also include a podiatrist and trained nursing staff. The basic tenets of treatment include offloading, wound bed preparation using repeated debridement, treating local and systemic infection and to identify and correct vascular impairment if it is present. Once the ulcer has healed, recurrences are common and patient education for foot care is of paramount importance as is an annual examination in a dedicated foot clinic. Once an ulcer develops it should be promptly referred to a specialist unit.


Negative Pressure Wound Therapy Major Amputation Diabetic Foot Ulcer Pulse Volume Recording International Diabetic Foundation 
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  1. 1.
    Wild S, Roglic G, Green A et al. Global prevalence of Diabetes mellitus: estimates for the year 2000 and projection for 2030 Diabetes Care 2004; 27:1047–1053.PubMedCrossRefGoogle Scholar
  2. 2.
    Amos AF, McCarty DJ, Zimmet P. The rising global burden of diabetes and its complications: estimates and projections to the year 2010. Diabetes Mod 1997; 14(Suppl):581–585.Google Scholar
  3. 3.
    Sicree R, Shaw J, Zimmet P. Prevalence and projections. In: Gan D, editor Diabetics Atlas 3rd ed. Bussels: International Diabetics Federation, 2006.Google Scholar
  4. 4.
    World Health statistics 2008. Availablefrom Accessed 2010.
  5. 5.
    International Diabetic Foundation Diabetes atlas 4th edn. International Diabetic Foundation, Brussels: 2009.Google Scholar
  6. 6.
    Boulton AJM, Vileikyte L, Ragnarson-Tennvall G et al. The global burden of diabetic foot disease. Lancet 2005; 366:1719–1724.PubMedCrossRefGoogle Scholar
  7. 7.
    Harrington C, Zagari MJ, Corea J et al. A cost analysis of diabetic lower extremity ulcers. Diabetes Care 2000; 23:1333–1338.PubMedCrossRefGoogle Scholar
  8. 8.
    Apelqvist J. Wound healing in diabetes: outcome and costs. Clin Podiatr Med Surg 1998; 5:21–29.Google Scholar
  9. 9.
    Moss SE, Klein R, Klin BE. Long term incidence of lower extremity amputations in a diabetic population. Arch Farn Med 1996; 5:391–398.CrossRefGoogle Scholar
  10. 10.
    Humphrey AR, Dowse GK, Thoma K et al. Diabetes and nontraumatic lower extremity amputations. Incidence riski factors and prevention—a 12 year follow up study in Nauru. Diabetes Care 1996; 19:710–714.PubMedCrossRefGoogle Scholar
  11. 11.
    Muller IS, deGrarco WJ. vanGenuen WH et al. Foot ulceration and lower limb amputation in type 2 diabetic patients in Dutch primary health care. Diabetes Care 2002; 25:570–574.PubMedCrossRefGoogle Scholar
  12. 12.
    Vishwanathan V, Thomas N, Tandon N et al. Profile of Diabetic foot and its associated complications. J Assoc Physicians India 2005; 53:933–936.Google Scholar
  13. 13.
    Pendsey SP. Understanding Diabetic foot. Int J Diab Dev Ctries 2010; 30:75–79.CrossRefGoogle Scholar
  14. 14.
    Boulton AJ. The pathway to ulceration: aetiopathogenesis. In: Cavauagh PR, ed The Foot in Diabetes. Chicester,UK: Wiley; 2000; 19–31.CrossRefGoogle Scholar
  15. 15.
    Levin ME. Pathogenesis and general management of foot lesions in the diabetic patient. In: Bowker JH, Pfeifer MA, eds. The Diabetic Foot, S. Louis. Mosby, 2001; 219–260.Google Scholar
  16. 16.
    Andersen CA, Roukis TS. The Diabetic foot. Surg Clin N. Am 2007; 87:1149–1177.PubMedCrossRefGoogle Scholar
  17. 17.
    Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lancet 2003; 361:1545–1551.PubMedCrossRefGoogle Scholar
  18. 18.
    Leese GP. Review: the varied attractions of the diabetic foot. Br J Diab Vasc Dis 2009; 9:155–159.CrossRefGoogle Scholar
  19. 19.
    Tanenberg RJ, Schumer MP, Greene DA et al. Neuropathic problems of the lower extremities in diabetic patients. In: Bowker HI, Pfeifer MA, eds, The Diabetic Foot, St. Louis, Mosby, 2001; 33–64.Google Scholar
  20. 20.
    Margolis DJ, Kantor J, Santanna J. Risk factors for delayed healing of neuropathic diabetic foot ulcers: Apooled analysis. Arch Dermatol 2000; 136:1531–1535.PubMedCrossRefGoogle Scholar
  21. 21.
    Sinnreich M, Taylor BV, Dyck PJ. Diabetic neuropathies, classification, clinicalfeaturesandpathophysiologic basis. Neurologist 2005; 11:63–79.PubMedCrossRefGoogle Scholar
  22. 22.
    Boulton AJM, Vinik AI, Arezzo JC et al. Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care 2005; 28:956–962.PubMedCrossRefGoogle Scholar
  23. 23.
    Boulton AJ, Kirsner RS, Vileikyte L. Clinical practice. Neuropathic diabetic foot ulcers. N Engl J Med 2004;351(1):48–55.PubMedCrossRefGoogle Scholar
  24. 24.
    Zochodone DW. Diabetic polyneuropathy: an update. Cuit Opin Neurol 2008; 21:527–533.CrossRefGoogle Scholar
  25. 25.
    Feldman EL, Russelll JW, Sullivan KA et al. New insights into the pathogenesis of diabetic neuropathy. Curr Opin Neurol 1999; 5:553–563.CrossRefGoogle Scholar
  26. 26.
    LoGerfo FW, Coffman JD. Current concepts: vascular and microvascular disease of the foot in diabetes. Implications for foot care. N Engl J Med 1984; 311(25):1615–1619.PubMedCrossRefGoogle Scholar
  27. 27.
    Akbari CM, LoGerfo FW. Diabetes and peripheral vascular disease. J Vasc Surg 1999; 30(2):373–384.PubMedCrossRefGoogle Scholar
  28. 28.
    Jude EB, Oyibo SO, Chalmers N et al. Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome. Diabetes Care 2001; 24(8):1433–1437.PubMedCrossRefGoogle Scholar
  29. 29.
    Emanuele MA, Buchanan BJ, Abraira C. Elevated leg systolic pressures and arterial calcification in diabetic occlusive vascular disease. Diabetes Care 1981; 4(2):289–292.PubMedCrossRefGoogle Scholar
  30. 30.
    Geerlings SE, Hoepelman AI. Immune dysfunction in patients with diabetes mellitus. FEMS Immunol Med Microbiol 1999; 26:259–265.PubMedCrossRefGoogle Scholar
  31. 31.
    Delamaire M, Maugendre D, Moreno M et al. Impaired leucocyte function in diabetic patients. Diabet Med 1997; 14:29–34.PubMedCrossRefGoogle Scholar
  32. 32.
    MacRury SM, Gemmell CG, Paterson KR et al. Changes in phagocytic function with glycaemic control in diabetic patients. Clin Pathol 1989; 42:1143–1147.CrossRefGoogle Scholar
  33. 33.
    Calvet HM, Yoshikawa TT. Infections in diabetes. Infect Dis Clin North Am 2001; 15:407–421.PubMedCrossRefGoogle Scholar
  34. 34.
    Tan JS, File TM Jr. Diagnosis and treatment of diabetic foot infectious. Baillieres Clin Rheumatol 1999; 13:149–161.CrossRefGoogle Scholar
  35. 35.
    Diamantopoulos EJ, Haritos D, Yfandi G et al. Management and outcome of severe diabetic foot infections. Exp Clin Endocrinol Diabetes 1998; 106:34.CrossRefGoogle Scholar
  36. 36.
    Armstrong DG, Liswood PJ, Todd WF. 1995 William J Stickel Bronze Award. Prevalence of mixed infections in the diabetic pedal wound: a retrospective review of 112 infections. J Am Podiatr Med Assoc 1995;85(910):533–537.PubMedGoogle Scholar
  37. 37.
    Ting X, Lu S, Mani R. Diabetic foot infection in the world: we need ways forward. Int J Low Extrem Wounds 2010; 9:3–5.CrossRefGoogle Scholar
  38. 38.
    Lavery LA, Armstrong DG, Wunderlich RP et al. Riskfactors for foot infections in individuals with diabetes. Diabetes Care 2006; 29(6):1288–1293.PubMedCrossRefGoogle Scholar
  39. 39.
    Frykberg RG. An evidence based approach to diabetic foot infections. Am J Surg 2003; 186(5A):44S–54S (discussion: 61S–4S).PubMedCrossRefGoogle Scholar
  40. 40.
    Encroth M, Apelqvist J, stcnstrom A. Clinical characteristics and outcome in 223 diabetic patients with deep foot infections. Foot Ankle Int 1997; 18(11):716–722.CrossRefGoogle Scholar
  41. 41.
    Bansal E, Garg A, Bhatia S et al. Spectram of microbial flora in diabetic foot ulcers. Indian J Pathol Microbiol 2008; 51:204–208.PubMedCrossRefGoogle Scholar
  42. 42.
    Gadepalli RG, DhDhawan B, Sreenivas V et al. A clinicomicrobiological study of diabetic foot ulcers in an Indian tertiary care hospital. Diabetes Care 2006; 29:1727–1732.PubMedCrossRefGoogle Scholar
  43. 43.
    Reyzelman AM, Armstrong DG, Vayser DJ et al. Emergence of nongroup A streptococcal necrotizing diabetic foot infections. J Am Podiatr Med Assoc 1998; 88:305–307.PubMedGoogle Scholar
  44. 44.
    Dang CN, Prasad YD, Boulton AJ et al. Methicillin resistant Staphylococcus aureus in the diabetic foot clinic: a worsening problem. Diabet Med 2003; 20:159–161.PubMedCrossRefGoogle Scholar
  45. 45.
    Lipsky BA, Berendt AR. Principles and practice of antibiotic therapy of diabetic foot infections. Diabet Metab Res Rev 2000; 16(Suppl):42–46.CrossRefGoogle Scholar
  46. 46.
    Bristow IR, Spruce MC. Fungal foot infection, cellulites and diabetes: areview. Diabet Med 2009; 26:548–551.PubMedCrossRefGoogle Scholar
  47. 47.
    Edmonds M, Foster A. The use of antibiotics in the diabetic foot. Am J Surg 2004; 187(5A):25S–28S.PubMedCrossRefGoogle Scholar
  48. 48.
    Lipsky BA. Osteomyelitis of the loot in diabetic patients. Clin Infect Dis 1997; 25:1318–1326.PubMedCrossRefGoogle Scholar
  49. 49.
    Jeffcoate WJ, Lipsky BA. Controversies in diagnosing and managing osteomyelitis of the foot in diabetes. Clin Infect Dis 2004; 39(Suppl 2):S115–S122.PubMedCrossRefGoogle Scholar
  50. 50.
    Lavery LA, Armstrong DG, Peters EJ et al. Probe-to-bone test for diagnosing diabetic loot osteomyelitis: reliable or relic? Diabetes Care 2007; 30(2):270–274.PubMedCrossRefGoogle Scholar
  51. 51.
    Bowcring CK. Diabetic foot ulcers: pathophysiology, assessment and therapy. Can Fam Physician 2001; 47:1007–1016.Google Scholar
  52. 52.
    Jirkovska A, Boucvek P, Woskova V. Identification of patients at risk for diabetic foot: A comparison of standardized non-invasive testing with routine practice at community diabetes climes. J Diabetes Complications 2001; 15:63–68.PubMedCrossRefGoogle Scholar
  53. 53.
    Armstrong DG, Lavery LA, Vela SA. Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration. Arch Intern Med 1998; 158:289–292.PubMedCrossRefGoogle Scholar
  54. 54.
    Mayfield JA, Sugarman JR. The use of the Semmes—Weinstein monofilament and other threshold tests for preventing, foot ulceration and amputation in persons with diabetes. J Fam Pract 2000; 49(11 Suppl): S17–S29.PubMedGoogle Scholar
  55. 55.
    Boulton AJM, Lavery LA, Armstrong DG et al. Comprehensive foot examination and risk assessment. Diabetes Care 2008; 5:1679–1685.CrossRefGoogle Scholar
  56. 56.
    Wagner FW Jr. Management of the diabetic neurotrophic foot part II. A classification and treatment program for diabetic, neuropathic, and dysvascular foot problems. In: Instructional Course Lectures: The American Academy of Orthopaedic Surgeons. St Louis: CV Mosby, 1979; 28:143–165.Google Scholar
  57. 57.
    Wagner FW. Supplement: algorithms of foot care. In: Levin_ME, O’Neal LW, eds. The Diabetic Foot, S. Louis: Mosby 1983; 291–302.Google Scholar
  58. 58.
    Brodsky JW. The diabetic foot. In: Coughlin MJ, Mann RA, Saltzman CL, eds, Surgery of the Foot and Ankle, St. Louis, Mosby 2007; 1281–1368.Google Scholar
  59. 59.
    Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection and ischemia to risk of amputation. Diabetes Care 1998; 21:855–859.CrossRefGoogle Scholar
  60. 60.
    Lipsky BA. A report from the international consensus on diagnosing and treating the infected diabetic foot. Diabetes Metab Res Rev 2004; 20(Suppl 1):S68–S77.PubMedCrossRefGoogle Scholar
  61. 61.
    Lipsky BA, Berendt AR, Deery HG et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2004; 39(7):885–910.PubMedCrossRefGoogle Scholar
  62. 62.
    Karchmer AW, Gibbons GW. Foot infections in diabetes: evaluation and management. Curr Clin Top Infect Dis 1994; 14:1–22.PubMedGoogle Scholar
  63. 63.
    Aly S, Sommerville K, Adiseshiah M et al. Comparison of duplex imaging and arteriography in the evaluation of lower limb arteries. Br J Surg 1998; 85:1099–1102.PubMedCrossRefGoogle Scholar
  64. 64.
    Sumpio BE, Lee T, Blume PA. Vascular evaluation and arterial reconstruction of the diabetic foot. Clin Podiatr Med Surg 2003; 20:689–708.PubMedCrossRefGoogle Scholar
  65. 65.
    Raines JK, Darling RC, Buth J et al. Vascular laboratory criteria for the management of peripheral vascular disease of the lower extremities. Surgery 1976; 79:21–29.PubMedGoogle Scholar
  66. 66.
    Symes JF, Graham AM, Mousseau M. Doppler waveform analysis versus segmental pressure and pulse volume recording: assessment of occlusive disease in the lower extremity. Can J Surg 1984; 27:345–347.PubMedGoogle Scholar
  67. 67.
    Takolander R, Rauwanda JA. The use of non-invasive vascular assessment in diabetic patients with foot lesions. Diabetes Med 1995; 13(Suppl 1):S39–S42.Google Scholar
  68. 68.
    Ballard JL, Eke CC, Bunt TJ et al. A prospective evaluation of transcutaueous oxygen measurements in the management of diabetic foot problems. J Vasc Surg 1995; 22:485–490.PubMedCrossRefGoogle Scholar
  69. 69.
    Veves A, Boulton AJ. The optical pedobarograph. Clin Podiatr Med Surg 1993; 10:463–370.PubMedGoogle Scholar
  70. 70.
    vanSchie CH. Abbot CA, Vileikyte L et al. A comparative study of the Podo Track, a simple semi quantitative plantar pressure measuring device and the optical pedobarograph in the assessment of pressure under the diabetic foot. Diabet Med 1999; 16:154–159.PubMedCrossRefGoogle Scholar
  71. 71.
    Abouaesha F, vanSchie CH, Griffiths GD et al. Plantar tissue thickness is related to peak plantar pressure in the high risk diabetic foot. Diabetes Care 2001; 24:1270–1274.PubMedCrossRefGoogle Scholar
  72. 72.
    Edmonds ME, Blundell MP, Morris ME et al. Improved survival of the diabetic foot: the role of a specialized foot clinic. Q J Med 1986; 60:763–771.PubMedGoogle Scholar
  73. 73.
    Frykberg RG, Zgonis T, Armstrong DG et al. Diabetic foot disorders: a clinical practice guideline 2006 revision). J Foot Ankle Surg 2006; 45(Supp l):S1–S64.PubMedGoogle Scholar
  74. 74.
    Caputo GM, Cavanagh PR, Ulbrecht JS et al. Assessment and management of foot disease in patients with diabetes. N Engl J Med 1994; 331:854–860.PubMedCrossRefGoogle Scholar
  75. 75.
    Cavanagh PR, Lipsky BA, Bradbury AW et al. TreatmentforDiabeticfootulcers. Lancet 2005;366:1725–1735.PubMedCrossRefGoogle Scholar
  76. 76.
    Pinur MS, Shields N, Trepman F et al. Current practice patterns in the treatment of Charcot foot. Foot Ankle Int 2000; 21:916–920.Google Scholar
  77. 77.
    Myerson M, Papa J, Eaton K et al. The total contact cast for management of neuropathic planter ulceration of the foot. J Bone Joint Surg 1992; 72:261–269.Google Scholar
  78. 78.
    Uccioli L, Faglia F, Monticone G et al. Manufactured shoes in the prevention of diabetic foot ulcers. Diabetes Care 1995; 18:1376–1378.PubMedCrossRefGoogle Scholar
  79. 79.
    Chandalia HB, Singh D, Kapoor V et al. Footwear and foot care knowledge as riskfactors for foot problems in Indian diabetics. Int J Diabetes Dev Ctries 2008; 28:109–113.PubMedCrossRefGoogle Scholar
  80. 80.
    Steed DL. Debridement. Am J Surg 2004; 5(Suppl):71S–74S.CrossRefGoogle Scholar
  81. 81.
    Sieggrcen MY, Maklebust J. Debridement choices and challenges. Adv Wound Care 1997; 10:32–37.Google Scholar
  82. 82.
    Rao DB, Sane PG, Georgiev EL. Collagenase in the treatment of dermal and decubitus ulcers. J Am Geriatr Soc 1975; 23:22–30.PubMedGoogle Scholar
  83. 83.
    Ziffren SE, Heist MA, May SC et al. Secretion of collagenase by maggots and its implication. Ann Surg 1953; 138:932–934.PubMedCrossRefGoogle Scholar
  84. 84.
    Foster AVM, McColgan M, Edmonds ME. Should oral antibiotics be given to “clean” foot ulcers with no cellulitis? Diabet Med 1998; 15(Suppl 2):S10.Google Scholar
  85. 85.
    Armstrong DG, Lipsky BA. Diabetic foot infections: stepwise medical and surgical management. Int Wound J 2004; 1(2):123–132.PubMedCrossRefGoogle Scholar
  86. 86.
    Calhoun JH, Overgaard KA, Stevens CM et al. Diabetic foot ulcers and infections: current concepts. Adv Skin Wound Care 2002; 15:31–45.PubMedCrossRefGoogle Scholar
  87. 87.
    Lipsky BA, Itani K, Norden K. Treating foot infections in diabetic patients: a randomized, multicenter, open-label trial of linezolid versus ampicillin-sulbactam/amoxicillin-clavulanate. Clin Infect Dis 2004; 38(1):17–24.PubMedCrossRefGoogle Scholar
  88. 88.
    Donahue VM, Chrzan JS, Rosenblum BI. Evaluation of a collagen—alginate wound dressing in the management of diabetic foot ulcers. Adv Wound Care 1998; 11:114–119.Google Scholar
  89. 89.
    Guzman-Gardearzabal E, Leyva p Bohorquez G, Salas-Colin S. Treatment of chronic ulcers in the lower extremities with topicalbecaplemiin gel, 01%: Amulticenter open —label study. Adv Ther 2000; 17:184–189.PubMedCrossRefGoogle Scholar
  90. 90.
    Margolis DJ, Dantor J, Santanna J. Effectiveness of plateletreleasateforthe treatment of diabetic neuropathic foot ulcers. Diabetes Care 2001; 24(3):483–488.PubMedCrossRefGoogle Scholar
  91. 91.
    Evans D, Land L. Topical negative pressure for treating chronic wounds: A systematic review. Br J Plast Surg 2001; 54:238–242.PubMedCrossRefGoogle Scholar
  92. 92.
    Armstrong DG, Lavery LA. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre randomized controlled trial. Lancet 2005; 366:1704–1710.PubMedCrossRefGoogle Scholar
  93. 93.
    Lavery LA, Boulton AJ, Niezgode JA et al. A comparison of diabetic foot ulcer outcomes using negative pressure wound therapy versus historical standard of care. Int Wound J 2007; 4:103–113.PubMedCrossRefGoogle Scholar
  94. 94.
    Brem H, Balledux J, Bloom T. Healing of diabetic foot ulcers and pressure ulcers with human skin equivalent: A new paradigm in wound healing. Arch Surg 2000; 135:627–634.PubMedCrossRefGoogle Scholar
  95. 95.
    Marston WA, Hanft J, Norwood P et al. The efficacy and safety of Dermagraft in improving the healing of chronic diabetic foot ulcers: results of a prospective randomized trial. Diabetes Care 2003; 26:1701–1705.PubMedCrossRefGoogle Scholar
  96. 96.
    Faglia E, Mantero M, Caminiti M et al. Extensive use of peripheral angioplasty particularly infraopopliteal in the treatment of ischaemic diabetic foot ulcer: clinical results of a multicentric study of 221 consecutive diabetic subjects. J Intern Med 2002; 252:225–232.PubMedCrossRefGoogle Scholar
  97. 97.
    Faglia E, Mantero M, Caminiti M et al. Peripheral angioplasty as the first-choice revascularization procedure in diabetic patients with critical limb ischemia: prospective study of 993 consecutive patients hospitalized and followed between 1999 and 2003. Eur J Vasc Endovasc Surg 2005; 29(6):620–627.PubMedCrossRefGoogle Scholar
  98. 98.
    Cavallini M, Caterino S, Murante G et al. Efficacy of the popliteal to distal bypass in salvage of the ischemic diabetic foot. Ann Ital Chir 1995; 66:473–478.PubMedGoogle Scholar
  99. 99.
    Paraskevas PI, Baker DM, Pompella A et al. Does Diabetes mellitus play a role in restenosis and patency rates following lower extremity peripheral artery revascularization? A critical overview. Ann Vase Surg 2008; 22:481–491.CrossRefGoogle Scholar
  100. 100.
    Toursarkissian B, Shireman PK, Schoolficld J et al. Outcomes following distal bypass graft occlusion in diabetics. Ann Vasc Surg 2003; 17(6):670–675.PubMedCrossRefGoogle Scholar
  101. 101.
    Akbari CM, Macsata R, Smith BM et al. Overview ofthe diabetic foot. Semin Vasc Surg 2003; 16(1):3–11.PubMedCrossRefGoogle Scholar

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© Landes Bioscience and Springer Science+Business Media 2013

Authors and Affiliations

  1. 1.Department of General SurgeryBanaras Hindu UniversityVaranasiIndia
  2. 2.Department of Endocrinology and MetabolismBanaras Hindu UniversityVaranasiIndia

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