Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 950 - файл
.pdf
66 D. Dixon and M. Edmonds
Yammine K,
controlled trials. Foot. 2022;50.
Yellin J
amputations in patients with diabetic foot ulcers treated with cyclical pressurized topical wound
oxygen therapy: real-world outcomes. Adv Wound Care. 2021.
Young MJ,
ulceration using vibration perception thresholds: a prospective study. Diabetes Care. 1994;
17(6).
Estephan M. Telemedicine and diabetic foot ulcer outcomes. A meta-analysis of
aebler JA, Zhou FF, Niecko T, Novins O, Ockert A, et al. Reduced hospitalizations and
I, G
Breddy JL, Veves A, Boulton AJM. The prediction of diabetic neuropathic foot
Role of Technology for wound Care
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
in Diabetic Foot
V. Viswanathan and R. Mirshad
Abstract
India has the second-highest number of patients after China, accounting for 1 in
7 of all adults living with diabetes worldwide. The burden of diabetic foot
complications poses a severe challenge to the patient and the physician in terms
of physical and socioeconomic constraints. The mortality rate is 2.5 times higher
for patients with diabetic foot ulcers than for patients without DFU for five years,
and it is two times higher at ten years. The ideal management of diabetic foot
ulcers is debridement of the wound, management of any infection, revascularization procedu res when indicated, and off-loading the ulcer. A framework for
screening and early multifactorial interventions are required to control the
disease progression, increasing life expectancy, and decrease the economic
burden on the individual as well as the society.
Keywords
Diabetic foot ulcerWound careEarly diagnostic tool
V. Viswanathan (&)
Head and Chief Diabetologist, MV Hospital for Diabetes and Prof M Viswanathan
Diabetes Research Centre, Chennai, India
e-mail: drvijay@mvdiabetes.com
R. Mirshad
Research Associate, MV Hospital for Diabetes and Prof M Viswanathan Diabetes
Research Centre, Chennai, India
V. Viswanathan
Head and Chief Diabetologist, MV Hospital for Diabetes and Prof M Viswanathan
Diabetes Research Centre, No 4, West Madha Church Street, Royapuram, Chennai,
Tamil Nadu 600 013, India
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
R. Mani (ed.), Chronic Wound Management,
https://doi.org/10.1007/978-3-031-26110-7_4
67
68 V. Viswanathan and R. Mirshad
Introduction
Globally, an estimated 537 million adults live with diabetes; In India, with 74.2
million patients, it is predicted to increase to 124.9 million by 2045. India has the
second-highest number of patients after China, accounting for 1 in 7 of all adults
living with diabetes worldwide. Diabeti c foot ulcers and associated infections are
the foremost cause of hospital admissions. Diabetic foot ulcers affect 15% of people
with diabetes in their lifetime (Viswanathan 2007). Hence; more attention should be
to preventing DFUs than treating them.
Burden of Diabetic Foot Ulcers in India
In developing countries like India, the burden of diabetic foot complicat ions poses a
severe challenge to the patient and the physician in terms of physical and socioeconomic constraints. Mono/polymicrobial aetiology of diabetic foot infections was
widely reported with a high prevalence of gram-negative bacilli in India than in
western countries (Viswanathan and Rao 2013). Among people with diabetes, 25%
of them will develop Diabetic foot ulcers, in which half of the ulcers become
infected during the healing process (Ghosh and Valia 2017).
Diabetic foot accounts for nearly 35% of hospitalization among people with
diabetes, while 20% of these patients require amputation. DFUs contribute to
approximately 80% of all non-traumatic amputations (Ghosh and Val ia 2017).
Evidence from published literature showed 100,000 leg amputations per year due to
diabetes and expenditure of around $1,960 for the whole treatment of Diabetic Foot
Ulcers (Ghosh and Valia 2017). The study by Sathyavani et al. and Shobana et al.
showed that patients with DFUs spent four times more than those without diabetic
foot ulcers (Kumpatla et al. 2013; Shobhana et al. 2000). Approximately 5.7 years
(68.8 months) of an average patient’s income is required to pay for the entire DFU
therapy. According to a study, patients from developing countries such as India
spent almost 32% of their total income on foot problems (Abbas and Viswanathan
2007). It has been estimated that in developing countries like India, foot problems
contribute to 40% of the use of healthcare resources (Viswanathan et al. 2021a).
About half of DFU patients who undergo amputation once have a higher chance of
going through another amputation within the next two years. The mortality rate is
2.5 times higher for patients with diabetic foot ulcers than for patients without DFU
for five years, and it is two times higher at ten years (Ghosh and Valia 2017).
Role of Technology for wound Care in Diabetic Foot 69
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Newer Technology as an Early Diagnostic Tool For DFU
Diabetic foot complications are caused by a triad—Ischaemia, neuropa thy, and
infection. The initiating factors are neuropathy and ischemia and later followed by
infection. Excess pressure and mechanical or thermal damage are the few unattended minor injuries due to the loss of protective sensation. The presence of foot
deformities, hammerhead toes, claw foot, and limited joint mobility is caused by
motor neuropathy. Limited joint movement and high plantar pressure is often a
significant risk factor for foot ulceration in susceptible neuropathic Asian Indians
(Viswanathan et al. 2003).
Peripheral artery disease independently increases the risk of non-healing ulcers,
infection, and amputation. Other important risk factors for foot ulcers are prolonged
duration of diabetes with poor glucose control, old age, inadequate health care
services, and education. A prospective study conducted including diabetic patients
from Tanzania, Germany, and India found that peripheral vascular disease
(PVD) was frequent in Germany, while in Tanzania and Chennai, India, it was far
less common (Morbach et al. 2004).
Foot Evaluation
Peripheral Neurologic assessment: The loss of protective sensation resulting from
polyneuropathy in the diabetic foot is assessed by measuring specific parameters
such as Pressure perception, Vibration perception, Heat and cold sensation (Viswanathan 2007; Dutta et al. 2020).
Peripheral vascular assessment: Ankle Brachial Index (ABI), Ankle Doppler
Signal, Other tools for assessments are Toe Pressures/Toe Brachial Index, Transcutaneous Oxygen Tension Measurement, Skin Perfusion Pressure, Pulse
Oximetry. Vascular Imaging is usually intended to demonstrate PAD distribution
and aid the information about the type of revascularization. It is generally advised in
patients with nonhealing ulcers and severe tissue loss. Few imaging modalities
available in the market are Colour Doppler Ultrasound, Multidetector-Row Computed Tomography Angiography, Contrast-Enhanced Magnetic Resonance
Angiography, Intra-Arterial Digital Subtraction Angiography (Dovell and Hinchliffe 2020).
Illuminate® is an autofluorescence imaging device working on multispectral,
which helps to rapidly identify and classify bacteria. The accuracy of the device was
89.54%, and a positive predictive value for detecting Gram-positive bacteria,
Gram-negative bacteria, and no infection was 86.27%, 80.77%, and 91.67%,
respectively. This device helps assess early bacterial infection and helps the clinician provide the right first-line treatment, thus helping improve the wound closure
rate (Viswanathan et al. 2021b).
70 V. Viswanathan and R. Mirshad
Molecular techniques to rapidly differentiate pathogenic organisms include:
1. Polymerase chain reaction (PCR)
2. Microarray technology
3. Next (second) generation sequencing—16S ribosomal RNA (16S rRNA)
4. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry
(MALDI-TOF–MS)
5. Whole-genome sequencing (WGS), including third-generation sequencing.
Other assessments:
• Gait variations in persons with diabetes play an essential role in increasing the
peak plantar pressure in diabetic neuropathy due to restrictions in subtalar and
first metatarsophalangeal joints. Dynamic plantar pressure analysis can be done
to detect the early changes in gait (Gnanasundaram et al. 2020).
• Radiographs are useful in detecting previously unknown Charcot changes,
evaluating residual bone abnormalities of a prior injury, ulceration or surgery,
and any other abnormalities (Viswanathan et al. 2014).
Recent Advances in the Management of DFU
The ideal management of diabetic foot ulcers is debridement of the wound, management of any infection, revascularization procedures when indicated, and
off-loading the ulcer. Other add-on therapies are hyperbaric oxygen therapy
(HBOT), advanced wound dressing, and negative pressure wound therapy (NPWT).
Debridement
Debridement is a procedure to remove surface debris and necrotic tissues in all
chronic wounds. It fastens healing by promoting the production of granulation
tissue. There are three types of debridement surgically, biologically, and through
autolysis. Surgical debridement, also known as the ‘‘ sharp method,’’ is performed
by scalpels and its rapid and effective in removing hyperkeratosis and dead tissue.
Biological debridement is done using sterile maggots. Maggots can only digest
surface debris, bacteria, and necrotic tissues, leaving healthy tissue intact. Autolytic
debridement involves dressings that create a moist wound environment so that the
host defense mechanism (neutrophils, macrophages) can clear devitalized tissue
using the body’s enzymes (Alexiadou and Doupis 2012).
Wound dressing
Ulcers heal more quickly and are often less complicated by infection in a moist
environment. The ideal dressing should maintain a moist environment, be free from
contaminants, remove toxi c and excess exudates, be resistant to microorganisms,
allow gaseous exchange, and, lastly, should be easily removable and economical.
Role of Technology for wound Care in Diabetic Foot 71
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
PDGF-beta has been developed as a topical therapy to treat non-infected diabetic
foot ulcers. Platelet-rich plasma (PRP), an autologous product easily extracted from
the patient’s plasma, consists of a high platelet concentration in a fibrin clot that can
be applied to the ulcer area. Following the application, the fibrin clot is absorbed
during wound healing within days to week ’ s duration. The reports of previous
studies stated that the subcutaneous administration of granulocyte colonystimulating factor (GCFS) in patients with infected foot ulcers varies, with some
studies indicating faster resolution of the infection and more rapid healing.
Epidermal growth factor (EGF) can promote healing by acting on epithelial
cells, fibroblasts, and smooth muscle cells. Only Limited evidence for EGF use is
available; data shows a significantly higher rate of ulcer healing with EGF use
compared with placebo. Matrix metalloproteinases help to regulate the extracellular
matrix components. During the normal wound healing process, there is a balance
between the construction and the destruction of the extracellular matrix (Alexiadou
and Doupis 2012).
New advanced topical dressings are emerging that may improve wound care.
Such dressings are designed to modulate levels of biological molecules, such as
growth factors, that may promote wound healing. Collagen and oxidized regenerated cellulose composite materials are undergoing studies for such properties.
Offloading for a person with DFU
For a plantar healing ulcer, off-loading of the ulcer area is essential. Evidence from
the literature shows higher plantar pressures significantly contribute to the development of plantar ulcers in people with diabetes.
With rare exceptions, shoes should not be worn by diabetic patients with active
ulcers, except special therapeutic footwear, which isolates the foot's regions entirely
from weight-bearing. Some offloading forms such as a cast or other device must be
immediately employed until the ulcer is healed. Any impressions that need to be
taken of the foot (for custom-made insoles, for example) can be made even on the
healing ulcer if fully covered with a clear film dressing. Carefully explain the reason
for the footwear and the role that footwear can always play in ulcer and amputation
prevention.
For healing a neuropathic plantar forefoot or midfoot ulcer in a person with
diabetes, we recommend that a nonremovable knee-high offloading device is the
first choice of offloading treatment. A removable knee-high and removable ankle-
high offloading device are to be considered as the second-and third-choice
offloading treatment, respectively if contraindications or patient intolerance to
non-removable offloading exist. Appropriately fitting footwear combined with
felted foam can be considered the fourth-choice offloading treatment. If nonsurgical offloading fails, we recommend evaluating surgical offloading interventions
for healing metatarsal head and digital ulcers. We have added new recommendations for offloading treatment for healing ulcers that are complicated with infection
or ischemia and for healing plantar heel ulcers (Bus et al. 2020) (Figs. 1 and 2).
72 V. Viswanathan and R. Mirshad
Fig. 1 Offloading device
Negative-Pressure Wound Therapy (NPWT) has emerged as an add-on treatment
for diabetic foot ulcers. Experimental data suggest that NPWT help in decreasing
tissue edema, optimizes blood flow, removes exudate, proinflammatory cytokines,
and bacteria from the wound area, providing an occlusive environment for wound
healing under moist, clean, and sterile conditions. A study by Dsouza C et al.
showed a VAC dressing group, 76.7% of the ulcers had red granulation tissue at the
end of therapy compared to 46.7% in the conventional group. The mean wound bed
preparation time was found to be 15.60 days in the conventional dressing group and
8.50 days in the VAC therapy group. In the VAC group, 72.73% of ulcers had no
bacteria at the end of therapy (Dsouza et al. xxxx).
A randomized controlled clinical trial showed an increased frequency and
probability of wound closure with cold-stored (−80 °C) amniotic membrane
(HSAM) versus standard of care (SOC) in diabetic foot ulcers (DFUs) (Serena et al.
2020).
Role of Technology for wound Care in Diabetic Foot 73
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Person with diabetes, neuropathy, and a foot ulcer
Non-plantar ulcer
Use a removable ankle-high
offloading device, footwear
modificaons, toe specers or
orthoses, depending on type and
locaon of the foot ulcer
Plantar forefoot or midfoot ulcer
Infecon or ischemia present
If with either mild infecon or
mild ischemia
If with both mild infecon and
mild ischemia or either
moderate infecon or moderate
ischemia
If with both moderate infecon
and moderate ischemia or either
severe infecon or severe
ischemia
Primarily address the infecon
and/or ischemia and consider
using a removable offloading
intervenon based on the
paent’s funconing, level of
acvity and ambulatory status
No infecon or ischemia present
Use a non-removable knee-high
offloading device
If contraindicated or not tolerated
Consider using a removable
knee-high offloading device &
encourage the paent to wear
the device
If contraindicated or not tolerated
Use a removable ankle-high
offloading device& encourage
the paent to wear the device
If above devices are not available
Consider using felted foam with
appropriately fing footwear
Plantar heel ulcer
Consider using a knee-high
offloading device or offloading
interven
on that effecvely
reduces plantar heel pressure
If the ulcer fails to heal
If a metatarsal head ulcer,
consider Achilles tendon
lengthening, metatarsal
head resecon(s), or joint
arthroplasty
If a digital ulcer, consider
digital flexor tenotomy
Fig. 2 Flow diagram on the IWGDF 2019 recommended offloading treatment for a person with
diabetes and a foot ulcer (Bus et al. 2020)
Impact of Covid 19 Among People With DFU
The coronavirus disease 2019 (COVID-19) pandemic forced a lockdown all over the
world. This made it difficult for people with diabetes to have regular visits to their
physicians. People who developed diabetic foot infections also could not visit their
podiatrist or surgeon for procedures like debridement. This may lead to many
avoidable lower-limb amputations. A retrospective study by Viswanathan V et al.
showed an overall higher prevalence of major amputations during the pandemic
lockdown compared to the pre-pandemic period. Among major amputations, Below
Knee amputations were higher in number than Above Knee amputations in both the
pandemic and pre-pandemic groups. During the pandemic perio d, a 54.1% increase in
major amputations was observed mostly due to postponing the routine visit, improper
diet, nonadherence to medications, and physical inactivity (Viswanathan and
Nachimuthu 2021; Nachimuthu et al. 2020; Nachimuthu and Viswanathan 2021).
During the COVID-19 pandemic and following lockdowns patients with diabetic
foot ulcers were assessed by virtual triage and tele-consultation. There are telemedicine temperature mats which can screen for inflammation without having to
visit the clinic. The patients who show inflammation can then be called to the clinic
(Banks et al. 2020).. A study by Rastogi A et al., showed that in spite of absence of
face-to- face consultations, only 5% of patients required amputations, predominantly minor amputation that was easily manageable by remote consultations. There
was no difference in foot outcomes observed in people with diabetic foot complications who were evaluated face-to face in the pre-pandemic period and treated
virtual means during the pandemic, suggesting efficacy of video consultations for
managing diabetic foot complications (Rastogi et al. 2021).
74 V. Viswanathan and R. Mirshad
Future in the Prevention of DFU
As per the recom mendations by the American Diabetes Association (ADA) multidisciplinary team approach helps in preventing diabetic complications among
people with diabetes. Several studies have shown a marked reduction in amputation
rates and costs savings up to 1,824 U.S. $ in the standard treatment group and 1,127
U.S. $ in the intervention group. The team members for the multidisciplinary
approach consist of general practitioners, nurses, educators, podiatrists, consultants
(vascular surgeon, infection disease specialist, dermatologist, diabetologist, dietitian, orthopedic), and home care services. However, all team members have an
equal role in reducing the incidence of foot ulcers and amputation. The nurses and
podiatrists play an important role in diabetic foot care management. As the
prevalence of diabetes and its complications is increasing, there is an unquestionable need to train a nurse in this field.
The roles of a nurse in the prevention of DFU include,
1. Diabetic foot examination (limb movement, health, moisture, colour, temperature, edema, pain, and sensation of the foot).
2. Wound dressing.
3. Education on daily foot care.
4. Screen the high-risk foot (Peripheral neuropathy, peripheral vascular disease,
and infection).
5. Encourage patients and families to appropriate care and regular follow-up.
6. Rehabilitation after Foot surgeries and amputations.
Other duties that a nurse provides to produce excellent diabetic foot care should
be to select an appropriate dressing depending on the type of foot ulcer, which can
be either dry or wet ulcers. Nurses need adequate knowledge and skills in foot care
services to prevent, diagnose, and care for diabetic foot problems. Hence nurses
should undergo special training to use the latest instructions on diabetic foot care in
order that provides effective services to facilitate and promote diabetic patients’
health (Aalaa et al. 2012).
Conclusion
In people with diabetes, any risk factor or pre-ulcerative sign on foot should be
treated urgently. It is possible to reduce amputation rates through a care strategy
that combines: prevention, the multidisciplinary treatment of foot ulcers, close
monitoring, and the education of people with diabetes and healthcare professionals.
A framework for screening and early multifactorial interventions are required to
control the disease progression, increasing life expectancy, and decrease the economic burden on the individual as well as the society.
Role of Technology for wound Care in Diabetic Foot 75
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
References
Aalaa M, Malazy OT, Sanjari M, Peimani M, Mohajeri-Tehrani M. Nurses’ role in diabetic foot
prevention and care; a review. J Diabetes Metab Disord. 2012;11(1):24. Published 2012 Nov
21. https://doi.org/10.1186/2251-6581-11-24.
Abbas ZG, Viswanathan V. The diabetic foot in Africa and India. Int Diab Monit. 2007;19:8–12.
Alexiadou K, Doupis J. Management of diabetic foot ulcers. Diabetes Ther. 2012;3(1):4.
Bus SA, Armstrong DG, Gooday C, et al. Guidelines on offloading foot ulcers in persons with
diabetes (IWGDF 2019update). Diab Metab Res Rev. 2020;36(S1): e3274. https://doi.org/10.
1002/dmrr.3274.
Banks JL, Petersen BJ, Rothenberg GM, Jong AS, Page JC. Use of a remote temperature
monitoring mat for the early identification of foot ulcers. Wounds. 2020;32(2):44–9 PMID:
32155121.
Dsouza C, Rouchelle, Chirag, Diaz E, Rao S. A randomized controlled trial comparing low cost
vacuum assisted dressings and conventional dressing methods in the management of diabetic
foot ulcers. Int Surg J 2017;4:3858– 65.
Dutta A, Rastogi A, Jude EB. Screening developments for the foot in diabetes. The Diab
Foot J. 2020;23(2):62–9.
Dovell G, Hinchliffe RJ. Algorithms for diabetic foot care: vascular evaluation. The Foot Diab.
2020:495–506.
Ghosh P, Valia RB. Burden of diabetic foot ulcers in India: Evidence landscape from Published
literature. New Delhi, India: Braun Medical (India) Pvt Ltd;2017. https://doi.org/10.1016/j.jval.
2017.08.489.
Gnanasundaram S, Ramalingam P, Das BN, Viswanathan V. Gait changes in persons with
diabetes: early risk marker for diabetic foot ulcer. Foot Ankle Surg. 2020;26(2):163–8. https://
doi.org/10.1016/j.fas.2019.01.005.
Kumpatla S, Kothandan H, Tharkar S, Viswanathan V. The costs of treating long-term diabetic
complications in a developing country: a study from India. J Assoc Physicians India. 2013;61
(2):102–9 PMID: 24471248.
Morbach S, Lutale JK, Viswanathan V, Mollenberg J, Ochs HR, Rajashekar S, et al. Regional
differences in risk factors and clinical presentation of diabetic foot lesions. Diabet Med.
2004;21:91–5.
Nachimuthu S, Vijayalakshmi R, Sudha M, Viswanathan V. Coping with diabetes during the
COVID-19 lockdown in India: results of an online pilot survey. Diab Metab Syndr. 2020;14
(4):579–82. https://doi.org/10.1016/j.dsx.2020.04.053.
Nachimuthu S, Viswanathan V. Trend in COVID-19 vaccination among people with diabetes: a
short study from India. Diab Metab Syndr. 2021;15(4): 102190. https://doi.org/10.1016/j.dsx.
2021.102190.
Rastogi A, Hiteshi P, Bhansali AA, Jude EB. Virtual triage and outcomes of diabetic foot
complications during Covid-19 pandemic: a retro-prospective, observational cohort study.
PLoS One. 2021;16(5):e0251143. Published 2021 May 6. https://doi.org/10.1371/journal.pone.
0251143.
Serena TE, Yaakov R, Moore S, Cole W, Coe S, Snyder R, Patel K, Doner B, Kasper MA,
Hamil R, Wendling S, Sabolinski ML. A randomized controlled clinical trial of a
hypothermically stored amniotic membrane for use in diabetic foot ulcers. J Comp Eff Res.
2020;9(1):23–34. https://doi.org/10.2217/cer-2019-0142. Epub 2019 Nov 6. PMID: 31691579.
Shobhana R, Rao PR, Lavanya A, Vijay V, Ramachandran A. Cost burden to diabetic patients
with foot complications–a study from southern India. J Assoc Physicians India. 2000;48
(12):1147–50 PMID: 11280217.
Viswanathan V. The diabetic foot: perspectives from Chennai, South India. Int J Low Extrem
Wounds. 2007;6(1):34–6. https://doi.org/10.1177/1534734606297987.
Соседние файлы в папке @xirurgi_2025