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200 Vascular Surgery
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23. Diabetic Foot
Mauri J. A. Lepäntalo, Milla Kallio and Anders Albäck
A 54-year-old smoker with type 2 diabetes of 7 years duration had a minor abrasion to the lateral aspect of the left fifth toe. The patient was known to have
hypertension, nephropathy and retinopathy, and he was overweight. His glycaemic control was good following recent addition of insulin to his oral medication. The superficial ulcer did not bother the patient, and it was initially followed
up in his local healthcare centre. Two months later, the patient was referred to a
community hospital because of infection and suspicion of osteomyelitis. He now
had an infected ulcer lateral to the head of the fifth metatarsal, with a discharge.
Plain X-ray films showed suspected osteomyelitis. Dorsalis pedis and posterior
tibial pulses were reported to be present. The C-reactive protein (CRP) level was
31 mg/l, leucocytes 14.8 × 109/l, and blood glucose 12 mmol/l.
Question 1
What condition(s) are likely to be responsible for the foot problem?
A. Infection.
B. Atherosclerotic macroangiopathy.
C. Diabetic microangiopathy.
D. Neuropathy.
Question 2
What is the simplest tool available in the surgery or outpatient clinic to detect
osteomyelitis?
A. Plain X-ray films.
B. Clinical examination with blunt nasal probe.
201
202 Vascular Surgery
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C. Magnetic resonance imaging.
D. Computer tomography.
Question 3
What simple tools are available in the surgical outpatient clinic to assess angiopathy?
A. Palpation of foot arterial pulses.
B. Examination of audible signal with hand-held continuous wave Doppler.
C. Ankle pressure measurement.
D. Duplex scanning of lower extremity arteries.
Question 4
What simple tools are available in the surgery or outpatient clinic to assess
neuropathy?
A. Monofilament sensation testing.
B. Achilles tendon reflex.
C. Tuning fork testing.
D. Electroneuromyography (ENMG).
The patient was admitted to the medical ward for treatment of his infected foot.
Despite the administration of intravenous antibiotic treatment, later modified
according to the results of bacterial cultures, the infection progressed. One week
after admission, lateral and superficial plantar compartments were drained operatively on the lateral side of the fifth metatarsal head and between the fourth and fifth
metatarsal heads. Abundant pus was obtained, and the fifth metatarsal head was
observed to be soft. The operative wound was left open. The infection seemed to
subside, and the patient was discharged after a 16-day admission with oral clindamycin treatment and local wound care.
Question 5
What major problems were neglected at this point?
A. Presence of osteomyelitis.
B. Presence of ischaemia.
C. The wound was left without coverage with split thickness skin grafting.
D. The weight-bearing wound area of the foot was not protected with a cast.
Diabetic Foot 203
a
Fig. 23.1.
Foot at the time of admission to the vascular unit.
Despite continuous antibiotic treatment and local treatment of the open lesion on
the lateral aspect of the foot, the situation worsened over the next 2 months and the
patient was readmitted to the hospital. The patient had fever and his CRP level was
123 mg/l. The serum creatinine was 1.6 mg/dl. An immediate wound debridement
and amputation of the fourth toe was performed, after which the patient was admitted to a vascular surgical unit (Fig. 23.1). There was a faint popliteal pulse with no
other pulses palpated distally. Ankle brachial indices (ABIs) were 1.35 and 1.21. The
patient could not feel the touch of the monofilament on the plantar surface of the
great toe or the first and fifth metatarsal heads.
Question 6
How would you further examine the circulation non-invasively or invasively?
A. Toe pressure measurement.
B. Ankle pressure measurements and pulse wave recordings.
C. Treadmill test with pressure measurements.
D. Duplex scanning of distal arteries.
E. Magnetic resonance angiography.
F. Digital subtraction angiography.
b
The toe pressures were 73 mm Hg on the right side and 29 mm Hg on the left
side. A selective angiography was obtained the next day (Fig. 23.2).
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Fig. 23.2. Angiography of the left lower limb.
Diabetic Foot 205
Question 7
What angiographic findings typical of diabetes can you see?
A. Normal aortoiliac segments.
B. Haemodynamically non-significant occlusive disease of crural vessels.
C. Significant occlusive disease of crural vessels.
D. Severe occlusive disease of all foot vessels.
E. Patent foot vessel.
Question 8
What treatment strategy would you prefer?
A. No possibilities for reconstruction. Choose the best medical treatment, then wait
and see.
B. No possibilities for reconstruction. Foot-level amputation up to bleeding
tissue.
C. Below-knee amputation.
D. Possible acute debridement, reconstruction to pedal artery, and further wound
excision later.
E. No wound excision and reconstruction to pedal artery until the wounds are
clean.
Question 9
If you consider vascular reconstruction, what would be your preferred inflow site in
this patient?
A. Common femoral artery.
B. Superficial femoral artery.
C. Popliteal artery.
A popliteopedal reconstruction was made 5 days after admission to the vascular
surgical unit. The great saphenous vein was used in situ with the supragenicular
popliteal artery as a recipient vessel. Despite achieving an acceptable initial flow of
51 ml/min, the graft thrombosed the next day and a thrombectomy and a revision of
the graft was made. A narrow segment below the knee was replaced with a reversed
proximal great saphenous vein under angioscopic control. A flow of 110 ml/min was
measured with transit time flowmetry.
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Question 10
Which of the following methods are adequate for intraoperative control?
A. Angiography alone.
B. Doppler alone.
C. Flowmetry alone.
D. Flowmetry with a method giving morphological information.
E. Intraoperative duplex scanning alone.
The postoperative ABI was 0.97. Wound excision and three-ray amputation of the
lateral toes were performed 2 days after revascularisation. The patient was discharged 2 weeks after admission and transferred to the community hospital. Split
thickness skin grafting was performed there. The patient was discharged home with
a heel-sandal (a sandal in which the body weight is borne only by the heel), antibiotic treatment for one more week, and local wound care. The healing of the wound
progressed well. Six weeks after the vascular reconstruction, the patient was pre-
a
b
Fig. 23.3.
Foot at 1-year follow-up.
Diabetic Foot 207
scribed insoles. He also used a silicon piece correcting the position of the second toe
(Fig. 23.3).
At 1-year follow-up, ABI was greater than 1.3/0.91 and toe pressures were
65/55 mm Hg. Duplex surveillance findings indicated a possible vein graft stenosis.
Question 11
What are the findings indicating vein graft stenosis in the duplex examination?
A. Midgraft peak systolic velocity (PSV) of less than 45 cm/s.
B. V2/V1 ratio greater than 3 (V2, PSV at the site of the maximum stenosis; V1,
PSV in the normal graft adjacent to the stenosis).
C. Maximum PSV greater than 300 cm/s.
D. End-diastolic flow velocity (EDV) greater than 20 cm/s.
A control angiography was performed, but no severe stenosis was found (Fig.
23.4).
Commentary
This case illustrates the problems related to delayed diagnosis and treatment of diabetic neuroischaemic foot. The aetiology of diabetic foot ulceration and infection is
multifactorial. Our patient evidently had infection and probably also neuropathy.
Neuropathy often abolishes sensation, and an unpleasant odour and discharge may
be the first signs of infection to the patient, especially if the lesion is situated on the
plantar aspect of the foot. The role of microangiopathy in diabetic foot is not
confirmed, but ischaemia due to atherothrombotic disease often plays a major role
[1]. [Q1: A, B, D]
The simplest method is to examine the ulcer with a blunt nasal probe. If it hits the
bone, then osteomyelitis is most likely. The diabetic wounds should be classified
systematically according to a precise system, such as the Armstrong classification
(Table 23.1), which takes into account both the depth of the lesions and the presence of ischaemia and infection [2]. Plain X-ray films are of limited value and
magnetic resonance imaging (MRI) is the most reliable tool for diagnosis of
osteomyelitis [3]. [Q2: B]
The patient was reported to have palpable distal pulses at one time but not at
another time. Furthermore, the popliteal pulse was reported to be palpable and ABI
to be normal. Palpation of foot pulses is not a fully reproducible observation, and
they may be considered normal if both tibialis posterior and dorsalis pedis pulses
are clearly felt [4]. If either is not palpated, non-invasive evaluation is necessary. It
is far more difficult to palpate the popliteal pulse, and it has been suggested that if
an inexperienced palpator feels the popliteal pulse, this indicates an aneurysm.
Systolic pressure measurements taken at the level of the ankle by a Doppler device
are the most common non-invasive method for assessment of atherothrombotic
disease. However, the results may be biased due to the presence of mediasclerosis,
which is present in 15–40% of diabetics [5]. Incompressible arteries may allow the
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Fig. 23.4. Control angiography
after 1-year follow-up.
Diabetic Foot 209
Table 23.1. Classification of diabetic foot lesions by grading and staging according to the depth of the lesion
and the presence of infection and ischaemia, as proposed by Armstrong et al. [2]. Updated
Depth
Grade 0: pre- or post-ulcerative site which has healed
Grade I: superficial wound through the epidermis or epidermis and dermis which does not penetrate
to tendon, capsule or bone
Grade II: wound which penetrates to tendon or capsule
Grade III: wound which penetrates to bone or joint
Infection and ischaemia:
Stage A: clean wound
Stage B: non-ischaemic infected wound
Stage C: ischaemic non-infected wound
Stage D: ischaemic infected wound to tendon, capsule or bone
signal to be heard in cuff pressures as high as the patient tolerates. In patients with
mediasclerosis, the ABI typically exceeds 1.15 [6]. The audible Doppler signals may
help the examiner, as an open inflow channel gives high-pitched biphasic signals
but collateral flow around an occlusion usually gives only a low-pitched monophasic murmur. [Q3: A, B, C]
Symptoms of neuropathy include loss of sensation, hyperaesthesia and burning,
and aching pain, which are often worse at night [7]. Many patients with severe neuropathy are asymptomatic. Achilles tendon reflex, monofilament sensation testing
and 128-Hz tuning fork testing are other recommended clinical tests [8]. [Q4: A, B, C]
The primary diagnostic work-up in this case was clearly deficient. The patient
obviously had osteomyelitis, which would have necessitated prompt drainage and
amputation. Furthermore, the role of ischaemia should also have been evaluated
and corrected within 3–5 days after proper drainage. [Q5: A, B]
The Doppler-derived pressures were clearly pseudohypertensive due to the arterial wall stiffness. Pseudohypertension affects digital arteries far less frequently, and
therefore toe pressures are more reliable. A pulse volume recording at the ankle can
also help to detect mediasclerosis. Another method is to measure systolic blood
pressure at the ankle with Doppler but without an occluding cuff – the pole test [9].
The examiner listens to the Doppler signals of the supine patient while the foot is
elevated gradually until the signals disappear. The scale in the pole gives the pressure at the ankle (0.75 × pressure (cm) equals the pressure (mm Hg)). In centres
where duplex scanning of distal arteries can be done by trained validated examiners
this method would preferably be the next investigation. Magnetic resonance angiography is also a method of choice if high-quality images are available and especially
when the patient suffers from marked nephropathy. On the other hand in centres
where technically demanding endovascular procedures can be done during diagnostic contrast angiography this is – as in our case – the primary imaging technique. [Q6: A, B, D, E, F]
Atherosclerotic changes in diabetes are typically situated in femoral and crural
arteries, or only in crural arteries, in contrast to non-diabetic patients who tend to
have the first symptoms from the obliteration of the aortic bifurcation. Despite
proximal crural artery occlusion, the pedal arteries may be patent, as was the dorsalis pedis artery in this patient. [Q7: A, C, E]
The treatment strategy is affected strongly by the presence and severity of
infection. A superficial ulceration may be only the tip of the iceberg. There may be
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