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Background
Foot ulcers affect one in ten diabetics during their lifetime. Patients with diabetes have increased risk of lower-extremity amputations and the main cause is diabetic peripheral arterial disease accelerated by the direct damage to the nerves and blood vessels by high blood glucose levels. Wound healing is also impaired from affected collagen synthesis. Diabetic vascular disease has three main components: arteritis and small vessel thrombosis; neuropathy (possibly ischaemic in cause); and large vessel atherosclerosis. In combination these are almost bound to cause problems in the weight- bearing areas. The diabetic foot ulcers are often deeper and more frequently infected than other leg ulcers reflecting the severe end vessel ischaemia and opportunistic infection which is the common experience of the diabetic. Factors, such as age and the duration of the disease will increase its incidence and risk of death from uncontrolled infection. Once tissue damage has occurred in the form of ulceration or gangrene, the aim is preservation of viable tissue, but the two main threats are infection and ischaemia. Ulcers should not be automatically treated with antibiotics since although as open chronic wounds there may be many commensal organisms, about half are not infected. Several foot-ulcer classification methods have been proposed in order to organize the proposed appropriate treatment plan but none have been universally accepted. The Wagner- Meggitt classification is based mainly on wound depth and consists of 6 wound grades (Table 1). The University of Texas system grades the ulcers by depth, then stages them by the presence or absence of infection and ischaemia. As there is the need for rapid and more appropriate therapy to facilitate healing, the international working group on the diabetic foot proposed the PEDIS classification which grades the wound on a 5- feature basis: perfusion (arterial supply), extent (area), depth, infection and sensation. They also classified diabetic foot infections into four grades: Grade 1 (no infection; Grade 2 (mild) in subcutaneous tissue only; Grade 3 (moderate) with extensive erythema and infection of deeper tissue and Grade 4 (severe) with systemic inflammatory response indicating severe infection (Table 2). Most diabetic foot infections require some surgical intervention, ranging from minor (debridement) to major interventions including amputation. The main emphasis of the current international guidelines on the management of the diabetic foot is prevention, early recognition and treatment. Prevention of the diabetic foot entails controlling diabetes, smoking, obesity; daily foot checks, removing callosity (neuropathic foot), daily moisturizing, regular toenail cutting, and well fitted footwear.
The thesis is that if the guidelines on the management of the diabetic foot are followed primary amputation is only necessary for the unsalvageable diabetic foot (Table 3). Endovascular procedures are the future in the treatment of diabetic arterial disease and hence the diabetic foot.
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