Treatment of Diabetic Foot

Diabetic foot is one of the most common complications of diabetes mellitus, which affects 25% of patients. This is the most common cause of lower limb amputation, but doctors in developed countries resort to such radical treatment methods extremely rarely. In most cases, the limb can be preserved due to high-quality conservative therapy and surgical interventions to restore blood flow in the lower extremities. Most surgical procedures in developed countries are performed using minimally invasive techniques.

Content

1. Treatment principles
2. Conservative therapy and care
3. Lower limb revascularization
4. Surgical debridement
5. Why is it better to undergo treatment abroad
6. Treatment in Europe with Booking Health

Treatment principles

Patients with diabetic foot should receive comprehensive treatment: conservative and surgical therapies aimed at improving the condition of nerves and blood vessels, carbohydrate and lipid metabolism. These patients need unloading of the foot and constant care.

Controlling diabetes is an essential part of treatment. With chronically elevated blood glucose levels, diabetic foot progresses rapidly, as the vessels and nerves are irreversibly altered. If the lumen of large and medium vessels can still be increased with the help of endovascular interventions and open surgical procedures, then a microcirculatory disorder is much less susceptible to treatment. To control diabetes, patients receive hypoglycemic agents and/or insulin.

Since one of the key pathology progression mechanisms for diabetic foot is atherosclerotic vascular lesions, patients are prescribed medications to slow down the progression of atherosclerosis and reduce cardiovascular risks. Damage to the vessels in the foot also means that other arteries located in the brain, heart, eyes, kidneys are also not in the best condition. Therefore, the treatment prescribed by doctors not only slows down the development of diabetic foot, but is also good for health in general, as it reduces the risk of heart attack, stroke, kidney failure and other severe pathologies that often occur against the background of diabetes.

If diabetic foot has already been diagnosed, this means that the patient has leg ulcers, and possibly deep tissue lesions, and foci of infection appear. People with diabetes often receive not only conservative therapy, but also surgical treatment. During the diagnostics, doctors check the circulation in the lower extremity. If it is violated, then the first stage is revascularization – restoration of blood supply using minimally invasive procedures, less often – open operations. Only after that doctors perform surgical procedures to excise dead tissue, skin grafting and other interventions. The exception is cases when the patient has developed severe infectious complications such as phlegmon or gangrene. Then the purulent foci are opened and drained, but all necrotic tissues are not excised. This is done only after lower limb revascularization.

The main goal of the treatment of patients with diabetic foot is not only the preservation of the lower extremity, but also the preservation of life. In the case of untreated critical ischemia of the lower extremity, the risk of death reaches 20% within 6 months, the probability of foot amputation within 12 months is 95%, and the risk of death within a year after amputation is 50%. Timely performed foot revascularization surgery not only saves the limb, but also increases the patient's survival rate.

Conservative therapy and care

Patients require constant foot care. Key recommendations are as follows: 

• Wash your feet with soap and water every day.
• Wipe dry with a soft towel, including between the fingers.
• Regularly examine the feet in order to see ulcers and cracks in time.
• Treat keratinized areas of the feet with pumice.
• Use foot care creams.
• You need careful nail care: they should be cut carefully, without cutting off the corners, in order to avoid ingrown nails into the skin of the toes.
• Wear warm shoes and socks so that blood circulation in the feet does not deteriorate due to hypothermia.
• Do massage and gymnastics, and apply other skin care treatments that can improve blood circulation.

Self-care is useful for diabetic foot prevention, but after the appearance of ulcers, the help of doctors is required. It should be provided as early as possible, as wounds on the feet can become infected and heal very poorly.

Lifestyle recommendations are as follows: 

• Weight normalization. 
• Smoking cessation. 
• Reduced salt intake in case of high blood pressure.
• Low-carb diet.
• Regular physical activity, but without involving the feet.

After the appearance of trophic ulcers, the treatment of diabetic foot involves unloading the lower limb to relieve pressure on the skin and deep tissues. Special unloading half-shoes, bandages, crutches, orthoses or splints with pneumatic ankle fixation are used. In the case of osteomyelitis (bone inflammation and destruction), fistula formation, gangrene, lesions of the ankle and calcaneus, individual unloading bandages are not used, but the choice is made in favor of orthoses. The patient should avoid walking whenever possible.

For wound care, healthcare professionals use dressings that can absorb large amounts of fluid. Ointment dressings are not used.

Vacuum therapy is used for removing exudate and dead cells. It also helps remove bacteria, relieve inflammation, and improve blood flow. When using the method, tissue regeneration improves and edema decreases. The procedure is often used to cleanse a wound prior to skin grafting.

Vacuum therapy is used only in the absence of a purulent focus, after adequate surgical treatment of the wound.

Systemic drug treatment for diabetic foot: 

• Statins to relieve the severity of atherosclerosis.
• Antihypertensives to lower blood pressure.
• Antibiotics – in case of development of infectious complications.
• Antiplatelet agents that are prescribed for life after surgical restoration of the blood supply to the lower extremity in order to prevent blood clots.
• Prostaglandins and other vasodilators are used instead of lower extremity revascularization surgery, if it is contraindicated or not performed for other reasons.

The treatment of wounds abroad involves the use of growth factors. Stem cells are used to enhance tissue regeneration. 

Lower limb revascularization

Ischemic and neuroischemic forms of the diabetic foot are associated with impaired blood supply. It can be improved with lower limb revascularization procedures and surgeries. To do this, it is necessary to expand the vessels that feed the tissues of the foot.

In developed countries, 80% of interventions are carried out using a minimally invasive technique – from the inside of the vessels, without large incisions on the foot. In 20% of cases, surgeons resort to open surgical interventions.

Minimally invasive interventions: 

• Balloon angioplasty is the main surgical procedure for most patients.
• Stenting is used when there is a high risk of repeated arterial stenosis. 

Balloon angioplasty involves the introduction of a balloon into the narrowed area. It is delivered through the femoral artery by making a small incision in the groin. This is a minimally traumatic intervention, safe for health, and extremely rarely causing complications. This is an X-ray guided procedure. The doctor delivers the balloon to the narrowed area and inflates it by injecting saline with a contrast agent. The balloon expands and enlarges the lumen of the artery.

Stenting is an additional stage of the surgical procedure, which is not required for all patients with diabetic foot. A stent is a metal frame that is placed inside the artery to keep its lumen open. Modern stents do not cause blood clots and are resistant to mechanical stress, therefore, they provide stable results of endovascular treatment and make it safe for health.

Some patients require open surgery for the treatment of diabetic foot associated with poor blood supply: 

• Endarterectomy – removal of atherosclerotic plaques that close the lumen of the vessels. 
• Profundoplasty – restoration of the profunda femoris artery, implying its dissection, removal of atherosclerotic plaques and plastic repair with a patch (for example, from bovine pericardium).
• Iliofemoral, femoral popliteal, femoral-tibial bypass surgery – formation of a new path of blood flow bypassing the narrowed areas of the arteries. 

For most patients, even with critical limb ischemia, minimally invasive procedures are not inferior in efficiency to open interventions. Therefore, developed countries give preference to these surgical procedures – they are less traumatic, safe for health and do not require long-term recovery. The treatment of diabetic foot with an open surgery is mainly used with a large extent of the narrowed area and with the development of calcification – the last stage of atherosclerosis, in which plaques are covered with solid calcium salts.

Surgical debridement

Primary debridement for patients with diabetic foot is performed as soon as possible, but radical tissue excision is performed only after revascularization.

Major interventions: 

• Necrectomy involves excision of the affected tissue, which in Europe is usually performed using ultrasound, rather than mechanical instruments.
• Opening and drainage of purulent foci in case of infectious complications.
• Lower limb amputation at different levels, depending on the degree of damage to the tissue of the foot.

The defects are closed with skin grafts and collagen-based bioplastic material. Whenever possible, doctors strive to avoid amputations in order to improve the quality of life of patients, avoid unsafe operations, patient disability and the need for constant care. Even if amputations are performed, then only when absolutely necessary and in a minimal volume.

Why is it better to undergo treatment abroad

In developed countries, patients receive quality care, conservative therapy, endovascular and surgical treatment. Europe has specialized hospitals for diabetic foot. Their appearance in the 21st century has led to the fact that the frequency of lower limb amputations has decreased many times.

Benefits of diabetic foot treatment abroad: 

• Full-fledged comprehensive treatment according to international protocols.
• In 80% of cases, lower limb revascularization is carried out using safe and minimally traumatic endovascular procedures.
• Angioplasty is supplemented with stenting to prevent repeated vascular stenosis. 
• Wound management involves the use of modern sparing methods, including ultrasound cavitation. 
• In 90% of cases, lower limb amputation can be avoided.
• Quality care after surgery.
• Ulcer healing is followed by plastic surgery for defect closure.
• Development of individual recommendations for foot care.
• Successful treatment of not only diabetic foot, but also diabetes control, as well as treatment of other complications of this pathology. 

The patients undergoing treatment abroad receive both local and systemic treatment aimed at preventing further deterioration of the condition of the blood vessels and peripheral nerves. Whenever required, doctors take care of the correction of glucose and cholesterol levels, blood pressure, blood coagulation function.

Treatment in Europe with Booking Health

To undergo effective and safe treatment of diabetic foot in one of the European hospitals, you can use the services of the Booking Health company. On our website, you can see the cost of treatment and compare prices in different hospitals in order to book a medical care program at a favorable price. Treatment in European hospitals will be easier and faster for you, and the cost of treatment will be lower.

You are welcome to leave your request on the Booking Health website. Our specialist will contact you and provide a free consultation on treatment in Europe. Booking Health will fully organize your trip abroad. We provide the following benefits for you:

• We will select the best medical hospital for treatment in Europe, whose doctors specialize in the treatment of diabetic foot and achieve the best results.
• We will solve the problem of the language barrier, establish communication with the doctor of the European hospital.
• We will reduce the waiting time for the medical care program. You will undergo treatment on the most suitable dates.
• We will reduce the price. The cost of treatment in Europe will be lower due to the lack of overpricing and coefficients for foreign patients.
• We will solve all organizational issues: we will draw up the documents, meet you abroad and take you to the hospital, book a hotel, provide interpreting services.
• We will prepare a program and translate medical documents. You do not have to repeat the previously performed diagnostic procedures.
• We will keep in touch with the hospital after the completion of treatment in Europe.
• We will arrange additional diagnostic examinations and treatment in European hospitals, if required.
• We will buy medicines and forward them to your native country.

Your health will be in the safe hands of the world's leading doctors. The Booking Health specialists will help reduce the cost of treatment, organize your trip to one of the European hospitals, and you can fully focus on restoring your health.

Authors: Dr. Nadezhda Ivanisova, Dr. Sergey Pashchenko