|Year : 2016 | Volume
| Issue : 8 | Page : 42-46
Clinical profile and management outcome of diabetic foot ulcers in a tertiary care hospital in Haryana
Vishal Mago1, Neetu Kochhar2
1 Department of Plastic Surgery, Bhagat Phool Singh Government Medical College for Women, Sonepat, Haryana, India
2 Department of Obstetrics and Gynecology, Bhagat Phool Singh Government Medical College for Women, Sonepat, Haryana, India
|Date of Web Publication||3-Jan-2017|
Bhagat Phool, Singh Government Medical College for Women, B-10 Medical Campus, Khanpur Kalan, Sonepat, Haryana
Source of Support: None, Conflict of Interest: None
Background: Diabetic foot ulcers are predisposing factor in 85% of lower limb amputations. This study was done to evaluate risk factors for the development of diabetes and associated foot problems in the rural area of Khanpur Kalan and adjoining villages of Haryana to educate the rural population for the promotion of healthy foot care and footwear habits. Objective: The aim of this study was to determine major risk factors and management outcome of diabetic foot ulcers to prevent amputation. Methods: This study was conducted in the Department of Plastic Surgery, Bhagat Phool Singh Government Medical College for Women, Khanpur Kalan, Sonepat, from December 2013 to November 2015 in 64 patients who reported in our outpatient department and emergency. Results: Sixty-four patients with type 2 diabetes mellitus were enrolled in the current study with different stages of diabetic foot presentations. They underwent different methods of surgical management: debridement, amputations, and skin grafting giving good and fast results. Eight patients underwent below-knee amputations, and six were subjected to forefoot amputation. Ten great toe amputations were performed. Two finger amputations were performed. Conclusion: Early diagnosis and management of diabetic foot ulcers can improve patient outcomes and reduce health-care costs.
Keywords: Amputation, diabetic foot, foot ulcers
|How to cite this article:|
Mago V, Kochhar N. Clinical profile and management outcome of diabetic foot ulcers in a tertiary care hospital in Haryana. N Niger J Clin Res 2016;5:42-6
|How to cite this URL:|
Mago V, Kochhar N. Clinical profile and management outcome of diabetic foot ulcers in a tertiary care hospital in Haryana. N Niger J Clin Res [serial online] 2016 [cited 2021 Feb 25];5:42-6. Available from: https://www.mdcan-uath.org/text.asp?2016/5/8/42/197434
| Introduction|| |
Diabetes mellitus has become an epidemic worldwide. Lack of awareness due to illiteracy in villages, lack of doctors and paramedical staff trained in diabetes, limited access to health care, and poverty are some of the major obstacles to delivering diabetes health care to rural areas. Many countries lack proper podiatry and specialist nursing provision for diabetic foot ulcers.
Diabetic foot problems are the commonest reason for hospitalization of diabetic patients.
Screening for diabetes is seldom done in rural areas, resulting in a much greater burden of undiagnosed diabetes in rural areas.Outcome is related to poor glycemic control and longer diabetes duration.
One-third of all diabetic patients have significant peripheral neuropathy and/or peripheral vascular disease.
Diabetic foot ulcers are most commonly seen on weight bearing surfaces. Foot deformities common in patients with diabetes can accentuate bony prominences and predispose the patient to pressure and the development of ulcers. Poor fitting shoes and the lack of protective sensation further exacerbate this problem.Rural population in villages of Haryana still have the habit of walking barefoot, practise open field defecation and fetching water from long distances.
Common diabetic foot ulcers are likely to occur in up to 25% of people with diabetes mellitus at some time in their life. Patients with foot ulcers need prompt assessment, diagnosis, treatment, and long-term follow-up to conserve the foot.
Rural background of Haryana, persons walking barefoot, farmers working in fields, sedentary lifestyle, and hooka smoking predisposed patients with diabetes to be more prone to foot ulcers.
Diabetic ulcers result from neuropathy or ischemia. Neuropathy is characterized by loss of protective sensation and biomechanical abnormalities. Lack of protective sensation allows ulceration in areas of high pressure. Decreased blood supply to ulcer area is associated with reduced oxygenation, nutrition, and ulcer healing. Necrotic tissue is laden with bacteria making area prone to fulminant infection.
Wagner's classification which was developed in the 1970s, has been the most widely accepted and universally used grading system used in our study for lesions of the diabetic foot.The first four grades (grade 0, 1, 2, and 3) are based on the physical depth of the lesion in and through the soft tissues of the foot. The last two grades (grade 4 and 5) are completely distinct because they are based on the extent of gangrene and lost perfusion in the foot. Complications like necrotizing fasciitis, plantar abscess and Charcot foot are more common due to bare foot walking and poor health care.
Protective footwear helps to reduce ulceration in diabetic feet at risk. Relieving pressure on the ulcer area is necessary to allow healing.
Severe foot infections need intravenous antibacterial therapy, and frequent assessment of the need for surgical drainage and debridement. Necrosis in neuropathic feet requires intravenous antibacterials and surgical debridement.Wet necrosis in neuroischaemic feet needs vascular reconstruction. Aggressive management of diabetic foot ulceration will reduce the number of feet proceeding to infection and necrosis in villages of haryana, and thus reduce the number of major amputations in diabetic patients.
Rural background of Haryana, persons walking barefoot, farmers working in fields, sedentary lifestyle, hooka smoking predisposed patients with diabetes to be more prone to foot ulcers. The aim of this study was to determine major risk factors and management outcome of diabetic foot ulcers in order to prevent amputation.
| Methods|| |
This study was carried out in the outpatient department and emergency patients of diabetic foot attending our hospital. Sixty-four consecutive diabetic patients with foot ulcers of Wagner's Grade 1-4 were assessed at baseline for demographic information, detailed history, neuropathy, peripheral pulses, and frequency of diabetic complication. Glycemic control was determined on the basis of hemoglobin A1c (HbA1c) levels. Appropriate medical management was provided by medical specialists and plastic surgical treatments were carried out. Patients follow-up was done till healing as the end point of the study. The outcome was recorded as healed, incomplete healing, and amputation. [Table 1] shows the record of amputations performed in our study. Split thickness skin grafting was performed in 34 patients with good results. Primary closure was obtained in two patients. V-Y closure was done in four patients [Table 2].
| Results|| |
Sixty-four patients with type 2 diabetes mellitus were evaluated in the current study with different stages of diabetic foot presentations. Forty-four were males and twenty were females. Two cases of female patients with diabetic hand ulcers were also seen. [Table 3] gives the age distribution of patients in our study.
Mean age was 35 years (35-70 years). The mean duration of diabetes was 7 years (8-15 years). In the majority of the cases (72%), foot ulceration was present, whereas in 30% a neglected minor trauma was the source of the infection.
Serial debridements, regular betadine dressings, and skin grafting gave good and fast results. Only eight had below knee amputations and four underwent forefoot amputation. Ten great toe amputations were performed. Pseudomonas was the main organism in majority of pus cultures with an overlap of Citrobacter or Acinetobacter in some isolates. Primary closure was obtained in two patients. V-Y closure was done in four patients.
Chi-square test was used to compare the ulcer healing among intervention and standard groups. Discrete variables were expressed as percentages and analyzed by Chi-square test. A P value < 0.05 was considered as statistically significant.
| Discussion|| |
The primary goal in the treatment of diabetic foot ulcers is to obtain wound closure. 15% of more than 150 million people with diabetes world-wide will at some stage develop diabetic foot ulceration. 
The resolution of foot ulcer and recurrence can lower the probability of lower foot amputation.  Presence of infection, severity, and vascularity determine the management of the foot ulcer. 
Foot ulcerations, infections, and Charcot neuropathic osteoarthropathy are three serious foot complications of diabetes mellitus which lead to gangrene and lower limb amputation. 
The first and most important procedure of ulcer therapy is debridement of all necrotic, callus and fibrous tissue.
Diabetic patients develop neurologic, vascular, and metabolic insults, are at high risk for developing infections of the soft tissue and bones of the feet. Aerobic gram-positive cocci are the major pathogens in diabetic foot infections.
Boyko, Rieber and Smith reported a twofold increased risk of leg lesions, including gangrene, among diabetic individuals with higher blood glucose levels compared with those with lower blood glucose levels.  Our studies demonstrated significant and increased amputation risk with elevated fasting plasma glucose, 2-hour postload glucose, or glycosylated hemoglobin.  The risk of amputation increases 2-4 folds with both age and duration of diabetes.
Treatment of diabetic foot incurs a lot of expenditure in USA so clinical practice guidelines can help in reducing costs. 
In the current study povidone iodine along with septilok was useful in wound dressing and facilitated healthy growth of granulation in ulcers in almost all patients.
Percora and others found forty-six percent of the amputations were attributed to ischemia, 59% to infection, 61% to neuropathy, 81% to faulty wound healing, 84% to ulceration, 55% to gangrene, and 81% to initial minor trauma. They found a pivotal event in most cases to be an episode involving minor trauma that caused cutaneous injury,which preceded 69 to 80 amputations. 
Repetitive trauma and high plantar pressure on the ulcer bed are two primary reasons for the predisposition to ulcers once they have developed. Offloading is very important in diabetic wound healing. Appropriate techniques of wound care can reduce rates of amputation as per consensus development conference on diabetic foot. 
Boyko and others reported a high ulcer risk with hammer or claw toe deformity and history of laser photocoagulation. Foot deformities, reduced skin oxygenation and foot perfusion, poor vision, greater body mass, and both sensory and autonomic neuropathy increase the chances of foot ulcers. 
Rieber and others found a critical triad (neuropathy, minor foot trauma, foot deformity) to be present in >63% of patient's causal pathways to foot ulcers. The risk factors edema and ischemia contributed to the development of 37 and 35% of foot ulcers, respectively. Rieber et al found callus formation was associated with ulcer development in 30% of the pathways. They identified, trauma and edema accounting for lesions on the plantar toes, forefoot, and midfoot. 
Most ulcers form over areas of bony prominences, especially when bunions, calluses or hammer-toe formations lead to abnormally prominent bony points. Foot deformities are believed to be more common in diabetic patients due to atrophy of the intrinsic musculature. 
McNeely et al outlined following three predictors of foot ulceration: absence of Achilles tendon reflexes, insensate to the 5.07 monofilament, and TcPO2 <30 mmHg. 
Grayson and others reported probing for bone to be included in the initial assessment of all diabetic patients with infected pedal ulcers. 
Frykberg and others emphasized the role of neuropathy and foot pressure abnormalities in his study.  Caputo and others pointed out role of glycaemic control in the progression of neuropathy, and ulceration. Early detection of the loss of protective sensation reduced the rates of limb-threatening complications. 
Ricco and others found patients with uncontrolled abscess, bone or joint involvement, gangrene, or necrotising fasciitis had a "foot-at risk" presentation and needed surgical treatment with debridement and revascularisation.
A diabetic foot infection is often the pivotal event leading to lower extremity amputation, which account for about 60% of all amputations in developed countries. Foot risk factors include peripheral neuropathy, peripheral arterial disease and foot deformities.
Staphylococcus species, Enterococcus species, Corynebacterium species, and various species of Enterobacteriaceae were commonly isolated. Common anaerobic isolates included Peptostreptococcus magnus, Peptostreptococcus prevotii, Pseudomonas and Bacteroides species. The polymicrobial character of diabetic foot infections in our patients definitely confirm the findings of other studies. ,,
Lipsky and others found in diabetic foot that bone infections are diagnosed on the basis of roentgenographs and nuclear medicine scans. 
Wagner proposed a grading and treatment system for diabetic foot. 
Oyibo SO and others in their study of 194 patients with new foot ulcers, 67.0% were neuropathic, 26.3% were neuroischemic, 1.0% were ischemic, and 5.7% had no identified underlying factors. Median ulcer size at presentation was 1.5 cm 2 (0.6-4.0). 
Lavery gave a clinical classification system for diabetic foot wounds which incorporated wound depth, the presence of infection, and peripheral arterial occlusive disease in every category of the wound assessment. The goal of this system is to improve communication, leading to a less complex, more predictable treatment outcome. 
Holstein and Sorensen suggested multifactorial treatment of the complex foot lesions by a multidisciplinary foot care team is considered mandatory to obtain satisfactory limb salvage. Resection of gangrene was required in 43% of the limbs. 
Dargis V and others have shown an effective multidisciplinary approach to diabetic foot care together with the provision of specialty footwear in the long-term management of high-risk patients with a history of neuropathic foot ulcers. 
Yercan et al performed coverage of the soft tissue defect by a lateral supramalleolar flap in 8 patients who had large-sized, non-healing diabetic ulcers. The average healing time of the ulcer region and recovery of regular walking status was 34 days. The average healing period of the donor site was 35 days.  Donor site healing in our study averaged 21 days with ulcer healing rates ranging from 3 to 6 months.
Rose and others suggest that skin grafting may be an effective method for promotion of wound healing in the management of chronic lower extremity wounds irrespective of wound location and presence of diabetes. 
Twenty four patients had minor or major amputations and the rate of amputation in our study was 37% while it was 17%, in studies by Kroger.  Oyobo and others found lower-limb amputations were performed for 15% of ulcers, whereas 65% healed spontaneously.
Debridement and skin grafting were necessary to restore the foot in 17 cases. 
Skin grafting was performed in 34 patients with good results in our study.
Hu et al. found the prevalence of diabetes foot complications in population of Jeddah to be 11.4%. Non-Saudi nationality, longer diabetes duration, and insulin use were significantly associated with the higher prevalence of diabetic foot infections. Each 1 g/L increase of Hb was associated with 2.8% lower prevalence of diabetes foot complications in their study. 
Zhang outlined previous antibiotic therapy, previous hospitalization and osteomyelitis to be associated with multi drug resistant Pseudomonas infection and this group of patients had a higher amputation/toe rate similar to our study.  This study shows that poor glycemic control, long duration of diabetes, unawareness regarding foot care, micro and macro vascular complications are risk factors for foot ulcers, but adherence to foot care advice and prompt optimum treatment reduces the overall rate of amputations.  Ahmed, Griffin and Rooh reported an amputation rate of 48% in their study which is higher than our study. They outline unhygienic conditions, late referral, lack of diabetes education and poor social status as etiological factors. 
Salahuddin, Azhar and Latif outlined an incidence of 12.2 % partial toe amputation .Second-toe amputation was done in 60 (35%) cases, hallux amputation in 41 (24%) cases, multiple toe amputations in 29 (17%) cases, bilateral feet involvement was observed in 16 (9.3%) cases, and transmetatarsal amputation was performed in 4 (2.3%). 
Better management of patients were obtained once there is proper grading of the patient, as the likelihood of a patient to undergo surgery for amputation was found to be dependent on the ulcer grade. Early detection implies avoidance of quick progression to the stage that may require amputation.
| Conclusion|| |
Prevention, education, regular foot examinations, aggressive plastic surgery intervention, and optimal use of therapeutic footwear is pivotal in reducing the incidence of lower-extremity amputations in rural set up of Khanpur Kalan.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Boulton AJ. The diabetic foot: A global view. Diabetes Metab Res Rev 2000;16 Suppl 1:S2-5.
Frykberg RG. Diabetic foot ulcers: Current concepts. J Foot Ankle Surg 1998;37:440-6.
Reiber GE, Boyko EJ, Smith DG. Lower extremity foot ulcers and amputations in diabetes. In: Harris MI, Cowie CC, Stern MP, editors. Diabetes in America. 2 nd
ed. Washington DC: Bethesda; 1995.
Frykberg RG, Armstrong DG, Giurini J, Edwards A, Kravette M, Kravitz S, et al.
Diabetic foot disorders: A clinical practice guideline. American College of Foot and Ankle Surgeons. J Foot Ankle Surg 2000;39 5 Suppl:S1-60.
Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 1990;13:513-21.
American Diabetes Association. Consensus development conference on diabetic foot wound care: 7-8 April 1999, Boston, Massachusetts. American Diabetes Association. Diabetes Care 1999;22:1354-60.
Boyko EJ, Ahroni JH, Stensel V, Forsberg RC, Davignon DR, Smith DG. A prospective study of risk factors for diabetic foot ulcer. The Seattle diabetic foot study. Diabetes Care 1999;22:1036-42.
Reiber GE, Vileikyte L, Boyko EJ, del Aguila M, Smith DG, Lavery LA, et al.
Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care 1999;22:157-62.
Armstrong DG, Lavery LA. Diabetic foot ulcers: Prevention, diagnosis and classification. Am Fam Physician 1998;57:1325-32.
McNeely MJ, Boyko EJ, Ahroni JH, Stensel VL, Reiber GE, Smith DG, et al.
The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration. How great are the risks? Diabetes Care 1995;18:216-9.
Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW. Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients. JAMA 1995;273:721-3.
Frykberg RG, Lavery LA, Pham H, Harvey C, Harkless L, Veves A. Role of neuropathy and high foot pressures in diabetic foot ulceration. Diabetes Care 1998;21:1714-9.
Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes. N Engl J Med 1994;331:854-60.
Lipsky BA, Pecoraro RE, Wheat LJ. The diabetic foot. Soft tissue and bone infection. Infect Dis Clin North Am 1990;4:409-32.
Caballero E, Frykberg RG. Diabetic foot infections. J Foot Ankle Surg 1998;37:248-55.
Wagner FW Jr. The diabetic foot. Orthopedics 1987;10:163-72.
Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJ. A comparison of two diabetic foot ulcer classification systems: The Wagner and the University of Texas wound classification systems. Diabetes Care 2001;24:84-8.
Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996;35:528-31.
Holstein PE, Sørensen S. Limb salvage experience in a multidisciplinary diabetic foot unit. Diabetes Care 1999;22 Suppl 2:B97-103.
Dargis V, Pantelejeva O, Jonushaite A, Vileikyte L, Boulton AJ. Benefits of a multidisciplinary approach in the management of recurrent diabetic foot ulceration in Lithuania: A prospective study. Diabetes Care 1999;22:1428-31.
Yercan HS, Ozalp T, Okcu G. Reconstruction of diabetic foot ulcers by lateral supramalleolar flap. Saudi Med J 2007;28:872-6.
Rose JF, Giovinco N, Mills JL, Najafi B, Pappalardo J, Armstrong DG. Split-thickness skin grafting the high-risk diabetic foot. J Vasc Surg 2014;59:1657-63.
Peters EJ, Lipsky BA. Diagnosis and management of infection in the diabetic foot. Med Clin North Am 2013;97:911-46.
Kröger K, Moysidis T, Feghaly M, Schäfer E, Bufe A; Initiative Chronische Wunden e.V. Germany. Association of diabetic foot care and amputation rates in Germany. Int Wound J 2016;13:686-91.
Hu Y, Bakhotmah BA, Alzahrani OH, Wang D, Hu FB, Alzahrani HA. Predictors of diabetes foot complications among patients with diabetes in Saudi Arabia. Diabetes Res Clin Pract 2014;106:286-94.
Zhang J, Chu Y, Wang P, Ji X, Li X, Wang C, et al.
Clinical outcomes of multidrug resistant Pseudomonas aeruginosa
infection and the relationship with type III secretion system in patients with diabetic foot. Int J Low Extrem Wounds 2014;13:205-10.
Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM. Preventive foot care in people with diabetes. Diabetes Care 1998;21:2161-2177.
Rooh UM, Ahmed M, Griffin S. Evaluation and management of diabetic foot according to Wagner classification a study of 100 cases. J Ayub Med Coll Abbotabad 2003;15:39-42.
|29.| Salahuddin O, Azhar M, Imtiaz A, Latif M. A developing world experience with distal foot amputations for diabetic limb salvage. Diab Foot & Ankle 2013;4:220.
[Table 1], [Table 2], [Table 3]