Piede diabetico

Piede diabetico: Alterazioni trofiche del piede causate principalmente da neuropatia periferica e/o vasculopatia obliterante che inducono diverse tipologie di lesioni: unghie ingrossate, alluce valgo, dito a martello, cute secca e screpolata, calli plantari, ulcere, neuroartropatia di Charcot. L’infezione si verifica come conseguenza dell’ulcerazione e non ne è una causa.

Epidemiologia – 2% nella popolazione diabetica; 15% nei pazienti diabetici in dialisi; le persone con diabete che hanno subito un’amputazione e che sono in dialisi hanno una mortalità a due anni del 75%.

L’ulcera diabetica inizialmente è una lesione cutanea con perdita di epitelio superficiale ma se non trattata diventa profonda interessando progressivamente derma, muscoli e ossa.  La classificazione delle ulcere diabetiche secondo Wagner si basa su tre parametri: la profondità dell’ulcera, il grado di infezione e l’estensione della necrosi.

• Grado 0: Nessuna lesione, piede senza rischio
• Grado 1: Ulcera superficiale
• Grado 2: Ulcera complicata
• Grado 3: Ulcera profondamente complicata
• Grado 4: Gangrena localizzata
• Grado 5: Gangrena dell’intero piede

Il callo plantare –  ispessimento cutaneo (ipercheratosi) che si forma a causa della secchezza cutanea (neuropatia autonomica), dell’insensibilità e dello stress  da pressioni elevate (scarpe strette, camminata errata) della pianta del piede. Il callo stesso agisce come un corpo estraneo e può causare ulcerazioni nel piede insensibile.

TERAPIA:

• Rimozione con micromotori, plantari personalizzati per scaricare la pressione e riequilibrare l’appoggio, calzini di cotone, tutori specifici, mantenere i piedi puliti e usare creme idratanti (evitando le creme tra le dita).
• Scarpe adatte: Comode, senza cuciture interne, con punta non stretta.

Deformità del piede – Si ritiene che una combinazione di neuropatia motoria, cheiroartropatia e alterazioni della pressione dell’andatura provochi il piede neuropatico “ad alto rischio”, con dita artigliate, teste metatarsali prominenti, arco plantare alto e perdita di massa muscolare.

Neuro-osteoartropatia di Charcot (o “piede di Charcot”) – è una malattia degenerativa su base infiammatoria che può insorgere in pazienti affetti da neuropatia ed è caratterizzata da un progressivo riassorbimento osseo delle articolazioni del piede (più raro l’interessamento di altre articolazioni), associato talvolta a crolli strutturali ed a marcate deformità, tali da richiedere nei casi più gravi il ricorso ad interventi di chirurgia correttiva o ad amputazione.

EZIOLOGIA del piede diabetico –neuropatia somatica e autonomica, ischemia periferica distrettuale, insufficienza renale, traumi meccanici (scarpe inadatte) e chimici come l’uso  di trattamenti topici inappropriati.  

DIAGNOSTICA – anamnesi, visita e diagnostica base come per il diabete mellito di base. Inoltre:

Ispezione visiva per lesioni cutanee, pelle secca, calli, ulcere, gonfiori, arrossamenti, deformazioni ossee, piede di Charcot

Ossimetria transcutanea

valutazione polsi periferici –

• Polso tibiale
• Polso pedidio
• Polpo popliteo e femorale (in caso di assenza dei due precedenti polsi periferici)

test di sensibilità (monofilamento, diapason)

Test del riflesso achilleo – L’assenza di questo riflesso è ben correlata con un rischio di ulcerazione del piede

Dopplerflussimetria arti inferiori – valuta la presenza di stenosi, occlusioni, aneurismi, trombosi venose profonde (TVP), insufficienza venosa o reflusso valvolare a carico delle arterie femorale, poplitea, tibiale e relative vene.

Indice caviglia-braccio (ABI, Ankle-Brachial Index).  valuta la circolazione arteriosa degli arti inferiori, calcolando il rapporto tra la pressione sistolica alla caviglia (arteria tibiale posteriore o pedidia) e quella al braccio; è fondamentale per diagnosticare precocemente l’arteriopatia obliterante periferica (AOP). Valori di riferimento: normale 0.9-1.3; Borderline 0.9-1.0; patologico (AOP) <0.9. L’ABI è comodo per la sua natura non invasiva, mentre il suo eccellente rapporto costo/benefici deriva dalla procedura di misurazione relativamente semplice, in particolare se quest’ultima è eseguita con un dispositivo pletismografico oscillometrico. Tuttavia, possiede un grande difetto, che viene alla luce in situazioni specifiche, ossia in caso di pazienti con arterie incomprimibili dove i suoi risultati sono pressoché diagnosticamente inutili. Con la definizione arterie incomprimibili (calcificate o rigide) intendiamo le arterie interessate dalla calcificazione arteriosa della media, anche nota con il nome di sclerosi calcifica mediale di Mönckeberg. Si richiede quindi una maggiore pressione del bracciale per conseguire la compressione. Ciò si traduce in risultati ABI falsati, più diffusi nei pazienti con diabete, insufficienza renale e artrite reumatoide

Indice alluce-braccio (TBI) per la diagnosi dell’arteriopatia obliterante periferica (AOP). La calcificazione colpisce raramente le arterie negli alluci, rendendoli idonei per la misurazione della pressione sanguigna. Il TBI è il metodo preferito per accertare disturbi di perfusione degli arti inferiori, nettamente superiore rispetto all’ABI.  Un TBI ≥0,6 indica l’assenza di problemi di perfusione significativi e richiede solo la gestione delle lesioni. Al contrario, un TBI <0,6 indica l’angioplastica come prerequisito per la gestione delle lesioni.

Rx arti inferiori, nel caso di sospetta osteomielite

RMN per valutare lesioni a tessuti molli

TERAPIA delle ulcere diabetiche – Nel caso dell’ulcera neuropatica plantare, il paziente deve indossare degli appositi scarponi o particolari tipi di gesso (come il total contact cast). La maggior parte di tali pazienti riesce a guarire, in questo modo, in circa 6-8 settimane.

Il trattamento per il piede ischemico e ulcera in fase avanzata, potrebbe essere necessario un intervento chirurgico che includerà una delle seguenti opzioni: 

• Intervento endovascolare mininvasivo con palloncino o stent o by-pass
• Debridement chirurgico della ferita 
• Amputazione di un arto, piede, dito del piede o altro osso

References:

1. American Diabetes Association. Position Statement. Diagnosis and classification of diabetes mellitus. Diabetes Care 2010;33:S62-9
2. Boulton AJM, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet 2005; 366: 1719-24.
3. Armstrong DG, Tan TW, Boulton AJM, Bus SA. Diabetic foot ulcers: a review. JAMA 2023; 330: 62-75.
4. Lavery LA, Hunt NA, Ndip A, et al. Impact of chronic kidney disease on survival after amputation in individuals with diabetes. Diabetes Care 2010; 33: 2365-2369.
5. Rogers LC, Lavery LA, Armstrong DG. The right to bear legs. J Am Podiatr Med Assoc 2008; 98: 166-168.
6. Kerr M, Barron E, Chadwick P, et al. The cost of diabetic foot ulcers and amputations to the National Health Service in England. Diabetic Med 2019; 36: 995-1002.
7. Skrepnek GH, Mills JL, Armstrong DG. Foot-in-Wallet Disease: tripped up by “cost-saving” reductions? Diabetes Care 2014; 37: 196-197.
8. Boulton AJM. The diabetic lower limb – a forty-year journey: from clinical observation to clinical Science. Diabetic Medicine 2019; 36:1539-1549.
9. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. New Engl J Med 2017; 376: 2367-2375.
10. Zhang Y, Lazzarini PA, McPhail SM, et al. Global disability burdens of diabetes-related lower-extremity complications in 1990 and 2016. Diabetes Care 2020; 43: 964-974.
11. Abbott CA, Carrington AL, Ashe H, et al. The North-West Diabetes Foot Care Study: incidence of, and risk factors for new diabetic foot ulceration in a community-based patient cohort. Diabetic Med 2002; 19: 377-384.
12. McDermott K, Fang M, Boulton AJM et al. Etiology, Epidemiology and Disparities in the Burden of Diabetic Foot Ulcers. Diabetes Care 2023; 46: 209-221.
13. Joslin EP. The menace of diabetic gangrene. N Engl J Med 1934; 211: 16-20.
14. Young MJ, Breddy JL, Veves A, et al. The prediction of diabetic neuropathic foot ulceration using vibration perception thresholds: a prospective study. Diabetes Care 1994; 17: 557-560.
15. Brown SJ, Handsaker JC, Bowling FL, et al. Diabetic peripheral neuropathy compromises balance during daily activities. Diabetes Care 2015; 38: 1116-22.
16. Handsaker JC, Brown SJ, Bowling FL, et al. People with diabetic peripheral neuropathy display a decreased stepping accuracy during walking: potential implications for risk of tripping. Diabet Med 2016; 33: 644-649.
17. Boulton AJM, Armstrong DG, Albert SF, et al. Comprehensive foot examination and risk assessment: a report of the taskforce of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care 2008; 31: 1679-1685.
18. Reiber GE, Vileikyte L, Boyko EJ, et al. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care 1999; 22: 157-162.
19. Prompers L, Huijberts M, Apelqvist J, et al. High prevalence of ischemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia 2007; 50: 18-25.
20. Hinchliffe RJ, Forsythe RO, Apelqvist J, et al. Guidelines on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers and diabetes. Diabetes Metab Res Rev 2020; 36 (suppl 1): e3276.doi.10.1002/dmrr.3276
21. Forsythe RO, Hinchliffe RJ. Management of critical limb ischemia in the patient with diabetes. J Cardiovasc Surg (Torino) 2016; 57: 273-281.
22. Mohammedi K, Woodward M, Hirakawa Y, et al. Microvascular and macrovascular disease and risk for major peripheral arterial disease in patients with type 2 diabetes. Diabetes Care 2016; 39: 1796-1803.
23. Game FL, Chipchase SY, Hubbard R, et al. Temporal association between the incidence of foot ulceration and the start of dialysis in diabetes mellitus. Nephrol Dial Transplant 2006; 21: 3207-3210.
24. Ndip A, Lavery LA, Lafontaine J, et al. High levels of foot ulceration and amputation risk in a multiracial cohort of diabetic patients on dialysis therapy. Diabetes Care 2010; 33: 878-880.
25. Ndip A, Rutter MK, Vileikyte L, et al. Dialysis treatment is an independent risk factor for foot ulceration in patients with diabetes and stage 4 or 5 chronic kidney disease. Diabetes Care 2010; 33: 1811-1866.
26. Barrado FC, Kuypers DK, Matricali GA. Charcot neuroarthropathy after simultaneous pancreas-kidney transplantation: risk factors, prevalence and outcome. Clin Transplant 2015; 29: 712-719.
27. Vileikyte L, Pouwer F, Gonzalez JS. Psychosocial research in the diabetic foot: are we making progress? Diabetes Metab Res Rev 2020; 36 (suppl 1) e3257.doi.10.1002/dmrr3257
28. Gonzalez JS, Vileikyte L, Ulbrecht JS, et al. Depression predicts first but not recurrent diabetic foot ulcers. Diabetologia 2010; 53: 2241-2248.
29. Boulton AJM. Diabetic Neuropathy: is pain God’s great gift to mankind? Semin Vasc Surg 2012; 25: 61-65.
30. Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 1998; 21: 855-859.
31. Oyibo S, Jude EB, Tarawneh I, et al. A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification system. Diabetes Care 2001; 24: 84-88.
32. Fitridge R, Chuter V, Mills JL et al. . The 2023 intersocietal IWGDF, ESVS, SVS guidelines on peripheral arterial disease in patients with diabetes and a foot ulcer.
33. Senneville E, Lipsky BA, Abbas ZG, et al. Diagnosis of infection in the foot in diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 (suppl 1): e3281.
34. Lam K, van Asten SA, Nguyen T, et al. Diagnostic accuracy of probe to bone to detect osteomyelitis in the diabetic foot: a systematic review. Clin Infect Dis 2016 63: 944-948.
35. Katz IA, Harlan A, Miranda-Palma B, et al. A randomized trial of two irremovable offloading devices in the management of plantar neuropathic diabetic foot ulcers. Diabetes Care 2005; 28: 555-559.
36. Jeffcoate WJ, Price PE, Phillips CJ, et al. Randomized controlled trial of the use of three dressing preparations in the management of chronic ulceration of the foot in diabetes. Health Technol Assess 2009; 13: 1-86.
37. Nabuurs-Fransen MH, Sleegers R, Huijberts HS, et al. Total contact casting of the diabetic foot in daily practice: a prospective follow-up study. Diabetes Care 2005; 28: 243-247.
38. Hinchliffe RJ, Brownrigg JR, Andros G, et al. Effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral artery disease: a systematic review. Diabetes Metab Res Rev 2016; 32 (suppl 1): 136-144.
39. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2012; 54: e132-173.
40. Ertugrul B, UcKay I, Schoni M, Peter-Riesch B, Lipsky BA. Management of diabetic foot infections in the light of recent literature and new international guidelines. Expert Rev Anti-Infect Ther 2020; Feb 19 Epub.
41. Game FL, Jeffcoate WJ. Primary non-surgical management of osteomyelitis of the foot in diabetes. Diabetologia 2008; 51: 962-967.
42. Lázaro-Martinez JL, Aragón-Sánchez J, Garcia-Morales C. Antibiotics versus conservative surgery for treating diabetic foot osteomyelitis: a randomized comparative trial. Diabetes Care 2014; 37: 789-795.
43. Tone A, Nguyen S, Devemy F, et al. Six-week versus twelve-week antibiotic therapy for non-surgically treated diabetic foot osteomyelitis: a multicentre open-label controlled randomized study. Diabetes Care 2015; 38: 302-307.
44. Li HK, Rombach I, Zambellas R, et al. OVIVA Trial collaborators. Oral Vs IntraVenous Antibiotics for bone and joint infection. N Engl J Med 2019; 380: 425-436.
45. Boulton AJM, Armstrong DG, Hardman MJ, et al. Diagnosis and management of diabetic foot infections. Arlington (VA). American Diabetes Association 2020.
46. Game FL, Apelqvist J, Attinger C, et al. Effectiveness of interventions to enhance healing of chronic ulcers of the foot in diabetes: a systematic review. Diabetes Metab Res Rev 2016; 32 (suppl 1): 154-168.
47. Edmonds ME. A renaissance in diabetic foot care: new evidence-based treatments. Lancet Diabet Endocrinol 2018; 6: 837-838.
48. Edmonds ME, Lázaro-Martinez JL, Alfayate-Garcia JM, et al. Sucrose octasulfate dressing versus control dressing in patients with neuroischemic diabetic foot ulcers (Explorer): an international, multicenter, double-blind, randomized controlled trial. Lancet Diabetes Endocrinol 2018; 6: 186-196.
49. Game F, Jeffcoate W, Tarnow L, et al. LeucoPatch system for the management of hard-to-heal diabetic foot ulcers in the UK, Denmark, and Sweden: an observer-masked, randomized controlled trial. Lancet Diabetes Endocrinol 2018; 6; 870-878.
50. Rayman G, Vas P, Dharariya K, et al. International Working Group on the Diabetic Foot (IWGDF). Guidelines on use of interventions to enhance healing of chronic foot ulcers in diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 (suppl 1): 3283.
51. Lavery LA, Fulmer J, Shebetka KA, et al. Grafix Diabetic Foot Ulcer Study Group. The efficacy and safety of Grafix for the treatment of chronic diabetic foot ulcers: results of a multi-centre, controlled, randomized, blinded, clinical trial. Int Wound J 2014; 11: 554-560.
52. Tettelbach W, Cazzell S, Sigal F, et al. A multicentre prospective randomized controlled comparative parallel study of dehydrated human umbilical word (EpiCord) allograft for the treatment of diabetic foot ulcers. Int Wound J 2019; 16: 122-130.
53. Tettelbach W, Cazzell S, Reyzelman AM, Sigal F, Caporusso JM, Agnew PS. A confirmatory study on the efficacy of dehydrated human amnion/chorion membrane dHACM allograft in the management of diabetic foot ulcers: a prospective, multicentre, randomized, controlled study of 110 patients from 14 wound clinics. Int Wound J 2019; 16: 19-29.
54. Boulton AJM, Armstrong DG, Löndahl M, et al. New Evidence-Based Therapies for Complex Diabetic Foot Wounds. Arlington (VA) May 2022: American Diabetes Association.
55. Löndahl M, Katzman P, Nilsson A, et al. Hyperbaric oxygen therapy facilitates healing of chronic foot ulcers in patients with diabetes. Diabetes Care 2010; 33: 998-1003.
56. Margolis DJ, Gupta J, Hoffstad O, et al. Lack of effectiveness of hyperbaric oxygen therapy for the treatment of diabetic foot ulcer and the prevention of amputation: a cohort study. Diabetes Care 2013; 36: 1961-1966.
57. Fedorko L, Bowen JM, Jones W, et al. Hyperbaric oxygen therapy does not reduce indications for amputation in patients with diabetes with non-healing ulcers of the lower limb: a prospective, double-blind, randomized controlled clinical trial. Diabetes Care 2016; 39; 392-399.
58. Santema KTB, Stoekenbroek RM, Koelemay MJW, et al. Hyperbaric oxygen therapy in the treatment of ischemic lower-extremity ulcers in patients with diabetes: results of the DAMO2CLES multicenter randomized controlled trial. Diabetes Care 2018; 41: 112-119.
59. Löndahl M, Boulton AJM. Hyperbaric oxygen: useless or useful? A debate. Diab Metab Res Rev 2020 Mar;36 Suppl 1:e3233. doi: .10.1002/dmrr.3233
60. Niederauer MQ, Michalek JE, Liu Q, et al. Continuous diffusion of oxygen improves diabetic foot ulcer healing when compared with a placebo control: a randomized, double-blind, multicenter study. J Wound Care 2018; 27 (suppl 9): S30-S45.
61. Frykberg RG, Franks PJ, Edmonds ME, et al. A multinational, multicenter, randomized, double-blinded, placebo-controlled trial to evaluate the efficacy of cyclical topical wound oxygen therapy (TWO2) in the treatment of chronic diabetic foot ulcers: the TWO2 study. Diabetes Care 2020; 43: 616-624.
62. Yellin JI, Gaebler JA, Zhou FF, et al. Reduced hospitalizations and amputations in patients with diabetic foot ulcers treated with cyclical pressurized topical wound oxygen therapy: real-world outcomes. Adv Wound Care (New Rochelle). Online ahead of print on 6 December 2021
63. Carter MJ, Frykberg RG, Oropallo A, et al. Efficacy of topical oxygen therapy in healing chronic diabetic foot ulcers: systematic review and meta-analysis. Adv Wound Care 2023, Apr; 12 (4): 177-186. doi: .10.1089/wound.2022.0041
64. Isaac AL, Armstrong DG. Negative pressure wound therapy and other new therapies for diabetic foot ulceration: the current state of play. Med Clin North Amer 2013; 97: 899-909.
65. Armstrong DG, Lavery LA. Negative pressure wound therapy after partial diabetic foot amputation: a multicenter, randomized controlled trial. Lancet 2005; 366: 1704-1710.
66. Blume PA, Walters J, Payne W, et al. Comparison of negative pressure wound therapy using vacuum-assisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcers: a multicenter, randomized controlled trial. Diabetes Care 2008; 31: 631-636.
67. El Sayed NA, Aleppo G, Aroda VR, et al. Retinopathy, Neuropathy and Foot Care: Standards of Care in Diabetes – 2023. Diabetes Care 2023; 46 (Suppl 1): S203-S215. doi: .10.2337/dc23-S012
68. Chen P, Vilorio NC, Dhatariya K, et al: Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update). Diab Metab Res Rev 2023; May 25; 3644
69. Jeffcoate WJ. Charcot foot syndrome. Diabetic Med 2015; 32: 760-770.
70. Ergen FB, Sanverdi SE, Oznur A. Charcot foot in diabetes and an update on imaging. Diabetic Foot Ankle 2013; 4: .10.3402/dfa.V4i0.21884
71. Shen W, Wukich D. Orthopedic surgery and the diabetic Charcot foot. Med Clin North Am 2013; 97; 873-882.
72. Rayman G, Vas PR, Baker N, et al. The Ipswich Touch Test: a simple and novel method to identify inpatients with diabetes at risk of foot ulceration. Diabetes Care 2011; 34: 1517-1518.
73. Bowling FL, Abbott CA, Harris WE. A pocket-sized disposable device for testing the integrity of sensation in the outpatient setting. Diabet Med 2012; 29: 1550-1552.
74. Dorresteijn JA, Valk GD. Patient education for preventing diabetic foot ulceration. Diabetes Metab Res Rev 2012; 28 (suppl 1): 101-106.
75. Lincoln NB, Radford KA, Game FL, et al. Education for secondary prevention of foot ulcers in people with diabetes: a randomized controlled trial. Diabetologia 2008; 51 1954-1961.
76. Lavery LA, Higgins KR, Lanctot DR, et al. Preventing diabetic foot ulcer recurrence in high-risk patients: use of temperature monitoring as a self-assessment tool. Diabetes Care 2007; 30: 14-20.
77. Aan de Stegge WB, van Netten JJ, Bus SA. Does the skin heat up before it breaks down in diabetic foot ulceration? Diabete Metab Res Rev 2023, 08 Feb 2023.
78. Krishnan S, Nash F, Baker N, et al. Reduction in diabetic amputations over eleven years in a defined UK population: benefits of multidisciplinary teamwork and continuous prospective audit. Diabetes Care 2008; 31: 99-101.
79. Boulton AJM. Diabetic Foot Disease during the Covid-19 pandemic. Medicina 2021; Jan 22; 57 (2): 97.
80. Frykberg RG, Gordon IL. Reyzelman AM, et al. Feasibility and efficacy of a smart mat technology to predict development of diabetic plantar ulcers. Diabetes Care 2017; 40: 973-980.doi: .10.2337/dc16-2294
81. Abbott CA, Chatwin KE, Foden P, et al. Innovative intelligent insole system reduces diabetic foot ulcer recurrence at plantar sites: a prospective, randomized, proof-of-concept study. Lancet Digit Health 2019; Oct 1 (6): e308-e318.
82. Jeffcoate WJ, Bus SA, Game FL, et al. Reporting standards of studies and papers on the prevention and management of foot ulcers in diabetes: required details and markers of good quality. Lancet Diabetes Endocrinol 2016; 4: 781-788.