Trophic ulcers in diabetes

The urgency of therapy for the lesion of the feet required the isolation of the diabetic foot syndrome. Trophic ulcers in diabetes - a pathological condition of the feet in this pathology of the endocrine system, which occurs against the background of the defeat of peripheral nerves, vessels, skin and soft tissues, bones and joints and is manifested by acute and chronic ulcerative defects, osteoarticular lesions, purulent necrotic and gangrenous ischemic processes.

The main components of the complex treatment of trophic ulcers in diabetes:

• compensation of the disease with stabilization of blood sugar level by the appointment of insulin and other antidiabetic drugs;
• immobilization or unloading of the affected limb;
• local therapy of ulcerative-necrotic lesions with the use of modern dressings;
• systemic directed antibiotic therapy;
• the suppression of phenomena of critical ischemia
• surgical treatment, including depending on the situation, revascularization of the limb, necrectomy in the area of ulcerative defect and skin plasty.

Treatment of trophic ulcers with diabetes is the most important measure of preventing the development of severe complications, leading to loss of limb. According to different authors, 6 to 14 weeks of outpatient treatment is needed to completely heal the ulcerative defect. To heal complicated ulcerative defects (osteomyelitis, phlegmon, etc.), a longer time is necessary, while only the periods of inpatient therapy are 30-40 days or more.

To conduct adequate therapy, it is necessary to evaluate all the factors affecting the healing of such ulcerative defects as trophic ulcers in diabetes:

• Neuropathy (determination of vibration sensitivity with the help of a graded tuning fork, pain, tactile and temperature sensitivity, tendon reflexes, electromyography);
• vascular status (pulsation of arteries, ultrasound dopplerography of arteries and duplex antigoscanning, in the planning of reconstructive operations - angiography, including magnetic resonance angiography);
• microcirculatory disorders (transcutaneous oxygen tension, laser Doppler flowmetry, thermography, etc.);
• volume and depth of tissue damage (visual assessment and revision of the wound, photometry, ultrasound of soft tissues, radiography, CT, MRI);
• infectious factor (qualitative and quantitative determination of all types of microflora with an assessment of antibacterial sensitivity).

Deformation of the foot and biomechanical disturbances lead to an abnormal redistribution of pressure on the plantar surface of the foot, which is why the unloading of the foot is the basis for both prevention and treatment of diabetic ulcers. Trophic ulcers in diabetes can not heal until the mechanical stress on the leg is eliminated. This is achieved using orthopedic insoles and shoes, foot orthoses, which are selected individually for each patient in specialized orthopedic centers. In more severe cases, as well as inpatient treatment of the patient use bed rest, crutches and wheelchairs.

Uncomplicated plantar trophic ulcers with diabetes are well treated with removable boots made of lightweight synthetic materials (total contact cast). These materials (Scotchcast-3M and Cellocast-Lohmann) possess not only considerable strength, but also low weight, which keeps the patient's mobility. The unloading mechanism when this dressing is applied is enclosed in the redistribution of the load towards the heel, as a result of which the pressure on the forefoot, bearing the ulcerative defect, decreases. When forming the dressing in the projection of the plantar trophic ulcer in diabetes, a window is made, which allows to avoid support on the area of the ulcerative defect. The dressing is removable, which allows you to use it only while walking and facilitates care. The application of the dressing is contraindicated in limb ischemia, the presence of edema of the limb and inflammatory changes.

Treated trophic ulcers in diabetes in different ways. This therapy depends on the condition, the stage of the wound process. Local therapy and care alone can compensate for long-term damage, neuropathy and ischemia, but an adequate choice of local therapy strategy can speed up reparative processes. Trophic ulcers in diabetes can not be treated with aggressive antiseptics (hydrogen peroxide, potassium permanganate, etc.), which have an additional damaging effect on the tissue caused by neuropathy and ischemia. The treatment of the ulcerous surface must be carried out with a jet of isotonic sodium chloride solution. To treat ulcerative lesions, try to use interactive bandages that do not contain cytotoxic components. These include preparations from the group of hydrogels and hydrocolloids, alginates, biodegradable wound covers based on collagen, reticular atraumatic wound covers and other means that are prescribed depending on the stage of the wound process and the features of its course, in accordance with the indications and contraindications to the use of this or other dressing means.

In the presence of severe hyperkeratosis in the circumference of the trophic ulcer with diabetes and in the formation of necrotic tissue, the mechanical removal of hyperkeratosis and tissue necrosis sites using a scalpel is considered a universally recognized method. Despite the fact that qualitative comparative studies of the effectiveness of excision of damaged tissues with a scalpel and autolytic or chemical purification did not produce, experts are similar in opinion that the best method is surgical. With a complicated course of trophic ulcers with diabetes (phlegmon, tendonitis, osteomyelitis, etc.), a surgical treatment of a purulent necrotic focus with a wide opening of the entire pathological process and the removal of nonviable tissues is indicated. Uncomplicated trophic ulcers in diabetes, which occur during the phenomena of severe limb ischemia, are not treated by the method of necrectomy, since any active intervention in this situation can lead to an expansion of the ulcerative defect, activation of the infection and development of the gangrene of the foot.

Trophic ulcers in diabetes complicated by infection are a life-threatening condition, since in neglected cases or in inadequate treatment leads to a high limb amputation in 25-50% of cases. Are patients affected by the development of infectious lesions to a greater extent than patients without a major disease? A controversial issue. However, there is no doubt that the consequences of infection in diabetic foot syndrome are more severe, which is most likely due to the uniqueness and complexity of the anatomical structure of the foot, as well as to the peculiarities of the inflammatory response disorder due to metabolic disorders, neuropathy and ischemia. Pathogens with superficial infection of trophic ulcers with diabetes, clinically represented by cellulitis, in typical cases - gram-positive aerobic and anaerobic cocci. Trophic ulcers in diabetes complicated by the development of a deep foot infection involving the purulent necrotic process of tendons, muscles, joints and bones, as well as in the case of tissue ischemia, the infection is of a polymicrobial nature and usually consists of associations of gram-positive cocci, gram-negative rods and anaerobes. Antibiotic therapy in these situations has been confirmed by its effectiveness in numerous randomized trials with the level of recommendations "A". In cellulite, as an empirical antibacterial therapy, ciprofloxacin or ofloxacin with clindamycin or metronidazole, levofloxacin or moxifloxacin in monotherapy, protected penicillins (amoxiclav, etc.) is prescribed. In the case of deep foot infections, in addition to the above schemes, combinations of cephalosporins of III-IV generation with metronidazole, sulperazone are used. Carbapenems.

Signs of critical ischemia are achieved by various shunt interventions, endovascular methods (subcutaneous transluminal angioplasty, stenting of arteries, etc.) or a combination of both. Conducting limb revascularization is technically possible in most patients with ischemic form of diabetic foot syndrome. After elimination of limb ischemia and restoration of normal microcirculation, the course of the wound process in the area of the ulcerative defect proceeds identically in patients with ischemic, mixed and neuropathic form of the diabetic foot syndrome and has a favorable prognosis. If there is no way to restore blood flow through revascularization of the limb, then trophic ulcers in diabetes are associated with a high risk of limb loss.

After reconstruction of arteries of the lower limbs, smoking cessation, control of hypertension and dyslipidemia, administration of acetylsalicylic acid and platelet deaggregants are necessary. A number of placebo-controlled studies have demonstrated that pharmacological treatment, including the administration of prostaglandin E: (alprostadil), has a positive effect on peripheral blood flow in patients with critical limb ischemia, but there is currently no convincing evidence of the effectiveness of such therapy for the introduction of certain drugs or treatment regimens into everyday practice.

A similar situation also arises in the treatment of diabetic neuropathy. Of the medicines used drugs tioktovoy acid (tioktatsid), multivitamins (milgamma, etc.), actovegin. The effectiveness of these drugs to treat such pathologies as trophic ulcers in diabetes from the perspective of evidence-based medicine has not been studied. However, randomized studies to study the elimination of symptoms and manifestations of neuropathy with thioctic acid preparations have revealed their relatively low efficacy both in themselves and in comparison with placebo.

In the II stage of the wound process, surgical treatment for diabetic foot syndrome is expediently completed by performing reconstructive and reconstructive surgeries using various techniques of plastic surgery in order to maintain the support function of the foot and earlier rehabilitation of patients. For surgical treatment of plantar ulcerative defects, the end region of the stump of the foot, calcaneal region use various methods of full-layer skin plasty. Most often, plastic is used with a rotary cutaneous-fascial flap, in a number of cases a dendritic dermal-fascial plantar flap is used in Zimani-Osborne, plastic with VY flaps of the foot according to Dieffenbach. When a combination of plantar pathologies with osteomyelitis of the metatarsal head or osteoarthritis of the metatarsophalangeal articulation, the plastic is used with the back skin flap of the scraper finger. To close large plantar ulcer defect, it is possible to use a rotational cutaneous-fascial flap taken from the non-supportive surface of the foot. The donor wound is then closed with a split skin flap.

Wide multicenter randomized trials confirming the effectiveness of plastic methods of closing trophic ulcers in diabetes compared with conservative treatment methods have not been conducted, but experts are of the same opinion that surgical treatment is the quickest and most economical way to eliminate these diseases.

According to some studies, the prognosis of treatment of such a pathology as trophic ulcers in diabetes does not depend on the duration of the disease, however, the elderly and senile age of the patient have a significant effect on the outcome of the treatment and are associated with a high risk of limb amputation.