Combined approach for management of diabetic foot ulcer

Diabetic foot ulcers occur as a result of peripheral neuropathy, microvascular and macrovascular arterial disease, suboptimal glycemic control and foot infections. Peripheral neuropathy has the greatest risk of foot ulceration. In fact, every year 5 percent of diabetic patients develop foot ulcers and 1 percent requires amputation. Combined approach for management of diabetic foot ulcers in the form of strict diabetic control, correction of associated diabetic complications, such as neuropathy and/or angiopathy, hyperlipidemia, and infection, surgical intervention in the form of ulcer cleaning, debridment, dressing and skin coverage with the suitable mean, with the aid of physical therapy in the form of electric stimulation and low power laser irradiation has been reported to achieve the shortest and the maximum success of diabetic foot ulcers management. Low power laser irradiation has been reported to cause biological effects on tissue healing by increasing production of collagen by fibroblasts and stimulation of keratinocyte activity and microcirculation with increase of lymphatic drainage. Electric stimulation increases tissue collagenase, enhance vascularization, regional blood flow and tissue oxygen levels; also increase macrophage migration to the site of ulcer. In this study 20 diabetic patients with foot ulcers were Selected from general medicine, surgery departments and out patient diabetes clinic in Matareya Teaching Hospital. All patients were subjected to history taking with special emphasis on duration of diabetes, presence or absence of neuropathy and/or angiopathy. Physical examination included neurological and vascular examination as well. Local examination of the foot included: circumference and depth of ulcer, and measurement of foot oedema. Investigations included: Laboratory investigations [fasting and 2 hours post-prandial blood sugar, glycated haemoglobin, lipid profile, liver and kidney functions]. Electrodiagnostic tests included: nerve conduction study [motor and sensory before and after treatment] was carried out for common peroneal and posterior tibial nerve. Six patients were subjected to surgical procedures for coverage of their ulcers and the rest of the patients were managed conservatively medically together with laser irradiation and electric stimulation. The mean of total surface area of ulcer before treatment was 20 +/- 12.9 cm[2]. While the depth was 2.09 +/- 1.09 mm and after treatment both were zero [complete healing]. Mean duration of healing was 4.7 +/- 2.75 months. Statistical significant improvement of laboratory investigations was recorded after three months of treatment. Statistical significant improvement in edema, sense of pain and nerve conduction velocity [motor and sensory] of common peroneal and posterior tibial nerve was evident after treatment. Good results were obtained by work of Combined team including physician for meticulous control of blood glucose, hyperlipidemia, control of infection and other associated complications of diabetes mellitus, surgeon for ulcer debridment and doing skin flap for necessary cases, clinical pathologist for the laboratory investigations; physiatrist to evaluate the neurophysiological function of motor and sensory components of both common peroneal and posterior tibial nerves before and after treatment. Physiotherapist for local evaluation of ulcers [area and depth], edema and sense of pain and application of the physical therapy program in the form of laser irradiation and faradic stimulation sessions