The diabetic foot-A team effort

By Mario Dascal, MD, Section of Orthopaedics, Department of Surgery, University of Manitoba,
Winnipeg, MB

Diabetes is a multisystem disorder that adversely affects blood vessels and nerves. Diabetes is increasing in prevalence worldwide, and its complications lead to significant morbidity and mortality. Peripheral neuropathy is the factor that underlines neuropathic ulcers and undetected trauma in the lower extremities. The loss of protective sensation related to the nerve damage leads to a number of manifestations, specifically plantar ulcerations, and to Charcot changes. To date, there are no specific treatments to prevent or reverse peripheral neuropathy.

Open ulcerations serve as a portal of entry for bacteria, which can lead to skin, soft tissue and bone infections. There are four different plantar ulcer development mechanisms related to how the force is being applied (ischemic necrosis, mechanical destruction, inflammation and spreading sepsis). For the management of neuropathic foot ulcerations, the key elements include control of infection, wound debridement, moist wound healing, and displacement of pressure from the affected area.

For the displacement of pressure, a number of different techniques exist. However, the most effective and efficient is the use of the total contact cast. This device serves to protect the foot, displace pressure from the affected areas and ensure optimal compliance, as it is not removable.

With regards to the Charcot Foot, it is characterized by a relatively painless, progressive and destructive arthropathy secondary to an underlying neurological deficit with trauma being an essential component. There are four defined steps, specifically prodromal (acute inflammatory stage), development/fragmentation, coalescence and reconstruction/consolidation. Early diagnosis and treatment is essential to prevention of the typical deformities of the Charcot Foot.

The total contact cast is of vital importance for the management of Charcot arthropathy of the foot and ankle, as it serves to protect and stabilize the foot. Furthermore, the total contact cast helps to preserve shape and minimize progression of Charcot changes. Mechanical protection is the key element of conservative therapy, but surgical reconstruction of morphologic abnormalities may be necessary to obtain optimal functional outcomes.