Is my foot wound infected photo
Are there alternatives to amputation?
Our author Dr. Karl Zink says: It is better to ask where there are no alternatives to amputation. Using very clear examples, he names the risks and opportunities of conservative foot wound treatment with wound care, antibiotic therapy, etc.
Amputations are usually the end of a long period of suffering for the patient concerned. Around 53,000 people with diabetes have to undergo an amputation every year (as of 2010). 15,000 of these amputations are major amputations: These people lose their leg in the area of the lower leg, thigh or knee joint. The other 38,000 amputations are minor amputations - here the amputation is limited to the feet, mostly toe amputations (28,000).
"Armstrong": many examples
Foot wounds in diabetic foot syndrome can be classified according to the Armstrong classification (see table 1): The depth of the wound is shown on the horizontal line, and on the vertical line it is described whether there is a circulatory disorder or an infection or both.
As can be assumed, the further you go to the right and the further down you go, the greater the risk of amputation. In the lower right corner, the amputation probability is 100 percent. The options that exist for treating diabetic foot syndrome can best be explained using case studies.
Example 1 (red area)
If you ask whether there are alternatives to amputation, it is easier to ask yourself where there are no alternatives - in other words, as doctors say, where the indication for amputation is definitely given.
First and foremost, serious, non-treatable circulatory disorders are to be mentioned here, which have led to tissue destruction and as a result of resting pain that can no longer be sufficiently relieved even by strong painkillers. The possible foot findings range from smaller ulcers that no longer heal to dead, now black tissue parts - necrosis of individual toes or entire parts of the foot.
Example 2 (red area)
The next to be mentioned are situations in which an infection has settled on an existing, usually chronic wound. The infection then spreads into deeper tissue layers in the foot, the bacteria break down and liquefy the tissue; this alone leads to tissue destruction.
In addition, the inflammatory reaction leads to vascular occlusions, and necroses also develop as a result. The clinical picture that results from this is called wet gangrene. In this case, an amputation is required to stop the infection from spreading and to remove the irreversibly destroyed tissue.
Example 3 (green area)
The situations in which no amputation is required are also actually clear. These are wounds that do not reach any deeper foot structures and in which there is also no higher-grade circulatory disorder. Healing can usually be achieved here. It is important with these wounds that they heal quickly and do not become chronic. Even with a superficial wound, there is always the risk of infection and thus the development of moist gangrene - the patient very quickly slips into sample group 2.
The development of a chronic wound can have several causes:
- Circulatory disorder: There may be a circulatory disorder that affects the healing of the wound. Therefore, a circulatory disorder must always be ruled out.
- Insufficient pressure relief: Neuropathic foot wounds are mostly caused by pressure damage caused by shoes that are too tight, but sometimes also by internal pressure caused by deformed feet or by long-term effects of neuropathy.
To rule out a circulatory disorder, the pulses must be palpated and the blood pressure measured on the ankle or toe. Next, the extent and location of the bottlenecks and occlusions can be determined using a color Doppler examination. As an experienced examiner, you get a good assessment of whether the blood flow is sufficient or whether an expansion of the arteries or the creation of a bypass is necessary.
To relieve pressure, appropriate relief shoes or bandage shoes, prefabricated orthotics or specially built orthotics must be worn with existing wounds. Unfortunately, the wearing time of the relief aids is insufficient for many patients and therefore the healing progress is often not given. That is why plastering the leg with a Total Contact Cast (TCC) is very effective, as this aid cannot be removed by the patient himself.
Another path that is increasingly being followed by competent foot surgeons is the surgical correction of incorrect loads caused by shortened tendons. This includes wounds on the tip of the toes that can be quickly healed by severing the long flexor tendon.
It is also possible to extend the extensor tendon of the big toe in order to reduce the pressure on the metatarsal head of the ball of the big toe so that the wound can heal here. Unfortunately, such interventions are too seldom considered because wound healing disorders are feared. If the blood circulation situation is clarified beforehand and then the loss of sensitivity is taken into account, these operations can also be successful in patients with diabetes.
Example 4 (orange area):
A patient comes with a deep wound, the bone is clearly visible in the wound, pus is already flowing out of the wound, the area around the wound is reddened, the X-ray shows a bone that has been partially destroyed by the bone infection.
The foot wounds that are infected are like the icebergs: only über are visible above water, the remaining ⁹⁄₁₀ are under water and not visible. The patient often only sees a small, z. B. 1 cm wound on the sole of the foot - most of the infected tissue extends deep into the foot and is not visible from the outside. In this case there are two treatment options: conservative treatment with pressure relief and administration of antibiotics or amputation or removal of the diseased bone.
The probability of healing without amputation is rather low and carries the risk of the infection spreading further. More amputations may then have to be carried out later than at the present time. The safer way here would be amputation, but then it leads to the loss of part of the foot.
Example 5 (blue areas):
Here you can see that the amputation probability is significantly lower, but not zero either. Here all measures must be taken to bring the wound to healing. These measures would be:
Optimal pressure relief
An optimal pressure relief can be achieved by plastering. Ready-made industrial orthotics and individual orthotics also provide excellent pressure relief if they are optimally adapted and worn over the long term. This can be supported by well-placed padding directly on the foot. Bandage shoes with cushioned inserts are somewhat worse. Relief shoes that have edges or are even not used as intended are to be rejected, e.g. B. Forefoot relief shoes for ulcers in the metatarsal area.
Optimize the blood flow situation if necessary
First of all, the blood flow situation should be determined by an ultrasound examination. If there is insufficient blood flow, balloon dilatation or, if this does not work, the creation of a bypass to restore blood flow is appropriate.
Optimal wound treatment
The wound must be treated with regular cutting out of the wound edges and freshening the wound bed. The wound treatment must be done moist.
Administration of antibiotics
Depending on the degree of inflammation and the infected structures, the patient is given antibiosis.
Well: Especially with deeper wounds, it must always be clear to the patient that waiting at any time can worsen the wound situation due to an infection.
Waiting makes everything worse
This cannot be safely avoided even with the best dressing technology and the best wound treatment. The thought that one could notice an emerging infection in good time is deceptive, since the early warning symptom pain is absent in polyneuropathy. If the patient with polyneuropathy experiences pain, it is usually a sign of an advanced, deep foot infection. Some types of bacteria, e.g. B. streptococci, manage to irretrievably destroy large pieces of tissue within a few hours. Anyone who then opts for conservative therapy must always bear this risk of infection with all the negative consequences.
It should also be borne in mind that antibiotic therapy must be maintained for a very long time in the case of bone infections to be treated - often for 4 to 8 weeks. This can lead to the cultivation of multi-resistant pathogens. Long-term administration of antibiotics can have effects on the gastrointestinal tract: from nausea and diarrhea to dangerous colon inflammation due to overgrowth of the intestine with bacterial strains that produce toxins (Clostridium difficile).
Find competent experts
Therefore, everything must be done to bring wounds to heal quickly with the above measures. Sometimes it is also possible and necessary to undertake a small surgical procedure in order to achieve the goal of freedom from wounds. Patients can find competent contacts for the treatment of diabetic foot wounds on the website of the Foot Working Group in the German Diabetes Society. Here doctors and patients will discuss the necessary and possible therapies together and also care for the patients in the chosen treatment path.
by Dr. Karl Zink | Senior physician
Diabetes Clinic Bad Mergentheim, Theodor-Klotzbücher-Straße 12, 97980 Bad Mergentheim, email: [email protected]
Published in: Diabetes-Journal, 2015; 64 (2) pages 22-25
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