Contents
Main forms of trophic ulcers
Trophic ulcers (long-term non-healing wounds) are the most common form of diabetic foot syndrome.
You should not put off going to the doctor and treating diabetic foot until later, as this syndrome can lead to atrophy of the limbs.
It is of fundamental importance that diabetic ulcers are divided into neuropathic (in patients with normal blood flow to the legs, and neuro-ischemic (or ischemic) – occurring against the background of impaired blood flow.
A small proportion of patients with diabetes suffer from leg ulcers – these ulcers are usually the result of venous disease (venous insufficiency).
What ulcers are more common?
Contrary to popular belief, neuropathic ulcers are more common, accounting for approximately 55-75% of all diabetic ulcers.
Why do trophic ulcers occur?
While severe disruption of blood flow can itself cause destruction (necrosis) of the skin, diabetic neuropathy itself does not destroy foot tissue. But it creates conditions for minor (and not so minor) injuries that the patient does not notice.
A patient with diabetes may cut himself while trimming his toenails and not feel pain, may not feel a foreign object in his shoe (a rock, a piece of glass, a forgotten sock, coins accidentally dropped into a shoe), may step on a thumbtack lying on the floor, and don’t feel it.
Unfortunately, all these examples are absolutely real in diabetes mellitus. For example, the author of these lines encountered the last type of injury (stepping on a button, not noticed by the patient) no less than 3 times during his practice.
Naturally, all these damages lead to the development of trophic ulcers.
Treatment of trophic ulcers
- Correct local treatment. Treatment of the wound with the application of a new therapeutic dressing is carried out daily or once every 1-2 days (depending on the condition of the wound and the type of treatment used).
a). The use of modern dressings (which do not stick to the wound, unlike gauze). Today, a large number of such materials are available, belonging to various classes – alginates, hydrophilic fiber, atraumatic meshes, polyurethane foam dressings, hydrogels, hydrocolloids, etc. The choice of dressing is made by a medical professional (a doctor or a nurse in a specialized office) based on an examination of the wound, X-ray data and etc.
a). Washing the wound with antimicrobial agents that do not damage growing tissues – such as a solution of miramistin, chlorhexidine, etc. We remind you that iodine, alcohol, brilliant green and potassium permanganate are contraindicated in diabetes, because slow down healing.
ç). Regular treatment of the wound by a doctor or nurse (removal of non-viable tissue, callus around the wound (often formed with neuropathic ulcers)). Usually carried out every 3-15 days.
- Protecting the ulcer from the stress of walking. As long as the patient steps on the wound, no matter what expensive medications or dressings are used, the wound will not heal. Unfortunately, even a few steps during the day can negate the results of the treatment. Most neuropathic ulcers are painless, so the patient does not feel like they are stepping on the wound, damaging it. To protect the wound, there are special unloading devices. The first to be used in Russia was the “half shoe,” in which there is no load on the forefoot when walking. But today, according to international and Russian recommendations, the most effective method of unloading is the unloading “boot” (Contact Cast, see figure on the right), made of polymer fixing materials (used today instead of gypsum). This method ensures faster wound healing, reduces the load not only on the forefoot, but also on the hindfoot, and allows you to work and lead an active lifestyle (unlike the “half shoe”).
- Proper use of antibiotics for wound infections (usually the selection of the drug is made based on the results of culture from the wound). Antibiotics are required in approximately 40-60% of patients receiving outpatient treatment for diabetic ulcers.
- Normalization of blood sugar levels (diabetes compensation). It is very important that a patient with diabetic foot syndrome constantly receives high-quality diabetes treatment.
Treatment of neuro-ischemic ulcers
To confirm the diagnosis, it is necessary to assess the patency of blood vessels using modern methods – usually ultrasound (ultrasound, duplex or triplex scanning of arteries), less often – angiography or multi-slice computed tomography, etc. Rheovasography (RVG) does not give reliable results and should not be used!
With this form of diabetic ulcers, all of the above conditions must also be met, but conservative treatment in this case is much less effective than for neuropathic ulcers. Healing is promoted to some extent by certain “vascular” drugs – vasaprostan (analogue – alprostan), and low molecular weight heparins (clexane, fraxiparin, etc.), but they are quite expensive and require experience in their use by attending physicians. Other “vascular” drugs are essentially useless in the treatment of neuro-ischemic ulcers.
The most effective way to restore blood flow is surgery on the arteries of the legs, eliminating the narrowing (bypass or balloon angioplasty), which since 2003 have become more available to patients with diabetic foot syndrome in Moscow. Abroad, patients with diabetes have been undergoing such operations for many decades. Intravascular interventions (balloon angioplasty), unlike bypass surgery, are performed under local anesthesia and do not require anesthesia.
The problem is that with a strong decrease in arterial blood flow, the probability of ulcer healing against the background of properly carried out conservative treatment is only 20-30%. Therefore, the question of surgical restoration of arterial patency is so relevant.