the journal of diabetic foot complications open access ... · the journal of diabetic foot...

Open access publishing The Journal of Diabetic Foot Complications

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Type 1 diabetic foot complications

Authors: Amit Kumar C. Jain, MBBS, D.DIAB, F.DIAB, DNB, FPS*

The Journal of Diabetic Foot Complications, 2016; Volume 8, Issue 1, No. 3, Pages 17-22 © All rights reserved.

Key words: Abscesses, Diabetic Foot, Necrotizing Fasciitis, Wet Gangrene

Corresponding author

* Amit Kumar C. Jain, MBBS, D.DIAB, F.DIAB, DNB (General Surgery), FPS (Podiatric Surgery) Consultant General Surgeon, Diabetic Lower Limb and Podiatric Surgeon Assistant Professor Department of Surgery St John’s Medical College Bangalore, India 560034 Email: [email protected]

Abstract:Diabetic foot problems are an unfortunate complication of diabetes, and their incidence is increasing worldwide. Diabetic foot ulcers (DFU) affect 15% of patients with diabetes during their lifetime. For years DFUs have been commonly categorized through the Wagner classification. Recently, a new diabetic foot classification was proposed that evaluates the diabetic foot beyond ulceration. This classification includes all the common diabetic foot complications seen in day-to-day practices. Just the way diabetes mellitus is classified into Type 1 diabetes mellitus, Type 2 diabetes mellitus, and others, this new diabetic foot classification categorizes diabetic foot complications into three simple types. This study highlights various Type 1 diabetic foot complications seen in our practice, and represents the first time this type of study is presented in the literature.

Diabetes is one of the major non-communicable diseases affecting people worldwide, and it is one of the most challenging health problems in the 21st century.1 The number of people with diabetes worldwide was estimated at 131 million in 2000; it is projected to increase to 366 million by 2030.2

Approximately 3.1 million people in England have diabetes.1 Diabetes is a very common disease in India, with a prevalence of 12%-17% in the Indian urban population and a prevalence of 2.5% in the rural population.3

Diabetes related foot disease remains one of the most frequent causes of diabetes specific hospital admissions.4 Every year 5% of diabetic patients will develop a foot ulcer.5 Approximately 15% of all diabetics will develop some foot problem during the course of their illness.5 For many years, Wagner’s classification has been a popular classification through which DFUs were being studied.6,7,8

This author’s classification for diabetic foot complications, Table 1, is a new and simpler classification, is easy to understand, and includes all the common diabetic foot complications.6,7,9,10

According to this new classification, Type 1 diabetic foot complications are the most common complication seen in hospitalized patients in India.7,11 Type 1 diabetic foot complications

INTRODUCTION

Table 1. Author’s new classification of diabetic foot problems.

Type of Complications Lesions

1Type 1 Diabetic foot complications [Infective]

Cellulitis, Wet Gangrene, Abscess, Necrotizing Fasciitis, Osteomyelitis, etc.

2Type 2 Diabetic foot Complications [Non-Infective]

Non-healing Ulcers, Peripheral Arterial Disease, Hammer Toes, Entrapment Neuropathies, Diabetic Neuro-Osteoarthropathy, etc.

3 Type 3 Diabetic foot complications [Mixed]

Example -Charcot Foot with Infected Ulcer, Non-healing Ulcer with Osteomyelitis, etc.

Open access publishing The Journal of Diabetic Foot Complications, 2016; Volume 8, Issue 1, No. 3, Pages 17-22

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account for 86.6% to 91.06% of patients with diabetic foot problems admitted to the hospital.7,11 Complications include, for example, wet gangrene, cellulitis, abscess, and necrotizing fasciitis. Type 1 diabetic foot complications can occur either in isolation or in combination.

Various studies have shown that Type 1 diabetic foot complications are the most common cause for major amputations.7,11 In the Jain et al. series7, all major amputations done had Type 1 diabetic foot complications. In the Kalaivani series,11 75% of the major amputations done in the diabetic foot had Type 1 diabetic foot complications. The major amputation rate in Type 1 diabetic foot complications ranges from 8.89% to 13.39%.7,11 This article briefly reviews the common Type I diabetic foot complications seen in busy diabetic foot centers.

WET GANGRENEGangrene is a form of tissue necrosis with

added putrefaction.12 There are three main types of gangrene that affect the extremity. They are dry gangrene (ie, with or without secondary infection), gas gangrene, and wet gangrene.12

Wet gangrene of the foot is one of the characteristic lesions seen in diabetes and is sometimes called “Diabetic gangrene”.13 Wet gangrene is often seen in a well vascularized foot13 and is easily distinguishable from dry gangrene seen in arteriosclerosis of the large vessel.14

The moist appearance of the affected part, along with gross swelling and blistering, characterizes the wet gangrene. This type of gangrene develops rapidly and is almost painless because of the associated neuropathy.13

Wet gangrene is believed to develop from thrombosis of the small vessels due to infection.13 The affected part is soft, swollen, putrid, necrotic, and darkened to black color. The affected part (ie, digit or toe) is engorged with blood which favors the rapid growth of putrefactive bacteria.12 There is often a foul smell, and the toxins produced from the bacteria can get absorbed, producing the systemic manifestation of septicemia.12

Clinically, there is no clear line of demarcation in wet gangrene (Figure 1). Histologically, there is liquefaction necrosis of tissue.14

Wet gangrene is one of the common causes of amputation in the diabetic foot. The incidence of wet gangrene in recent studies shows a range from 31.3% to 35.7%.7,11 In one study11 it is the most common Type 1 diabetic foot complication seen in hospitalized patients for diabetic foot problems.

ABSCESSESAbscess in the diabetic foot can occur

either in the dorsum (Figure 2) or on the plantar aspect of the foot. Abscesses can also develop at the nail fold area (ie, paronychia) and web spaces.15 The entry of infection, especially on the plantar aspect, is usually from a trauma like a nail puncture or foreign body injury that occur

Figure 1. Wet Gangrene of 2nd toe of the right foot (note that there is no line of demarcation).

Figure 2. Abscess over the dorsum of the left foot.


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in neuropathic feet. The insensitivity allows such injury to go unrecognized.

Infections in the web spaces are insidious due to poor foot hygiene with accumulation of moist detritus or fungal infection in the inter-digital web spaces. Web space abscesses are dangerous because of the proximity to the digital vessels.15 On the plantar aspect of the foot, the central space is most commonly involved as compared to medial or lateral space abscesses. Many times the web spaces, or the central space infection, can cause thrombosis of the vessels leading to digital gangrene.15

In the Jain et al. series7 foot abscesses were the most common Type 1 diabetic foot complication seen in hospitalized patients and accounted for 42.2% of the cases. In another study by Jaykar et al.3 the most common mode of presentation of diabetic foot complication was again abscesses.3

TINEA PEDISTwo common fungal infections affecting the

diabetic foot are tinea pedis (ie, athletes foot) and onychomycosis (ie, fungal nail infection).16 Approximately 15% of the population has a podiatric fungal infection at any given time, and over 70% of individuals will experience foot-based fungal infection over their lifetime.17 The prevalence of diabetes among the patients with tinea pedis is around 24.8%.18 In fact, people with diabetes will get tinea pedis and onychomycosis 2.5-2.8 times more frequently than non-diabetics.19

Tinea pedis is most commonly caused by trichophyton rubrum (80%) and trichophyton interdigitale (15%) and less likely due to epidermophyton floccosum and microsporum.16 The three variants of tinea pedis are interdigital type, moccasin type, and vesiculobullous type.18 Interdigital tinea pedis is the most common form and often manifests in the fourth web space (Figure 3) and may spread to the undersurface of the toes.18

Tinea pedis and onychomycosis can lead to serious complications. In onychomycosis, the thick, sharp, brittle nail can pierce the skin

resulting in a secondary infection. Tinea pedis can create inflammation and fissuring that leads to breaches in the epidermis. This can produce a portal of entry for a bacterial infection leading to abscess, cellulitis, and gangrene of the digits. Therefore, one should not underestimate these conditions. Most often these two conditions are often ignored by the treating doctors. Even in the two studies done on this new classification,7,11 there was no mentioning of tinea pedis in the cases, and it is obvious that they were probably not recorded in the case sheets.

OSTEOMYELITISThis complication is a bit less common

than the Type 1 diabetic foot complication and is more frequently seen in Type 3 diabetic foot complications where it can occur from a non-healing ulcer. The osteomyelitis in the Type 1 diabetic foot is frequently a sequelae of an underlying abscess (Figures 4 and 5) and very rarely is from a haematogenous route. The incidence of osteomyelitis in the Type 1 diabetic

Figure 3. Tinea Pedis (inter-digital type) involving 4th web space of the right foot.

Figure 4. Sausage shaped great toe of the left foot (patient had underlying abscess and was on oral antibiotics, pre-scribed by the physician, for the prior three weeks).


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foot complications is around 2.68%.11 In another series of Jain et al.,20 9.52% of patients with osteomyelitis occur secondary to an abscess, in comparison to 90.48% that develop in an ulcer.

CELLULITISLower limb cellulitis is a common reason

for medical admission and causes significant long term morbidity.21 Venous eczema and tinea pedis are recognised risk factors for developing lower limb cellulitis.22 Cellulitis is common among patients with diabetes.23 The relative frequency of foot cellulitis is more than nine times greater in diabetics than in non-diabetics.15 Most often, this superficial soft tissue infection is caused by gram positive organisms like streptococcus and staphylococcus.23

The common symptoms of cellulitis (Figure 6) are swelling of the lower limb, pain, and

redness of the skin.24 Local examinations reveal tenderness, pitting oedema, and a local elevation in temperature.21,24 Systemic manifestations such as fever, tachycardia, and hypotension are present in up to 40% of the cases.25 Cellulitis is often treated conservatively with antibiotics until local or systemic complications occur. Cases that do not respond to antibiotics, or that are more severe, may progress to necrotizing fasciitis.21

NECROTIZING FASCIITISNecrotizing fasciitis (Figure 7) is a severe

form of a soft tissue infection involving superficial and deep fascia.26,27 This disease spreads rapidly and can involve the whole limb within hours.28 Necrotizing fasciitis can be classified into two types.26 Type 1 necrotizing fasciitis is a polymicrobial infection, and Type 2 necrotizing fasciitis is a monomicrobial infection caused by a streptococcus bacteria.27

Several predisposing factors, such as diabetes mellitus, alcohol, and chronic liver disease contribute to necrotizing fasciitis.26,29 Diabetes was present in up to 64% of patients affected with necrotizing fasciitis.26 The overall incidence of necrotizing fasciitis in diabetic foot complications in developing countries like India varies from 8.89% to 27.67%.7,11

In the early clinical course of the disease, the presentation is similar to the pattern found in cellulitis, and sometimes there is paucity of cutaneous findings.30,31 A high index of suspicion

Figure 5. The x-ray of the left foot of the above patient in Figure 4. (note the extensive osteomyelitis [Amit Jain’s Type 1C diabetic foot osteomyelitis]).

Figure 6. Cellulitis affecting the right foot and leg.

Figure 7. Necrotizing Fasciitis affecting the entire left lower limb (note the necrosis over the leg and thigh on the medial aspect; patient also had necrosis over posterior and lateral parts of the leg and thigh; cellulitic changes over the entire limb and blisters over leg can be well appreciated in the Figure).


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is therefore required.31 In cellulitis, the infection involves the dermis and subcutaneous tissue, whereas in necrotizing fasciitis, it starts at the level of the subcutaneous fat and deep fascia.29

Rapidly spreading erythema, oedema, and severe pain that is out of proportion to the nature of the lesion, are characteristics of necrotizing fasciitis.31 Extensive skin and fascial necrosis, and grey malodourous fluid referred to as “dishwater pus”, characterize necrotizing fasciitis.29,30,31

Necrotizing fasciitis is associated with a higher amputation rate and mortality. Mortality in various studies has ranged from 25% to 60% with limb amputation as high as 39%.26 In one of the largest series on necrotizing fasciitis from an

expert diabetic limb salvage center,27 necrotizing fasciitis resulted in a 26.4% incidence of major amputation with mortality of 6.8%.27 Aggressive debridement is the key to a successful outcome27,30 along with prompt detection.

CONCLUSIONDiabetic foot problems are one of the most

feared complications from diabetes. Type 1 diabetic foot complication is the most common type of complication seen in hospitalized patients, ranging from 86.6% to 91.06% occurrence. Unfortunately, major amputations often become necessary in Type 1 diabetic foot complications, ranging from 8.89% to 13.39% of cases.

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3. Jaykar RD, Kasube PS, Kakani NV. Prospective study of infections of foot in diabetic patients. Int J Recent Trends sci Tech. 2014;10(2):389-395.

4. Gooday C, Murchison R, Dhateriya K. An Analysis of clinical activity, admission rates, length of hospital stay and economic impact after a temporary loss of 50% of the non-operative podiatrists from a tertiary specialist foot clinic in the United Kingdom. Diabetic Foot and Ankle. 2013;4:21757.

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9. Jain AKC, Joshi S. Diabetic foot classifications: review of literature. Medicine science. 2013;2(3):715-721.

10. Kalaivani V, Vijayakumar HM. Diabetic foot in India- Reviewing the epidemiology and the Amit Jain’s classifications. Sch Acad J Biosci. 2013;1(6):305-308.

11. Kalaivani V. Evaluation of diabetic foot complication according to Amit Jain’s classification. JCDR. 2014;8(12):7-9.

12. Mohan H. Textbook of pathology. 3rd ed. Jaypee Brothers, India, 1998.

13. Faris I. The management of the diabetic foot. Churchill Livingstone, 2nd edition, UK, 1991.

14. Kozak GP, Campbell DR, Frykberg RG, Habershaw GM. Management of diabetic foot problems. 2nd ed. WB Saunders, Philadelphia, 1995.

15. Bowker JH, Pfeifer MA. In: Levin and O’Neal’s the diabetic foot. 7th ed. Mosby, Philadelphia, 2008

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18. Mansoor AA, Hamdi KI. Tinea pedis among diabetics in Basrah: prevalence and predictos. J Chinese Clin Med. 2007;2(9):488-492.

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References (cont.)

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