Step By Step Treatment of Diabetic Foot-New Treatment Possibilities

This is a case where actual applied statistics will reveal a worse prognosis, despite all therapies that are already applied. Despite this calculated prognosis, the patient decision to save his foot was the best one. New medical therapies and surgical procedures could improve the prognosis for this kind of cases.


Background
There are quite a number of treatments available for the management of diabetic foot ulcers: local therapies, vasodilators, antibiotics, neuropathic and neurotrophic drugs, wound dressings, skin substitutes, growth factors and inflammatory modulators [1]. The majority of therapies target the treatment of diabetic foot ulcer, but a local intervention (surgical intervention) to address the local area and to remove ulcers and necrotic areas is often necessary. However, not only one treatment, but several interventions and serial procedures are necessary to be practiced in this situation in tentative of management of diabetic foot ulcers.
American Diabetes Association is the main professional association that aims to standardize [2] the intervention to prevent this complication of diabetes mellitus, but the spread of this disease is the main reason for increasing incidence and prevalence of minor and major amputation caused by diabetic foot ulcers [3,4].
Lower-extremity peripheral artery disease (PAD) is a complication of diabetes and occurs in 4.3-29% of all patients, not only diabetics, worldwide. In patients with critical limb ischemia (CLI), the resting metabolic need of tissue is not being met by the arterial supply and local gangrena is the main manifestation of this complication of diabetes mellitus. CLI exists in 1-2% of the PAD population and is defined as ischemic rest pain, non-healing wounds, or gangrene [1].

Case Report
This is a case presentation of a 68 years old patient who was hospitalized in our clinic in February of 2015.
This patient with known type 2 diabetes mellitus is presenting wounds in the region of single leg, left side of the plant straight appearance of necrotic ischemic purple of finger 5 and lesions located in region between finger 4 and 5, swelling and redness in the middle plantar region, which progressively worsened ( Figure 1).
History of main disease: This patient is 68 years old, with a 20 years history of type 2 diabetes mellitus, treated with insulin from 2002 and with multiple micro and macro-vascular complications (diagnosed over time).
Local examination of the foot: figures attached. The local exam Ultrasound doppler exam for distal artery: Charge buildup broadcast, severe level with numerous superficial femoral artery seriously stenoses in Hunter channel, in 1/3 distal average: subocclusion-Flow redness at the distal posterior tibia artery-requires arteriography (Figures 2 and 3).

Arteriography Result
Right arterial axus: common femoral artery: deep and superficial calcified plaque with a maximum of 50% on the whole length; Popliteal Artery presents proximal aneurismal dilatation, otherwise no injuries; Anterior Tibial Artery: crosse occlusion, occlusion of tibialperoneal trunk distal posterior and peroneal tibia artery reload after a few centimeters. Peronier Artery is permeable by distal occlusion. Occlusion of tibia artery is located back to ankle.

Left arterial axus:
Common and Profound Femoral arteries present plaque with a flux altered 30-40%; Occlusion of the superficial femoral artery at origin with a slow distal reload. Popliteal Artery and Ankle Axis without injuries, Paddies Artery is gracile.
The Arteriography was performed and the conclusion of radiologist and vascular surgeon-there is no therapeutic resolve for this level of lesion.
At the same time, local culture from plague reveals Methicillinresistant Staphylococcus aureus.
X ray investigation of right foot: Valgus deviation in the right toe, demineralization of the distal and medium phalanx of 5th finger, bone   Actual and standardised treatment was presented and adequately adapted for a better quality of life to this complex patient. The treatmet applied was: parenteral antibiotics using local culture (Ciprinol and Cefuroxime using dose adaptation considering renal function), vasodilators (pentoxifilinum), angioreologic substances (Vessel Due), chronic treatment for cardiovascular risks (statin, hypotensor adapted treatement), aspirin, neurotrophic drugs (complex of B vitamins and thictic acid). The tratament of type 2 diabetes melltius is with insulin analogs for a HbA1c, as better as possible, without hypoglicemic events.

Evolution
The patient refused an ample surgical intervention. Given the unfavorable wound evolution, the surgeon intervened and amputated 5th finger (Figures 5 and 6). Later evolution was still unfavorable and it was decided amputation of 4th finger too, with favorable local evolution. Wound toilet and local dressing were practiced daily with general support of antibiotics. General treatment was the same that is presented above.

Discussions
Despite unfavorable initial prognostic and despite the medical advice to amputate a large part of the limb, the patient was recovered with a minimal intervention. Actual stage of disease and actual risk factors expose this patient to a new amputation [5,6]. As vascular surgery is not applicable-this was the surgeon decision, only the medical treatment could help this patient to maintain actual state for a long time, as long as possible.
Some new therapies (as growth factors or stem cells) could be an innovative solution for this kind of patient [7], ideally before this stage of disease is diagnosed. We need a lot of other markers to diagnose this kind of pathology before the stage when a large amputation is necessary.
There are obviously advantages and disadvantages to each kind of wound treatment and multiple solutions for wound dressing are present (Miculickz pomade, 1% silver sulfsadiazine cream, zinc hyaluronate solution, bovine colagen, hyperbaric oxigen therapy, hydrocolloid dressing or synthetic skin substitutes). Most of them need a real confirmation in randomised studies. Adjuvant care of diabetic foot ulcers implies: systemic factors-control of hyperglycemia, control of infection, treatment of vasculopathies (sulodexide, cilostatazol) or local factors-peripheral neuopathies, control of pressure at foot level (custom-made orthesis and shoes) [8].