When Wounds Require Multidisciplinary Care
Management of the diabetic foot is a tremendous challenge. It has been estimated that the annual healthcare costs of caring for the diabetic foot range in the billions.1 Approximately 15 percent of diabetic patients will develop a foot or leg ulceration at some point during the course of their disease and 50 percent of those patients suffer reulceration within 18 months.2 Researchers have observed that the prevalence of neuropathy in the diabetic population is 33.5 percent, the prevalence of vascular disease is 12.7 percent and the prevalence of foot ulcer is 4.75 percent.3
While the debate on a standardized ulcer classification continues, diabetic foot ulcerations have a variety of possible causes, including structural deformity, increased pressure and decreased circulation. However, neuropathy may be the most common risk factor with patients for diabetic infections. Paul Brand, MD, noted this when he discussed the “gift of pain,” which is absent in this patient population. “These patients can quite literally wear a hole in their foot in the same fashion where most people wear a hole in their sock,” adds David G. Armstrong, DPM, MSc, PhD.
Neuropathy in the diabetic patient results from abnormalities in the polyol pathway, problems with the perineural microvasculature, excessive protein kinase C activation and oxidative stress.4 Podiatrists should have a strong understanding of peripheral neuropathy, a devastating consequence of diabetes. Accordingly, these patients should see endocrinologists for diabetes control and neurologists for further diagnosis and treatment.
While vascular disease is not, in and of itself, a major risk factor for development of diabetic foot ulcers, it is associated with poor wound healing.5 In the presence of circulatory disease, one should refer the patient for vascular assessment and possible reconstruction. When patients present with gangrene, making an immediate referral for revascularization is essential in order to salvage as much of the foot as possible and reduce the risk of complete lower extremity amputation. Many cases of gangrene require some level of debridement and amputation. Digital amputation, transmetatarsal amputation, Symes amputation and below knee amputation are possible considerations.6 Appropriate vascular evaluation, reconstruction and treatment are essential to the optimum management of the ischemic diabetic foot wound.7
Lower extremity infections are frequent causes of substantial morbidity and mortality in the diabetic population. These infections consume a large portion of resources expended on diabetic complications.8 In fact, most lower extremity amputations stem from infection. While these infections may present as either monomicrobial or polymicrobial, gram positive bacteria predominate in these infections. Appropriate assessment, management and treatment are essential in the care of these infections and mandate a team approach, including infectious disease consultation and treatment.9
When A Patient Presents With Multiple Digit Gangrene
With this in mind, let us consider a couple of case studies of patients who require multidisciplinary care. We evaluated a 56-year-old female who had diabetes and multiple medical comorbidities. She required extensive medical and surgical evaluation. The patient initially presented with multiple digital gangrene and underlying necrosis (see photo on the left). She had severe peripheral vascular disease with multiple vessel occlusion and stenosis.