Guidelines for the diagnosis and treatment of diabetic foot in China
China Healthcare International Association for the Advancement of Diabetes Foot Disease
Chinese Medical Journal, 2017,97(04): 251- 258.
Diabetes foot is one of the serious chronic complications that cause disability and death in diabetic patients in China. Its incidence is high, treatment is difficult, and it costs a lot. At present, China mainly refers to the guidelines developed by the international podiatrists and the American Diabetic Podiatry Group. However, because China’s diabetic foot has its own characteristics, the China Healthcare International Exchange Promotion Association organized a national foot disease-related expert to draft a guideline for the diagnosis and treatment of diabetic foot.
1. Concept of diabetic foot and high-risk foot
Diabetes foot: foot infection, ulcer and (or foot) caused by distal nerve abnormalities of lower extremities and varying degrees of vascular disease in diabetic patients Deep tissue destruction.
High risk of diabetes: Diabetic patients do not have foot ulcers but peripheral neuropathy, regardless of the presence of foot deformity or peripheral arterial disease or history of foot ulcers or amputation (toe).
Second epidemiology of diabetic foot and lower extremity arterial disease
Foreign data show that in all non-traumatic low amputation operations, diabetes patients account for 40% to 60%. Of the low-end distal amputations associated with diabetes, 85% occur after a foot ulcer. The prevalence of foot ulcers in diabetic patients is 4% to 10%. Domestic multi-center research data show that the proportion of lower extremity arterial disease in Chinese patients over 50 years old is 19.5% . A single-center study showed that the proportion of lower extremity arterial disease in patients over 60 years of age was 35.4% . The incidence of new ulcers in Chinese patients with diabetes was 8.1% in 1 year, and the incidence of new ulcers in diabetic foot ulcers was 31.6% in 1 year .
Three, clinical manifestations of diabetic foot
Neuropathy: dry skin without sweat, tingling, burning, numbness, loss of feeling or loss, sore Change the shape, feel the cotton wool when walking.
Impact of lower limb ischemia: skin malnutrition, muscle atrophy, poor skin dryness, decreased skin temperature, hyperpigmentation, weakened or disappeared arterial pulsation of the extremities, patients may have intermittent claudication symptoms of the lower extremities. As the lesion progresses, rest pain may occur, gangrene appears at the toe end, ulceration occurs in the compression site of the heel or metatarsophalangeal joint, and some patients may have limb infection.
4. Auxiliary examination of diabetic foot
(1) Neurological examination
Diabetic peripheral neuropathy (DPN) can pass the following The method is diagnosed.
1.10 g nylon wire inspection method:
This method is a relatively simple sensory nerve detection method, which must have a special nylon wire (which bends 45° to produce 10 g pressure). Before the start of the examination, the nylon wire is usually tested 2 to 3 times in the palm or forearm of the patient, so that the patient feels the normal feeling of pressure of 10 g of nylon wire. The test should be carried out on both sides of the foot; the pressure applied to each checkpoint is about 2 to 3 s, and the time should not be too long; the examination site should avoid sputum, blisters and ulcers; the recommended test points are 1, 3, and 5. The abdomen, the first, third, and fifth metaphyseal heads, the center of the foot, the lateral side of the foot, the heel and the dorsal and the first and second metatarsal bones, a total of 10 points, patients with 2 or more abnormalities are considered abnormal.
This test is a semi-quantitative examination of deep tissue sensations. Before proceeding, the vibrating tuning fork handle is first placed at the patient’s mastoid to allow it to feel the vibration of the tuning fork, and then placed in the bony prominence of the biped for comparison (the inner side of the first metatarsophalangeal joint, the inner and outer iliac crest).
3.Reflection, pain sensation, temperature sensation:
These three methods of examination can also be applied to the diagnosis of diabetic peripheral neuropathy.
4. Nerve conduction velocity (NCV):
In the past, it was considered the “gold standard” for the diagnosis of DPN . It is generally believed that two or more NCV slowers combined with other symptoms and signs Check to consider the presence of DPN.
(2) Vascular lesion examination
1. Physical examination:
After palpation, sputum and femoral condyle, dorsal artery and/or posterior tibial artery pulsation to understand lower extremity vascular disease; Buerger test to understand lower limb ischemia.
2. Skin temperature check:
Infrared skin temperature test is a simple and practical method to evaluate local blood supply. It is best to use temperature difference to judge limb blood supply.
3. The ratio of radial artery to radial artery blood pressure, also known as ankle brachial index (ABI):
ABI reflects the blood supply status of the limb, with a normal value of 0.9 to 1.3, and 0.71 to 0.89 as light. Degree ischemia, 0.5-0.7 is moderate ischemia, <0.5 is severe ischemia, and patients with severe ischemia are prone to gangrene of lower limbs. If the brachial artery systolic pressure is too high, such as above 200 mmHg (1 mmHg= 0.133 kPa) or ABI> 1.3, patients should be highly suspected of lower extremity arterial calcification, some patients with normal ABI may have false negatives, can use treadmill exercise test Or toe arm index (TBI) determination to correct.
4. Transcutaneous oxygen pressure (TcPO2):
TbPO2>40 mmHg in normal human foot; if <30 mmHg indicates insufficient blood supply to the surrounding area, the foot is prone to ulceration, or existing ulcer It is difficult to heal; if TcPO2 < 20 mmHg, there is almost no possibility of foot ulcers.
5. Vascular imaging:
includes arterial color Doppler ultrasonography, CT angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA). Vascular color Doppler examination is non-invasive and simple. It can understand the condition of arteriosclerotic plaque and the presence or absence of arterial stenosis or occlusion. It is suitable for large-scale screening of vascular lesions. CTA and MRA have clear imaging features that can show the presence or absence of stenosis or occlusion of blood vessels, but the accuracy is lower than DSA. For patients with normal renal function, CTA can be used as the first choice for imaging examination of diabetic lower extremity vascular disease. DSA is still the gold standard for the diagnosis of lower extremity vascular disease, which can accurately show the arterial occlusion and the establishment of collateral circulation, which plays an important role in the choice of surgical treatment.