Diabetic Foot Ulcer: A Case Study Salvaging the Toe

Introduction

Diabetic foot ulceration, also termed as diabetic foot ulcers (DFU) is one of the most common complication in patients with diabetes.¹ As per the WHO report, the incidence of people suffering from diabetes is nearly 422 million and it is expected to rise by an additional 271 million by 2045.² The lifetime risk of a diabetic patient to develop a DFU is 15% to 25% with nearly 85% lower limb amputations occurring due to an infected non-healing DFU.^3,4 A spectrum of DFU is depicted in Figure 1 (Images a, b, c, d, e).

Case summary

A 44-year-old male with diabetes presented with an ulcer on his right great toe along with fever. Radiographs revealed osteomyelitis. An amputation of the right great toe had been recommended earlier. Instead, a treatment approach of surgical debridement, an effective antibiotic regimen, and optimal wound care practices, resulted in complete wound closure being achieved in 5 weeks.

Intervention

After debridement, the ulcer was dressed daily with plateletderived growth factor for 5 weeks. The antibiotic regimen was continued based on the pus culture and sensitivity report. Also, front-wedge offloading footwear was provided to support healing.

Discussion

Diabetic foot ulcers are one of the major complications of diabetes, responsible for most in-hospital days than any other complication of diabetes. Effective management of DFU is the need of the hour. The present case study highlights some of the important aspects which should be considered for the management of diabetic ulcers. The principles for effective diabetic ulcer management includes assessment of callosities, evaluation of ischaemia if needed, prompt vascular intervention,

prompt control of the infection according to pus or tissue c/s, sharp debridement of the necrotic tissue, wet-moist dressing, and proper off-loading of pressure from the wound by following non-weight bearing regime. In addition, post operative wound dressing should be performed diligently and tight blood glucose control should be maintained. Finally, specialists should provide clear instructions to the patients and their families, including adherence to the prescribed antibiotic regimen and the correct wound dressing techniques.

Table 1: Underlying causes of diabetic foot ulcer surveyed across two different clinics in Delhi (Data by: Bisht G S 2015 Senior Consultant Podiatry, Max Healthcare, New Delhi)

Apart from diabetes control, DFU management includes infection control, effective wound care, improvement in blood flow, and pressure relief.5 The wounds that are not properly managed can lead to infection, chronic wound development, and even be life threatening. For proper surgical wound care, patients must be kept under observation in hospital, which places a significant burden on medical specialists. For effective utilization of medical resources, patient self-care becomes very important. Medical specialists can educate patients regarding self-care procedures and periodically evaluate the wound.6,7 This approach not only relieves the burden on medical specialists, but also helps ensure the quality of surgical wound care.

Unfortunately, the current treatments for foot ulcers are inadequate, leading to complications and extended healing times. This results in DFU being considered a public health problem.^8-11 Also, every minute, DFU leads to the amputation of two lower limbs.¹² Effective treatment of DFU still needs more effectual therapeutics. In this paper, a case study with DFU is presented which highlights the essential stages for reliable wound management.

Case Study
Presenting complaints
A 44-year-old male, presented with a one-month history of a wound on the right great toe, a one-week history of fever, foulsmelling discharge from the wound, swelling of the right great toe and foot associated with pain, and uncontrolled blood sugar.

The patient reported that he was in good health until one month ago when he noticed hard skin on his right great toe. He cut it with a nail cutter, which developed into a superficial lesion. He applied Soframycin cream to the cracked skin daily, but, after 1 week he noticed that the lesion was not improving. He had consulted a physician, who advised daily dressing with Betadine ointment. After 7 days, the swelling in his right great toe gradually increased, accompanied by a small amount of foulsmelling discharge from the wound. He consulted the physician again, who started him on the antibiotic, cefixime and continued the daily Betadine ointment dressing. After another week, the patient developed fever, pain, and increased swelling in the right great toe and foul-smelling discharge from the wound. At this point, he consulted a surgeon, who advised admission and amputation of the great toe. However, the patient refused admission. Debridement of the ulcer was done, and daily dressing of wound was carried out, along with a course of oral antibiotics (Cefuroxime). Despite 4 days of debridement, there were no signs of improvement. Additionally, the foul-smelling discharge increased from the wound, patient reported mild fever and pain in the right great toe, and increased swelling of right foot. At this point, the patient came to the Podiatry Clinic

Known case of diabetes for 10 years on oral hypoglycaemicagents (OHA)

Patient was conscious, oriented, weak, and anxious. He was mildly febrile with a temperature of 99.7°F, pulse rate of 96/ minute, and blood pressure (BP) of 136/86 mm of Hg. His chest, cardiovascular system (CVS), and abdomen examination was normal.

There was an ulcer measuring 2cm in length, 3cm in width, and 1cm in depth on the medial side of the right great toe at the interphalangeal (IP) joint. The ulcer had moderate, foul-smelling, semi-sanguineous to purulent exudate. Bone was felt on probing. The base of the ulcer was covered with necrotic tissue, and the peri wound area was swollen with callous formation. The right foot was warm to touch, with mild tenderness of the right great toe. Swelling extended from the right great toe and foot up to above the ankle.

The dorsalis pedis and posterior tibial arteries were well palpable in both the lower limbs. However, the vibration sensation was diminished in both the feet over the metatarsophalangeal (MTP) joints and toes. X Ray of right foot, anteroposterior (AP), and oblique view showed: Osteomyelitis of base of terminal and distal end of proximal phalanx at IP joint of right great toe.

Patient was diagnosed with type 2 diabetes with peripheral neuropathy, diabetic nephropathy, and diabetic ulcer of right great toe with osteomyelitis.

Patient was advised admission for the management and debridement of ulcer by a surgeon. However, the patient refused admission and inpatient treatment because of financial constraints and other logistic issues, hence, he was managed on an outpatient department (OPD) basis. Regular debridement of the ulcer was done in the OPD, and necrotic bone segments were removed. For the initial 3 days, the patient was put on Clindamycin 300mg three times a day and Levofloxacin 500mg daily. Once the pus c/s report was available, the antibiotics were changed to Inj. Meropenem, 1gm twice daily for 7 days while Levofloxacin 500mg was continued for 4 weeks

Daily dressings were done with recombinant human plateletderived growth factor (rhPDGF). Initially dressings were done daily at the Podiatry Clinic for 1 week. The patient was then trained to do the dressings at home and advised to follow up at the clinic every three days for the next 2 weeks. After that, the patient followed up once a week.

Front-wedge offloading footwear was provide to relieve pressure from the ulcer area. (Figure 3).