Surgical issues in the treatment of diabetic foot

Dijabetičko stopalo spada u najčešće komplikacije šećerne bolesti. U dijagnostici i liječenju aktivno bi trebali učestovati: liječnik opće medicine, internist dijabetolog, vaskulami kirurg, fizijatar, neurolog, bolesnik i članovi porodice. U ranoj fazi bolesti (bez ulceracija) dominiraju polineuropatske promjene koje bi trebao prepoznati svaki kliničar. Rano liječenje daje bolje rezultate, a i jeftinije je. U ljudi s tegobama u smislu tmjenja u stopalima, treba učiniti GUK i urin na šećer i aceton (ili bolje OGTT krivulju), jer se može raditi o novootkrivenom dijabetesu. Prilikom pregleda karakteristični su pandžasti prsti i "spuštene" metatarzalne kosti stopala. Prsti mogu biti edematozni (spontana venska simpatektomija). Koža je suha i topla zbog vazodilatacije i gubitka sudomotome aktivnosti (spontana arterijska simpatektomija). Radi eventulnog prepoznavanja periferne arterijske bolesti, ambulantno bi trebalo učiniti ultrazvuk arterija, što se inače primjenjuje u zapadnim zemljama. Džepni Doppler je jednostavan za primjenu, relativno jeftin i rukovanje njime ne zahtijeva posebnu edukaciju. Internist dijabetolog liječenjem dijabetesa na adekvatan način umnogome odgađa pojavu komplikacija od kojih su najčešće dijabetska nefropatija, retinopatija i kardiovaskularne bolesti. Potonje imaju redovno teži tijek i u mnogome utiču na skraćenje života bolesnika. Kirurško liječenje dijabetičkog stopala je višeznačno: a) u ranoj fazi ekscizija klavusa, odstranjivanje neinficiranih ulkusa uz resekciju glavica pojedinih metatarzalnih kostiju; b) u poodmakloj fazi - ekscizija nekrotičnih i upaljenih mekih tkiva, uz poštedne otvorene amputacije, sa ili bez stavljanja kožnih transplantata. U svrhu liječenja se primjenjuje hodni gips ili "cipela", u najnovije vrijeme izrađene od plastične pjene. Na osnovu angiološke procjene i angiografije, obično u ovoj fazi poduzimaju se operacije bypassa u svrhu spašavanja ekstremiteta; c) hitna stanja sa osteomijelitičnim i gangrenoznim promjenama na okrajinama praćena su često sepsom, hiperglikemijom i ketoacidozom. Indicirana je hitna regulacija dijabetesa, antibiotici iv i otvorene (giljotinske) ili velike amputacije - natkoljenica ili potkoljenica. Fizijatar učestvuje u proteziranju i rehabilitaciji oboljelog. Razgibavanje paretičnih ekstremiteta, kontraktura, vježbe jačanja hipotrofične muskulature, umnogome doprinosi i boljem psihičkom stanju i samopouzdanju rehabilitiranog. Bolesniku trebaju pomagati i članovi njegove porodice. Uz redovno uzimanje preporučenog insulina, često je potrebna i redovna kontrola hipertonije. Neki bolesnici nisu u stanju sami sebi davati injekcije, a neki mjeriti tlak, iako imaju tlakomjer. Radi dijabetske retinopatije, oni često slabo vide, pa im je potrebna tuđa pomoć. Isto se odnosi i na njegu stopala.Diabetic foot appears as one of the most serious complications in diabetes. Pathological sequences demand that several sorts of medical specialists take part in the treatment: internist, orthopedic surgeon (and podiatrist), vascular surgeon, neurologist, general practitioner, patient himself and his family members. At an early stage of the disease (foot without ulcers) neurological changes dominate, which could be recognized by anyone familiar with diabetic foot. An early beginning of treatment gives better results and is much cheaper. Patients with a seizure of "tingling sensation" in feet have to undergo blood sugar and urine teste (even better OGTT test). At inspection "the claw toes" and "lowered metatarsal parts" of feet present. Venous sympatectomy provokes local swelling and arterial sympatectomy- dry skin (without sweating). To determine peripheral arterial disease a Doppler examination of legs could be undertaken in every out-patient department. Pocket-Doppler appliance is simple to use, inexpensive and does not demand special education. Internist Early diabetes treatment puts off the beginning of complications such as nephropathy, retinopathy and cardiovascular complications. Hyperglycemia on the contrary aggravates the appearance of illness and abbreviates patients life. Surgical treatment of diabetic foot is important in several ways: a) at an early stage-excision of "corns", clavus or infected superficial ulcers and resections of the heads of metatarsal bones, b) at the later stage-excision of necrotic skin and parts of soft, opened toe amputations. The foot healing can be increased in speed by using casts. If defects heel, patients temporary wear a "healing shoe" made of plastic material. In case of a peripheral arterial disease bypass operations have to be parformed to save a part of the leg ("limb salvage"). c) Osteomyelitis and gangrene of toes and metatarsus are often accompanied by septicaemia, hyperglycemia and ketoacidosis. In such circumstances antibiotics are used intravenously and ketoacidosis must be treated at the same time. Opened amputations are obligatory. Orthopedic surgeon (or podiatrist) takes part in rehabilitation and advising the patient about his artificial limb. Special exercises help patient overcome his contracted joints and hypotrophic muscle become stronger. This contributes not only to patient\u27s better psychological state, but also to his or her self-confidence. Patient himself and his family members. Taking insulin regularly and checking blood pressure are mainly done by the patient himself. Yet, some people cannot inject themselves nor mesure blood pressure. Diabetic retinopathy or cataracta often cause blindness, making those people dependent on other persons. Also, they are not able to take care about their ill feet