CC BY-NC-ND 4.0 · Rev Bras Ortop (Sao Paulo) 2020; 55(04): 389-396
DOI: 10.1055/s-0039-3402462
Artigos de Atualização
Tornozelo e Pé

Pé diabético. Parte 1: Úlceras e Infecções*

Artikel in mehreren Sprachen: português | English
1   Grupo de Cirurgia do Pé e Tornozelo, Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de São Paulo, Sâo Paulo SP, Brasil
› Institutsangaben

Resumo

As úlceras e infecções são complicações comuns nos pés dos pacientes diabéticos que já se encontram na fase tardia desta doença sistêmica que se tornou uma verdadeira epidemia do mundo moderno. Neste grupo específico de pacientes, são as infecções que constituem o principal fator envolvido na sequência de eventos que resultam na amputação do membro inferior. A neuropatia periférica (NC) constitui fator determinante na perda da sensibilidade protetora dos pés na fase tardia da doença e, por sua vez, favorece o desenvolvimento das úlceras plantares de pressão (UPP) e a destruição osteoarticular causado pela neuroartropatia de Charcot (NC). A obesidade, a doença arterial periférica (DAP) e a deficiência no sistema imunológico devida aos distúrbios metabólicos do diabetes desempenham papel adicional importante na morbidade desta doença, principalmente no que se refere à amputação dos membros inferiores. É importante para o médico ortopedista compreender que para tentar evitar estas complicações que costumam resultar na amputação da extremidade é necessário estabelecer estratégias de prevenção direcionadas, principalmente, para a educação do paciente diabético e também para medidas protetoras profiláticas.

* Trabalho desenvolvido no Grupo de Cirurgia do Pé e Tornozelo, Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil.




Publikationsverlauf

Eingereicht: 25. Juni 2019

Angenommen: 13. September 2019

Artikel online veröffentlicht:
27. April 2020

© 2020. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Sociedade Brasileira de Ortopedia e Traumatologia. Published by Thieme Revinter Publicações Ltda
Rio de Janeiro, Brazil

 
  • Referências

  • 1 Centers for Disease Control and Prevention. National Diabetics Statistics Report 2017. Department of Health and Human Services, Center for Disease Prevention and Control; 2017
  • 2 Hu FB. Globalization of diabetes: the role of diet, lifestyle, and genes. Diabetes Care 2011; 34 (06) 1249-1257
  • 3 Brodsky JW. The diabetic foot. In: Mann RA, Coughlin MJ. , editors. Surgery of the Foot and Ankle. 6th ed. St Louis, MO: Mosby; 1993: 278-283
  • 4 Amaral Junior AH, Amaral LAH, Bastos MG, Nascimento LC, Alves MJ, Andrade MAP. Prevenção das lesões de membros inferiores e redução da morbidade em pacientes diabéticos. Rev Bras Ortop 2014; 49 (05) 482-487
  • 5 Abbott CA, Carrington AL, Ashe H. , et al. North-West Diabetes Foot Care Study. The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med 2002; 19 (05) 377-384
  • 6 Prompers L, Huijberts M, Apelqvist J. , et al. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia 2007; 50 (01) 18-25
  • 7 Prompers L, Schaper N, Apelqvist J. , et al. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study. Diabetologia 2008; 51 (05) 747-755
  • 8 Wukich DK, Raspovic KM, Suder NC. Patients with diabetic foot disease fear major lower-extremity amputation more than death. Foot Ankle Spec 2018; 11 (01) 17-21
  • 9 Moulik PK, Mtonga R, Gill GV. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care 2003; 26 (02) 491-494
  • 10 Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet 2005; 366 (9498): 1719-1724
  • 11 Cavanagh P, Attinger C, Abbas Z, Bal A, Rojas N, Xu ZR. Cost of treating diabetic foot ulcers in five different countries. Diabetes Metab Res Rev 2012; 28 (Suppl. 01) 107-111
  • 12 Gibbons GW, Habershaw GM. Diabetic foot infections. Anatomy and surgery. Infect Dis Clin North Am 1995; 9 (01) 131-142
  • 13 Del Core MA, Ahn J, Lewis RB. , et al. The evaluation and treatment of diabetic foot ulcers and diabetic foot infections. Foot Ankle Int. 2018; 3 (1S): 13S-23S
  • 14 Robinson AH, Pasapula C, Brodsky JW. Surgical aspects of the diabetic foot. J Bone Joint Surg Br 2009; 91 (01) 1-7
  • 15 Wukich DK, Shen W, Raspovic KM, Suder NC, Baril DT, Avgerinos E. Noninvasive arterial testing in patients with diabetes: a guide for foot and ankle surgeons. Foot Ankle Int 2015; 36 (12) 1391-1399
  • 16 Wukich DK, Sadoskas D, Vaudreuil NJ, Fourman M. Comparision of diabetic Charcot patients with and without foot wounds. Foot Ankle Int 2017; 38 (02) 140-148
  • 17 Wukich DK, Raspovic KM, Suder NC. Prevalence of peripheral arterial disease in patients with diabetes Charcot neuroarthropathy. J Foot Ankle Surg 2016; 55 (04) 727-731
  • 18 Richard C, Wadowski M, Goruk S, Cameron L, Sharma AM, Field CJ. Individuals with obesity and type 2 diabetes have additional immune dysfunction compared with obese individuals who are metabolically healthy. BMJ Open Diabetes Res Care 2017; 5 (01) e000379
  • 19 Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW. Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients. JAMA 1995; 273 (09) 721-723
  • 20 Suder NC, Wukich DK. Prevalence of diabetic neuropathy in patients undergoing foot and ankle surgery. Foot Ankle Spec 2012; 5 (02) 97-101
  • 21 Peterson N, Widnall J, Evans P, Jackson G, Platt S. Diagnostic imaging of diabetic foot disorders. Foot Ankle Int 2017; 38 (01) 86-95
  • 22 Reiber GE. The epidemiology of diabetic foot problems. Diabet Med 1996; 13 (uppl 1, Suppl 1) S6-S11
  • 23 Lavery LA, Armstrong DG, Wunderlich RP, Mohler MJ, Wendel CS, Lipsky BA. Risk factors for foot infections in individuals with diabetes. Diabetes Care 2006; 29 (06) 1288-1293
  • 24 Richard JL, Lavigne JP, Sotto A. Diabetes and foot infection: more than double trouble. Diabetes Metab Res Rev 2012; 28 (Suppl. 01) 46-53
  • 25 Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996; 35 (06) 528-531
  • 26 Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJ. A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems. Diabetes Care 2001; 24 (01) 84-88
  • 27 Rossi WR, Rossi FR, Fonseca Filho FF. Pé diabético: o tratamento das úlceras plantares com gesso de contato total e análise dos fatores que interferem no tempo de cicatrização. Rev Bras Ortop 2005; 40 (03) 89-97
  • 28 Sheehan P, Jones P, Caselli A, Giurini JM, Veves A. Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Diabetes Care 2003; 26 (06) 1879-1882
  • 29 Lavery LA, Higgins KR, La Fontaine J, Zamorano RG, Constantinides GP, Kim PJ. Randomised clinical trial to compare total contact casts, healing sandals and a shear-reducing removable boot to heal diabetic foot ulcers. Int Wound J 2015; 12 (06) 710-715
  • 30 Armstrong DG, Lavery LA, Kimbriel HR, Nixon BP, Boulton AJ. Activity patterns of patients with diabetic foot ulceration: patients with active ulceration may not adhere to a standard pressure off-loading regimen. Diabetes Care 2003; 26 (09) 2595-2597
  • 31 Mueller MJ, Diamond JE, Sinacore DR. , et al. Total contact casting in treatment of diabetic plantar ulcers. Controlled clinical trial. Diabetes Care 1989; 12 (06) 384-388
  • 32 Blume PA, Walters J, Payne W, Ayala J, Lantis J. Comparison of negative pressure wound therapy using vacuum-assisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcers: a multicenter randomized controlled trial. Diabetes Care 2008; 31 (04) 631-636
  • 33 Fedorko L, Bowen JM, Jones W. , et al. Hyperbaric oxygen therapy does not reduce indication for amputation in patients with diabetes with nonhealing ulcers of the lower limb: a prospective, double blind, randomized controlled clinical trial. Diabetes Care 2016; 39 (03) 392-399
  • 34 Löndahl M, Katzman P, Nilsson A, Hammarlund C. Hyperbaric oxygen therapy facilitates healing of chronic foot ulcers in patients with diabetes. Diabetes Care 2010; 33 (05) 998-1003
  • 35 Bus SA, van Deursen RW, Armstrong DG, Lewis JE, Caravaggi CF, Cavanagh PR. ; International Working Group on the Diabetic Foot. Footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review. Diabetes Metab Res Rev 2016; 32 (Suppl. 01) 99-118
  • 36 Bus SA, van Netten JJ, Lavery LA. , et al. International Working Group on the Diabetic Foot. IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes. Diabetes Metab Res Rev 2016; 32 (Suppl. 01) 16-24
  • 37 Pound N, Chipchase S, Treece K, Game F, Jeffcoate W. Ulcer-free survival following management of foot ulcers in diabetes. Diabet Med 2005; 22 (10) 1306-1309
  • 38 Reiber GE, Lipsky BA, Gibbons GW. The burden of diabetic foot ulcers. Am J Surg 1998; 176 (2A, Suppl) 5S-10S
  • 39 Taylor SM, Johnson BL, Samies NL. , et al. Contemporary management of diabetic neuropathic foot ulceration: a study of 917 consecutively treated limbs. J Am Coll Surg 2011; 212 (04) 532-545 , discussion 546–548
  • 40 Laborde JM. Neuropathic plantar forefoot ulcers treated with tendon lengthenings. Foot Ankle Int 2008; 29 (04) 378-384
  • 41 Reiber GE, Boyko EJ, Smith DJ. Lower extremity foot ulcers and amputation in diabetes. In: Harris MI, Cowie CC, Stern MP. , et al., editors. Diabetes in America. 2nd ed. Bethesda, Md: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 1995: 409-428
  • 42 Raspovic KM, Wukich DK. Self-reported quality of life and diabetic foot infections. J Foot Ankle Surg 2014; 53 (06) 716-719
  • 43 Bagdade JD, Root RK, Bulger RJ. Impaired leukocyte function in patients with poorly controlled diabetes. Diabetes 1974; 23 (01) 9-15
  • 44 Wukich DK, Hobizal KB, Raspovic KM, Rosario BL. SIRS is valid in discriminating between severe and moderate diabetic foot infections. Diabetes Care 2013; 36 (11) 3706-3711
  • 45 Lam K, van Asten SA, Nguyen T, La Fontaine J, Lavery LA. Diagnostic accuracy of probe to bone to detect osteomyelitis in diabetic foot: a systematic review. Clin Infect Dis 2016; 63 (07) 944-948
  • 46 Aragón-Sánchez FJ, Cabrera-Galván JJ, Quintana-Marrero Y. , et al. Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 patients with histopathological confirmation of bone involvement. Diabetologia 2008; 51 (11) 1962-1970
  • 47 Lavery LA, Armstrong DG, Peters EJ, Lipsky BA. Probe-to-bone test for diagnosing diabetic foot osteomyelitis: reliable or relic?. Diabetes Care 2007; 30 (02) 270-274
  • 48 Morales Lozano R, González Fernández ML, Martinez Hernández D, Beneit Montesinos JV, Guisado Jiménez S, Gonzalez Jurado MA. Validating the probe-to-bone test and other tests for diagnosing chronic osteomyelitis in the diabetic foot. Diabetes Care 2010; 33 (10) 2140-2145
  • 49 Brodsky JW. Outpatient diagnosis and care of the diabetic foot. Instr Course Lect 1993; 42: 121-139
  • 50 Cierny III G, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clin Orthop Relat Res 2003; (414) 7-24
  • 51 Malhotra R, Chan CS, Nather A. Osteomyelitis in the diabetic foot. Diabet Foot Ankle 2014 05. DOI: 10.3402/dfa.v5.24445
  • 52 Sanverdi SE, Ergen BF, Oznur A. Current challenges in imaging of the diabetic foot. Diabet Foot Ankle 2012 3. DOI: 10.3402/dfa.v3i0.18754
  • 53 Lepäntalo M, Apelqvist J, Setacci C. , et al. Chapter V: Diabetic foot. Eur J Vasc Endovasc Surg 2011; 42 (Suppl. 02) S60-S74
  • 54 Pineda C, Espinosa R, Pena A. Radiographic imaging in osteomyelitis: the role of plain radiography, computed tomography, ultrasonography, magnetic resonance imaging, and scintigraphy. Semin Plast Surg 2009; 23 (02) 80-89
  • 55 Tone A, Nguyen S, Devemy F. , et al. Six-week versus twelve-week antibiotic therapy for nonsurgically treated diabetic foot osteomyelitis: a multicenter open-label controlled randomized study. Diabetes Care 2015; 38 (02) 302-307
  • 56 Schneekloth BJ, Lowery NJ, Wukich DK. Charcot neuroarthropathy in patients with diabetes: an update systematic review of surgical management. J Foot Ankle Surg 2016; 55 (03) 586-590
  • 57 van Battum P, Schaper N, Prompers L. , et al. Differences in minor amputation rate in diabetic foot disease throughout Europe are in part explained by differences in disease severity at presentation. Diabet Med 2011; 28 (02) 199-205
  • 58 Wukich DK, Hobizal KB, Brooks MM. Severity of diabetic foot infection and rate of limb salvage. Foot Ankle Int 2013; 34 (03) 351-358
  • 59 Wukich DK, Ahn J, Raspovic KM, La Fontaine J, Lavery LA. Improved quality of life after transtibial amputations in patients with diabetes-related foot complications. Int J Low Extrem Wounds 2017; 16 (02) 114-121