Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition)
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Abstract: In recent years, as living standards have continued to improve, the number of diabetes patients in China, along with the incidence of complications associated with the disease, has been increasing. Among these complications, diabetic foot disease is one of the main causes of disability and death in diabetic patients. Due to the differences in economy, culture, religion and level of medical care available across different regions, preventive and treatment methods and curative results for diabetic foot vary greatly. In multidisciplinary models built around diabetic foot, the timely assessment and diagnosis of wounds and appropriate methods of prevention and treatment with internal and external surgery are key to clinical practice for this pathology. In 2019, under the leadership of the Jiangsu Medical Association and Chinese Diabetes Society, the writing group for the Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition) was established with the participation of scholars from the specialist areas of endocrinology, burn injury, vascular surgery, orthopedics, foot and ankle surgery and cardiology. Drawing lessons from diabetic foot guidelines from other countries, this guide analyses clinical practices for diabetic foot, queries the theoretical basis and grades and gives recommendations based on the characteristics of the pathology in China. This paper begins with assessments and diagnoses of diabetic foot, then describes treatments for diabetic foot in detail, and ends with protections for high-risk feet and the prevention of ulcers. This manuscript covers the disciplines of internal medicine, surgical, nursing and rehabilitation and describes a total of 50 recommendations that we hope will provide procedures and protocols for clinicians dealing with diabetic foot.
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参考文献
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Figure 1. Monofilament test sites include plantar aspect of the distal first toe and the plantar aspects of the first and fifth metatarsophalangeal joints
Figure 2. (a) The examiner places the monofilament perpendicular to the skin surface. (b) The examiner applies enough force to buckle the monofilament
Figure 3. The tuning fork is held perpendicular to the skin and placed over the distal aspect of the first toe
Figure 4. The examiner evaluates pain by pressing the patient's skin from proximal to toenail with a disposable 40-g pressure needle or pin
Figure 5. Specific steps for assessing the Achilles tendon reflex. (a) Patient is maintained in a supine position with the knee flexed and abducted. (b) The examiner holds the patient's toe in slight dorsiflexion. (c) The examiner taps the Achilles tendon with a tendon hammer. (d) The normal reaction is gastrocnemius contraction and foot flexion to plantar surface
Figure 6. Tip-Therm specific steps. (a) The examiner places the warm end (34–45℃) over the skin surface of the instep. (b) The examiner places the cold end (5–10℃) over the skin surface of the instep
Figure 10. Mallet toe, hammer toe and claw toe (up) and operation method (down) which is to remove the shadow
Figure 11. Osteotomy for phalangeal osteomyelitis after removal of shaded section, using Kirschner wire fixation
Figure 14. Multiple metatarsal head resection. The shaded part is cut off and the dotted line is the cut line
Figure 21. Achilles tendon lengthening (ATL); the dotted line on the left represents the incision line and the figure on the right represents the operation after ATL
Table 1. Grades of Recommendation, Assessment, Development and Evaluation system evidence grades
Quality of evidence A (high quality) Very confident that the true effect value approximates the effect estimate B (moderate quality) There is a moderate degree of confidence in the effect estimates, and it is possible that the true value is close to the estimates, but there is still a possibility that the two are quite different C (poor quality) The degree of confidence in the effect estimate is limited and the true value may be quite different from the estimate D (very low quality) There is little confidence in the estimates of effects and the true values are likely to be very different from the estimates Strength of recommendations Level 1 recommendation (strong) The benefits clearly outweigh the risks and the credibility of both clinician implementation and population acceptance is high Level 2 recommendation (weak) The benefits are equal to the risks, depending on the specific clinical situation. In general, the preferences of doctors and patients play a more important role in the decision-making process 
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Table 2. Medical history of diabetic foot patients
General medical history (1) Occupational needs, (2) family history of diabetes, (3) previous hospitalization, (4) surgical history (5) allergies, (6) adverse reactions to anesthetics, (7) nutritional status, (8) quality of life, (9) alcohol, tobacco, depression, (10) diabetes duration, (11) current medications, (12) glycemic management, (13) diabetic complications, (14) diabetic comorbidities, (15) other systemic diseases, (16) patient compliance, (17) doctors Foot-specific history General foot history (1) Foot disease history, (2) treatment history of foot disease, (3) footwear, (4) foot warmth, (5) mechanical or chemical contact, (6) acupuncture or pain in the lower limbs, (7) proximal leg muscle atrophy and weakness, (8) foot deformity, (9) abnormal foot pressure and callosity, (10) lack of joint range of motion, (11) claudication or pain at rest (12) bilateral or unilateral edema Wound/ulcer history (1) Incentives (stimulus time or trauma), (2) duration, (3) recurrence, (4) location, (5) wound care, (6) wound size (length, width and depth), (7) interference with wound care (family or social), (8) offloading techniques
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Table 3. Lower limb physical examination
Dermatologic examination • Color, turgor, wetness, hair growth, chap • Nail atrophy or hypertrophy • Calluses and subcallus hemorrhage • Ulcers (location, size, depth, infection status), gangrene • Others: (1) tinea pedis (fungal infection), paronychia (bacterial infection), itchy with scratch marks (yeast infection), (2) microvascular change, light brown, scaly patches (diabetic dermatopathy), (3) diabetic steatosis, bullous disease, (4) eruptive xanthomatosis, distal sclerosis, disseminated granuloma annulare (5) anaphylaxis Vascular examination • Absence of hair growth, onychodystrophy, thinning skin (parchment-like skin), cyanosis and erythema, postural color change • Temperature gradient (ipsilateral and contralateral extremity) • Abdominal artery to dorsal foot artery auscultation, palpation of femoral artery to dorsal foot artery • Handheld doppler examination Neurologic and musculoskeletal examination • Vibration perception: tuning fork 128 cps, biothesiometer • Light pressure: Semmes-Weinstein 10-gram monofilament • Light touch: cotton wool, two-point discrimination • Pain: pinprick (sterile needle) • Temperature perception: cold and hot • Deep tendon reflexes: patellar and ankle reflexes, clonus testing, Babinski test, Romberg test • Biomechanical abnormalities: (1) structural deformities: hammertoe, bunion, tailor's bunion, hallux limitus, flat or high-arched feet, Charcot deformities, postsurgical deformities (including prior amputation); (2) limited joint mobility; (3) plantar pressure assessment: callus, corns, skin pressure red and other manifestations, computerized devices, Harris ink mat, pressure sensitive foot mat
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Table 4. Different types of ulcers and their clinical manifestation
Subjects Venous ulcer Arterial ulcer Neurogenic ulcer High risk factors Venous valve dysfunction, deep venous thrombosis, prolonged standing, pregnancy, exercise less, obesity, family history High cholesterol, arteriosclerosis, hypertension, diabetes, aging, smoker, thromboangiitis obliterans, arteriovenous fistula Diabetes, peripheral nerve injury Limb change Edema, hyperpigmentation, superficial varicose veins, dry scaly skin, eczematous dermatitis, lymphedema Toenail thickening, pale and dry skin, intermittent lameness, peripheral arterial pulse weaken or disappear, capillary reperfusion time is prolonged(> 3–4 s), Pale skin appeared 1 minute after leg elevation of 45° Sensory dysfunction, foot deformity Location Medial malleolar region: malleolar region, tibia, lower limb under a third Pressure parts or extremity (toe): tiptoe, head of phalanx of toes, lateral malleolus or metatarsal Pressure parts Characteristics Wide range, irregular edges, shallow ulcer, red granulation tissue, less necrotic tissue and more exudate Small scope and clear boundary, deep ulcer, basal paleness, black necrotic tissue, less exudate Deep ulcer with reddish base and easy bleeding Surrounding ulcer skin Hemosiderosis(severe), lipodermatosclerosis Adermotrophia and hair loss, mild pigmentation Thick callosity Pain Mild or moderate pain, pain lessens with lower limb elevation Pain obviously, pain lessens at rest or when the lower limbs are lowered No obvious pain Pulse Normal pulse and skin temperature Lower limbs pulse weakens or disappear and cold skin The pulsating test is not reliable
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Table 5. Texas classification
Texas classification Grade 0: the epidermis is intact before and after ulcer formation Grade 1:superficial ulcers, not involving tendons, joint sacs or bone Grade 2: the wound involves the tendon or capsule of the joint Grade 3: the wound involves bone or joint Stage A: no ischemia or infection A0 A1 A2 A3 Stage B: infection B0 B1 B2 B3 Stage C: ischemia C0 C1 C2 C3 Stage D: ischemia and infection D0 D1 D2 D3
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