Table Of ContentAtlas of the Diabetic Foot
Atlas of the Diabetic Foot,Second Edition
N. Katsilambros, E. Dounis, K. Makrilakis, N. Tentolouris and P. Tsapogas
©2010N. Katsilambros, N. Tentolouris, P. Tsapogas, E. Dounis
ISBN:978-1-405-19179-1
Atlas of the Diabetic Foot
Nicholas Katsilambros
MD
Professor in Internal Medicine
Athens University Medical School
Eygenideio Hospital
and Christeas Hall Research Laboratory
Athens, Greece
Eleftherios Dounis
MD, FACS
Director, Orthopaedic Department
Laiko General Hospital
Athens, Greece;
Head of the Foot and Ankle Service
Athens Bioclinic
Athens, Greece
Konstantinos Makrilakis
MD, MPH, PhD
Assistant Professor in Internal Medicine
1st Department of Propaedeutic Medicine
Athens University Medical School
Laiko General Hospital
Athens, Greece
Nicholas Tentolouris
MD
Assistant Professor
1st Department of Propaedeutic Medicine
Athens University Medical School
Laiko General Hospital
Athens, Greece
Panagiotis Tsapogas
MD
Medical and Diabetes Department
Medical Bioprognosis
Corfu, Greece
SECOND EDITION
A John Wiley & Sons, Ltd., Publication
This edition fi rst published 2010, © 2003, 2010 by N. Katsilambros, N. Tentolouris, P.
Tsapogas, E. Dounis.
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Library of Congress Cataloging-in-Publication Data
Atlas of the diabetic foot / Nicholas Katsilambros ... [et al.]. – 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4051-9179-1
1. Diabetes–Complications. 2. Foot–Diseases. 3. Foot–Ulcers. I. Katsilambros,
Nicholas.
[DNLM: 1. Diabetic Foot–Atlases. WK 17 A8818 2010]
RC951.A854 2010
616.4′62–dc22
2009026825
A catalogue record for this book is available from the British Library.
Set in 9/12 pt Minion by Toppan Best-set Premedia Limited
Printed in Singapore
1 2010
Contents
Acknowledgments, vi 7 Peripheral Vascular Disease, 91
Preface to the Second Edition, vii 8 Ischemic and Neuro-Ischemic Ulcers and
Gangrene, 106
Preface to the First Edition, viii
9 Heel Ulcers, 137
1 Introduction, 1
10 Charcot Foot, 148
2 Diabetic Neuropathy, 11
11 Infections, 169
3 Anatomic Risk Factors for Diabetic Foot
Ulceration, 21 12 Methods of Prevention, 194
4 Other Foot-Related Risk Factors, 48 13 Methods of Ulcer Healing, 200
5 Skin and Systemic Diseases with Manifestations in 14 Amputations, 224
the Feet, 62
Appendix, 243
6 Neuropathic Ulcers, 74
Index, 244
v
Acknowledgments
The writers of this A tlas express their thanks and grati- the Metaxa Cancer Hospital in Piraeus; and late Dr
tude to plastic surgeon Othon Papadopoulos, Assistant Dimitris Voyatzoglou of the Amalia Flemming Hospital
Professor at the University of Athens, for his help with in Athens.
certain cases in his area of specialty. They also thank They also express their gratitude to nurse Georgia
radiologist Dr Constantine Revenas of Laiko General Markou, the soul of the outpatient diabetic foot clinic,
Hospital in Athens for his help in the fi eld of ultra- for her precious duty in maintaining proper functioning
sonography; Dr Stamatia Georga, specialist in nuclear of the clinic and the patients ’ records. Many thanks are
medicine at the Papageorgiou Hospital in Thessaloniki; expressed to Katerina and Eleni Kapsimani for their pre-
radiologist Dr Constantine Lymperopoulos at the George cious help in providing shoes, insoles and plantar pres-
Gennimatas General Hospital of Athens for his help sure measurement equipment for photographing.
with the magnetic resonance imaging studies; and radi- Thanks must also go to the numerous doctors who
ologist Dr Rania Efthimiadou of the Ygeia Hospital have assisted the outpatient diabetic foot clinic, either as
in Athens. specialists in infectious diseases or orthopedics, or as
The authors are grateful to the following colleagues for scholars in the fi eld of diabetes and the diabetic foot, as
providing photographs: Professor Christos Liapis of the well as to the patients of the Diabetic Foot Clinic of the
University of Athens; Professor Elias Bastounis of the Laiko General Hospital in Athens, whose contribution
University of Athens; Dr Olympia Tzaida, pathologist at was the most signifi cant of all.
vi
Preface to the second edition
It is no exaggeration to state that the new (second) information. This work has been achieved through
edition of this book resulted from the marked success of the enormous efforts of my colleagues, co - authors of the
the fi rst edition. It must also be noted that the problems book, as well as through the technical help of the
of the diabetic foot continue to be a major and very publisher.
serious concern of every society in the world, even those
with the best healthcare systems. On behalf of the authors
This new edition has been enriched with a relatively N. Katsilambros
large number of representative pictures as well as new 2010
vii
Preface to the fi rst edition
Diabetes mellitus is a common disease all over the world in collaboration with the Orthopedic Department as well
and its frequency is steadily increasing. The availability as with other specialists depending upon individual
of a wide variety of treatment options results in improve- needs. A short text, which follows each illustration,
ment or even normalization of hyperglycemia as well as describes the history of the patient, the physical signs
of the accompanying metabolic disorders. However observed, the approach of treatment, and is followed by
people with diabetes continue to suffer from the compli- a short comment.
cations of the disease. It is hoped that this Atlas will be of assistance, as a
Diabetic foot - related problems occur frequently and reference guide and a teaching instrument, not only to
may have serious consequences. Amputations at different diabetologists and surgeons, but also to all doctors
anatomical levels are the most serious of them. involved in the treatment of diabetic patients. This book
The present Atlas represents a systematic description might help them not only to recognize and to treat the
of the many different foot lesions, which are often seen diabetic foot lesions, but also to prevent them.
in diabetic patients. Each fi gure corresponds to a case
treated in our Diabetes Centre in the Athens University On behalf of the authors
Medical School. Our patients are evaluated and treated N. Katsilambros
viii
1 CHAPTER 1
Introduction
N. Tentolouris
1st Department of Propaedeutic Medicine, Athens University Medical School,
Laiko General Hospital, Athens, Greece
Defi nition It is thought that foot ulcers are more common on the
plantar aspect of the feet. However, clinic- b ased data
D iabetic foot is defi ned as the presence of infection, from 10 European countries participating in the European
ulceration and/or destruction of deep tissues associated Study Group on Diabetes and the Lower Extremity
with neurologic abnormalities and various degrees of (EURODIALE) project showed that 48% of the ulcers
peripheral arterial disease (PAD) in the lower limb in affect the plantar aspect of the feet, while 58% are located
patients with diabetes. in non - plantar areas. Similar fi ndings have been reported
by other authors.
The majority (60– 8 0%) of foot ulcers will heal, 10– 1 5%
Epidemiology will remain active, and 5– 2 4% will end up in amputation
within a period of 6– 1 8 months after fi rst evaluation.
The prevalence of foot ulceration in the general diabetic Interestingly, 3.5– 1 3% of patients die with active ulcers,
population is 4 – 10%, being lower (1.5 – 3.5%) in young because co- m orbidity, including coronary artery disease
and higher (5 – 10%) in older patients. The annual inci- and nephropathy, is high in patients with foot ulcers.
dence of foot ulceration ranges from less than 1% to Neuropathic wounds are more likely to heal over a period
3.6% among people with type 1 or type 2 diabetes. It is of 20 weeks if they are smaller, of small duration and sup-
estimated that about 5% of patients with diabetes have a erfi cial. Neuro - ischemic ulcers take longer to heal and
history of foot ulceration, whereas the lifetime risk for are more likely to lead to amputation. The patient’ s
this complication is 15%. A selection of epidemiologic vascular status is the strongest predictor of healing rate
data on diabetic foot problems from large studies are and outcome.
summarized in Table 1.1 . The major adverse outcome of foot ulceration is
There are ethnic differences in the prevalence of foot amputation. Despite efforts at national levels, the rates of
problems. Foot ulcers are more common in Caucasians non - traumatic lower extremity amputation in people
than in Asian patients of the Indian subcontinent. This with diabetes remain 10 – 20 - fold higher than in those
difference may be related to physical factors (a lower without diabetes. Approximately 40– 7 0% of all non-
prevalence of limited joint mobility and lower plantar traumatic amputations of the lower limbs are performed
pressures in Asians) and to better foot care in certain on patients with diabetes. Many studies have documented
religious groups such as Muslims. The risk for foot ulcers the fact that foot ulcers precede approximately 85% of all
is higher in black, Native American and Hispanic amputations performed in patients with diabetes.
American individuals in comparison to white Americans. In addition, amputations in patients with diabetes are
performed at a younger age. The risk for ulceration and
amputation increases with both age and the duration of
diabetes. According to one report, the prevalence of
Atlas of the Diabetic Foot,Second Edition amputation in diabetic patients was 1.6% for the age
N. Katsilambros, E. Dounis, K. Makrilakis, N. Tentolouris and P. Tsapogas range 18– 4 4 years, 3.4% for ages 45– 6 4 and 3.6% in
©2010N. Katsilambros, N. Tentolouris, P. Tsapogas, E. Dounis
patients over 65 years. The age- a djusted amputation
ISBN:978-1-405-19179-1
1
2 Atlas of the Diabetic Foot
Table 1.1 Epidemiological data on the diabetic foot
Reference Country Population- or Prevalence (%) I ncidence
clinic - based
Foot ulcers Amputation Foot ulcers A mputation
Neil et al. 1989 UK Population 7 4 – –
Borssen et al. 1990 Sweden Population 0 .75 – – –
McLeod et al. 1991 U K Clinic 2.6 2 .1 – –
Moss et al. 1992 U SA Population – 3.6 10.1 a 2.1 a
Bouter et al. 1993 T he Netherlands P opulation – – 0.8 b 0.4
Siitonen et al. 1993 Finland P opulation – 0.5
Pendsey et al. 1994 I ndia Clinic 3 .6 – – –
Kumar et al. 1994 UK Population 1 .4 – – –
Humphrey et al. 1996 Nauru Population – – – 0.76
Abbott et al. 2002 UK Population 1 .7 1.3 2.2 –
Mueller et al. 2002 The Netherlands Population – – 2.1 0.6
Centers for Disease USA Population 11.8 – – –
Control and
Prevention 2002
Lavery et al. 2003 USA Population – – 6.8 0.6
Manes et al. 2004 B alkan region Clinic 7.6 – – –
a Incidence over 4 years. D ata from the Balkan region include Albania, Bulgaria, Greece, Romania, Serbia and the Former Republic of Macedonia.
b Include annual incidence of foot ulcers in patients hospitalized for foot problems.
rate for persons with diabetes (5.5 per 1,000 persons) was 1995 and 2000 and of 41% between 1984 and 2000,
28 times that of those without diabetes (0.2 per 1,000 respectively. Data from Leverkusen, Germany, also
persons) in 1997, increasing by 26% from 1990. showed a reduction in both the major and minor ampu-
Regardless of diabetes status, these rates were higher for tation rate in patients with diabetes by 37% between the
men than women and higher for Native Americans and years 1990 and 2005.
non- H ispanic black individuals than Hispanic or non- There is evidence that the decline in amputation rates
Hispanic white patients. Lower amputation rates have is due to a better quality of foot care, including the provi-
been reported for South Asians and for African - Caribbean sion of podiatrists, multidisciplinary foot teams and sur-
men. The higher prevalence of amputation may be due to gical interventions for lower extremity arterial disease.
aging of the diabetic population, the increasing prevalence Clinic - and community - based studies have demonstrated
of diabetes and better reporting. As the size of the diabetic that strategies aiming at patient educa tion, identifi ca-
population increases, more disease - related complications, tion of the foot at risk, implementation of preventive
and consequently more amputations, are expected in the measures (proper footwear, podiatrist services) and mul-
future unless effective interventions aimed at preventing tidisciplinary management can reduce the rate of ampu-
amputations are undertaken. tation in patients with diabetes by almost 50%.
The efforts of some countries to reduce amputation The most common cause of amputation in diabetes is
rates are encouraging. An examination of recent time - ischemia and infection; critical limb ischemia or non -
trend national data from The Netherlands and Finland healing foot ulcer is the cause of amputation in 50 – 70%
showed reductions in amputation rate of 40% between and infection in 30 – 50% of patients with diabetes.
