糖尿病足的研究進展

ResearchProgressinDiabeticfootZhijieXi,MDGuanghuaHospitalAffiliatedtoShanghaiUniversityofTraditionalChineseMedicine“Every30minutesalimbislostduetoalandmine.

Every30seconds,alimbislostduetodiabetes.”

-Bahara,Millsetal.InternationalWoundJournal2009.

TheHistory1552BC:thefirstknownmentionofdiabetes–foundontheEbersPapyrusEgyptianphysicianHesy-Raofthe3rdDynastymakesListsremediestocombatthe‘passingoftoomuchurine’WoodCarvingofHesy-RaIn

1885，F(xiàn)renchmanM.Laffonunderstoodoftherelationshipbetweendiabetesandplantarneuropathiculceration1889:ScientistsOskarMinkowski

andJosephvonMeringoftheUniversityofStrasbourg,Francedemonstratehowremovingadog’spancreasproducesdiabetes.OskarMinkowskiTheHistoryContinues..Oct.25,1923

BantingandMacleod

TheNobelPrizeinPhysiologyorMedicine.BantingshareshisawardwithBestMacleodshareshiswithCollip.TheNobelPrizeGoesTo….Banting&MacleodBanting'sandBest'slaboratory,whereinsulinwasdiscovered..20,2006:TheUnitedNationsrecognizesdiabetesasaglobalthreatanddesignatesWorldDiabetesDay,November14TheHistoryContinues..In2001,QulongTreatedlowerlimbthrombusobliteranswithtransversetransportationoftibiaIn2002，Tateishi-YuyamaE.Therapeuticangiogenesisforpatientswithlimbischaemiabyautologoustransplantationofbone-marrowcells2015，ProfessorQikaiHuareportedwhoused

transverselytibialtransportationforthetreatmentofdiabeticfootTheHistoryContinues..TheprevalenceofdiabetesTheprevalenceofdiabetesRiskfactorsofdiabeticfootMalesexSmokingHypertensionHyperlipidaemiaDM>10yearsdurationPeripheralneuropathyAbnormalfootstructurePeripheralarterialdiseaseInsulinresistancewithcompensatoryhyperinsulinaemiaH/Opreviousulceration/amputationPoorglycemiccontrol(HbA1c>7%)Diabeticfootlesionsfrequentlyresultwhen2ormorearepresentMODERNMANAGEMENTOFTHEDIABETICFOOTassessmentclassificationstaginginterventionSTAGINGANDINTERVENTIONThenaturalhistoryofdiabeticfootThenaturalhistoryofdiabeticfootClassification-WagnerGrade0-Skinintact,nofootdeformityGrade1-SuperficialulcerGrade2-DeepulcerGrade3-DeepulcerwithinfectionGrade4-LimitednecrosisGrade5-NecrosisoftheentirefootWagnergrade0Wagnergrade1Wagnergrade2Wagnergrade3Wagnergrade4Wagnergrade5MANAGEMENT?Mechanicalcontrol

?Woundcontrol?MicrobiologicalcontrolVascularcontrol?Metaboliccontrol

?Educationalcontrol

OffloadingMechanicalcontrolClawedsecondtoeSiliconerubberorthotictodivertpressurefromdorsumofclawtoeMechanicalcontrolPrevalonpressure-relievingheelprotectorwithpillowstylecushioningExtra-depthstockshoeMechanicalcontroltotalnon-weight-bearingispracticalAmbulatorymethodshavebeendevelopedMetaboliccontrolHyperglycaemia,hypertension,hyperlipidaemiaandsmokingarethegreatquartetoffactorsAreductioninglycatedhaemoglobintolessthan7%Highbloodpressureshouldbebelow140/80mmHg.Inpatientswithmicroalbuminuria,thetargetshouldbebelow130/80mmHg.LDLcholesterolisthemaintargetfortype2diabetes,aimingforlevelsbelow2mmol/L.Fibratescanbeusedtoreduceveryhighlevelsoftriglyceridesabove5mmol/LStopsmokingMetaboliccontrolVascularcontrolCriticalischaemiawithruboroffoot

ondependencyFootbecomespaleonelevationAnkleBrachialIndexABI=AnkleSBP(PTorDP)/HighestArmSBP

AnkleBrachialIndexABIvalueIndicates<0.9Abnormal0.8-0.9MildPAD0.5-0.8ModeratePAD<0.5SeverePAD<0.25VerySeverePADTheABIhaslimiteduseinevaluatingcalcifiedvesselsthatarenotcompressibleasinDiabeticsDSA(a)DSAshowingmultiplesignificantstenoses(arrow)ofthetibio-peronealtrunk.(b)Theposteriortibialartery(arrow)isheavilydiseasedwithmultiplecriticalstenosesandocclusions.(c)Guidewire(arrow)insertedtoposteriortibialartery.(d)Tibio-peronealtrunk(arrow)hasbeenangioplastied.(e)Posteriortibialarteryrecanalizedbyangioplastytothemedialplantararch(arrow).Doppler(a)Dopplerwaveformfromnormalfootshowingnormaltriphasicpattern.(b)Dopplerwaveformfromneuroischaemicfootshowingdampedpattern.InfraredimagingCTA

transversetibialtransportationVascularreconstructionSeveredeepinfectionPurplishdiscolourationindicatingsubcutaneousnecrosisGas(arrow)inthetissuesinseveresofttissueinfectionOsteomyelitisOsteomyelitiswithlossofbonedensityandcorticaloutlineofthedisplacedcalcaneumncreaseduptakeonSTIRsequenceindicatingoedemainfirstmetatarsalheadSeveredeepinfectionDeepulcerwithsubcutaneoussloughingvisibleExtentofdebridementnecessarytoremoveallnecrotictissuedowntohealthybleedingtissue.SeveredeepinfectionPurplishdiscolourationindicatingsubcutaneousnecrosisGas(arrow)inthetissuesinseveresofttissueinfectionOsteomyelitisOsteomyelitiswithlossofbonedensityandcorticaloutlineofthedisplacedcalcaneumncreaseduptakeonSTIRsequenceindicatingoedemainfirstmetatarsalheadSPECT-CTDebridementSharp

LarvalEnzymatic(Lytic)DebridementMaggotsinawoundDebridementVSDorVACGraftJacket–SamplecaseInfectedwounddehiscenceulcer–6weekss/pI&D,&IVantibioticsAfterdebridementGraftJacketappliedinOR(OsteosetantibioticbeadsandVACalsoused.)61DebridementskingraftPartial-thicknessskingraftsprayedwithiodineandclipsinsituSkingrafthascontractedandwoundhashealedWoundcontrolWoundcontroloftheneuropathicandneuroischaemiculceriscentreduponsharpdebridement.Thisisprobablythemostefficientwaytoremoveassociatedbiofilm,whichcontainsmultiplebacterialspeciesandformspolymicrobialcommunitiesFlagsurgeryVascularcontrolCriticalischaemiawithruboroffoot

ondependencyFootbecomespaleonelevationDoppler(a)Dopplerwaveformfromnormalfootshowingnormaltriphasicpattern.(b)Dopplerwaveformfromneuroischaemicfootshowingdampedpattern.CTADSA(a)DSAshowingmultiplesignificantstenoses(arrow)ofthetibio-peronealtrunk.(b)Theposteriortibialartery(arrow)isheavilydiseasedwithmultiplecriticalstenosesandocclusions.(c)Guidewire(arrow)insertedtoposteriortibialartery.(d)Tibio-peronealtrunk(arrow)hasbeenangioplastied.(e)Posteriortibialarteryrecanalizedbyangioplastytothemedialplantararch(arrow).UltrasoundGrey-scaleultrasound.Thereisa2