FOOT DIABETIC (synonym foot of the diabetic) — the complex of the anatomo-functional changes of foot caused by a diabetic neuropathy, an angiopatiya and an osteopathy against the background of to-rykh develop is purulent - necrotic processes.
According to Levin (M. of Levin, 1980) and E. G. Volgin (1981), the phenomena of a diabetic neuropathy, an angiopatiya and an osteopathy occur at 30 — 80% of patients with a diabetes mellitus (see. diabetes mellitus ).
The diabetic neuropathy is caused by extremely difficult and diverse endocrine and metabolic disturbances both in nervous cells, and in their shoots; decrease in protein synthesis, lipids and mediators, and also narusheniyekhm functions of century of N of page. Defeat of motor and sensory nerves of foot (see) it is characterized by considerable delay of speed and dispersion of the carried-out irritation, changes of transfer of primary irritation in synapses of c. N of page and peripheral nerves. At an electromyography signs of denervation of a part of muscle fibers of muscles groans come to light. At morfol. a research in nerve fibrils generally distal segmented demyelination, and also the expressed degenerative and destructive changes comes to light. Disturbance of conductivity does not depend on age of patients, expressiveness of distal segmented demyelination of nerves, duration and weight of a course of diabetes.
The diabetic angiopatiya represents a combination of atherosclerosis of vessels to a mikroangiopatiya, i.e. preferential defeat of capillaries, arterioles and venules. In capillaries and arterioles the thickening of a basal membrane progressing in a zavisgshost from duration of a diabetes mellitus and which is combined with increase in permeability of a vascular wall is noted. Also the proliferation of muscle cells of a vascular wall promoting development of thrombosis comes to light. At a mikroangiopatiya the peripheric pulse often remains, there is no alternating lameness, but trophic ulcers and gangrene can develop. However the isolated defeat of small vessels meets seldom. Atherosclerosis (see) vessels of the lower extremities at diabetes develops at younger age. At the same time typically multisegmented diffusion defeat of walls of subnodal, tibial arteries and arteries of foot. Angiopatiya at a diabetes mellitus is combined with changes of rheological properties of blood: povysheniyemadgezivny properties of thrombocytes and erythrocytes, viscosity of blood owing to a hyperglycemia and a lipidemia.
The diabetic osteopathy is caused by essential changes in a bone tissue, in organic and mineral components of a bone. At the same time activity of mesenchymal cells is oppressed, osteons form more slowly. However chemical and mineral composition of a bone significantly is not changed, exchange of calcium in a bone tissue is almost not broken. At treatment insulin notes reduction of contents in bones of magnesium. In cartilaginous tissue synthesis of polysaccharides is oppressed, there is an accumulation of collagen leading to formation of hyperostoses.
Changes in bones, disturbance of a motive and sensitive innervation of foot, atrophy of muscles conduct to laterposition of the forefront of foot and change of zones of so-called supertension on foot. New zones of supertension at S. are located with in a distal phalanx of the I finger, metatarsophalangeal joints III and IV fingers, the fourth and fifth plusnevy bones; sharply pressure during the walking in a heel increases. In zones of supertension necrotic changes of soft tissues are localized.
The progressing atrophy of muscles and deformation of foot, change of zones of supertension, decrease practically in all types of sensitivity, disturbance of a vegetative innervation promote formation of callosities, cracks, trophic ulcers, etc.
Changes in fabrics at S. of develop unevenly in this connection a wedge, manifestations are various and depend on a combination of the symptoms connected with a current of a diabetes mellitus and its complications.
At survey the deformation of foot caused by the lateral shift of its forefront clearly comes to light. Fingers of foot have the coronoid form, muscles are atrophied, skin dry without hair, but stop warm to the touch. Skin color is sometimes normal, but is more often bagro - in - cyanochroic. Cracks, callosities and other types of trophic disturbances are often observed. In connection with decrease in all types of sensitivity at development even of considerable it is purulent - necrotic processes patients do not note the expressed pain and late see a doctor. From a surface of trophic ulcers polymorphic microflora, especially often staphylococcus and gram-negative microorganisms is sowed; approximately find representatives of anaerobic flora in 80% of patients. Antibiotics, as a rule, do not influence structure of microflora, vegetans in depth is purulent - necrotic defect.
Nevrol. changes are presented by the progressing symmetric distal polyneuropathy, a recurrent ischemic mononeuropathy (see the Neuropathy in neurology), a neurogenic arthropathy (see) and diabetic amyotrophy (see).
The progressing symmetric distal polyneuropathy is characterized by defeat of eksteroretseptor and disturbance of sensitivity in the form of «socks», is frequent without signs of disturbance of a motive innervation. Patients complain of lack of sensitivity in foot or its some departments, rigidity of feet. Disturbance of deep vibration sensitivity and emergence of pain in feet is typical at night, to-rye disappear during the walking. Disturbance of a motive innervation comes later and is characterized by an atrophy of muscles of foot. The diabetic atrophy of muscles is most expressed in proximal department of a hip (sgibatel and razgibatel of a hip, a chetyrekhglavy muscle of a hip) with simultaneous defeat of short and long razgibatel of fingers of foot. Patol. bottom reflexes are absent.
Conservative treatment is directed to correction of diabetes, elimination of an infection by means of antibacterial from redstvo, a normal zatsigo peripheric circulation and microcirculation in fabrics of foot. Orthopedic treatment consists in selection of special footwear taking into account new zones of supertension, and later amputations (see) — in prosthetics. Surgical treatment includes operations on vessels of the lower extremity or lumbar sympathectomy (see). At development it is purulent - necrotic defeats of foot surgical treatment consists in amputation, to-ruyu make at the different level. Considering the local nature of gnoynonekrotichesky defeats, aim to keep basic function of foot and an extremity since at amputation at the level of a shin or a hip and without prosthetics at many patients within the next 2 — 3 years it is necessary to amputate other lower extremity.
Complex timely conservative and orthopedic treatment allows to avoid amputations at 40 — 60% of patients with S. of. Prosthetics of vessels owing to preferential damage of arteries of average and small caliber is unpromising. The lumbar sympathectomy at certain indications gives the chance to avoid amputation at 60 — 70% of patients from S. of.
Prevention consists in obligatory dispensary observation for patients with a diabetes mellitus not only of the endocrinologist, but also the traumatologist-orthopedist and the surgeon, and also in timely and rational conservative and orthopedic treatment.
Bibliography: Fedoseyev V. A. and To at - moves V. T. Kliniko-rentgenologiche-skaya the characteristic of changes in foot at diabetes, Surgery, No. I, page 38, 1982; The diabetic foot, ed. by M. E. Levin a. L. W. O'Neal, St Louis, 1977.
A. K. Georgadze, B. M. Gazetov.