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It has been estimated that about 15% of the 150 million people in the world with diabetes will develop a foot ulcer at sometime during their life.1 Foot problems affect people with diabetes globally but with the lack of podiatry and specialist nurses in some countries, many patients still do not have the appropriate care.2

Over the last decade there has been an increased interest in the care of the diabetic foot and many centres in the UK have now established their own foot care teams. Expertise in diabetic foot care has improved and many former research fellows from this unit have subsequently established their own clinics in various UK centres. Our clinic was established in 19873 and was the first diabetic foot clinic in the North West of England. The clinic and the team have grown in size since then and what was once a 'Cinderella' subject has become a speciality. Over fifty patients are seen each week in our foot ulcer clinic, and our high-risk patients are seen in our diabetes centre and community clinics for preventative treatment and foot care education. Our multidisciplinary team includes podiatrists, specialist nurses, doctors, scientists and an orthotist, whose individual skills and knowledge help to build a framework for care.4 Patients are referred to other specialist practitioners including vascular and orthopaedic surgeons for investigations and surgery. This team approach has brought together practitioners who were previously working in isolation for the benefit of our most important team member, the patient.

Diabetic foot problems can be expensive and time consuming to treat, and a trivial injury if not adequately treated could end in a major amputation. Minor trauma, neuropathy and deformity are the most frequent component cause of diabetic foot ulceration.5

Diabetes affects the somatic and autonomic nervous system and can cause a loss of sensation, an alteration in foot shape and a build up of callus under high-pressure areas. A patient with a foot ulcer and an insensitive foot will feel no pain and may continue to weight bear and cause further damage.

Pressure relief, callus debridement, control of infection and the adequacy of the blood supply are assessed in order to successfully treat a foot ulcer. Callus is debrided with a scalpel to prevent further damage and encourage ulcer healing. The larvae of the green bottle fly (Lucilia sericata) are also used to debride sloughy wounds of both inpatients and outpatients. The maggots feed on devitalised tissue and grow rapidly in size and promote rapid cleansing of necrotic and sloughy tissue.6

Casts are used to provide pressure relief for foot ulcers. The Scotchcast boot is a well-padded fibreglass cast that has been used in our clinic since 1998.7 Casts enable the patient to be ambulant while their ulcers heal and have reduced the number and duration of hospital admissions for foot ulceration. When the ulcers have healed patients are gradually weaned out of their cast and into extra-depth or bespoke shoes with cushioned insoles.

DIALEX - The DIAbetes Lower EXtremity Research Group
A.J.M. Boulton

References:

  1. King H, Aubert RE, Herman WH. Global burden of diabetes 1995-2025: prevalence, numerical estimates and projections. Diabetes Care 1998; 21: 1414-1431
  2. Boulton AJM. The diabetic foot: a global view. Diabetes / Metabolism Research and Reviews. 2000; 16 (suppl 1): S2-S5.
  3. Gem J, Boulton AJM. The diabetic foot and the role of a multidisciplinary clinic. J of Wound Care. 1996; 5: 452-475.
  4. Thompson FJ, Veves A, Ashe H, Boulton AJM et al, A team approach to diabetic foot care: the Manchester experience. The Foot 1991; 1: 75-82.
  5. Reiber GE, Vilekyte L, Boyko EJ, Del Aguila M, Smith DG, Lavery LA, Boulton AJM. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care 1999; 22: 157-162.
  6. Thomas S, Jones M, Shutler S, Jones S. Using larvae in modern wound management J of Wound Care; 1996; 5: 60-9.
  7. Knowles EA and Boulton AJM. Use of the Scotchcast boot to heal diabetic foot ulcers. Proceedings of the 5th European Conference on Advances in Wound Management. 1996; 199-201.
  8. King H, Aubert RE, Herman WH. Global burden of diabetes 19950-2025: prevalence, numerical estimates and projections. Diabetes Care 1998; 21: 1414-1431.
  9. Boulton AJM. The diabetic foot: a global view. Diabetes / Metabolism Research and Reviews. 2000; 16 (suppl 1): S2-S5.
  10. Knowles EA, Gem J, Boulton AJM. The diabetic foot and the role of a multidisciplinary clinic. J of Wound Care. 1996; 5: 452-475.
  11. Thompson FJ, Veves A, Ashe H, Boulton AJM et al, A team approach to diabetic foot care: the Manchester experience. The Foot 1991; 1: 75-82.
  12. Reiber GE, Vilekyte L, Boyko EJ, Del Aguila M, Smith DG, Lavery LA, Boulton AJM. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care 1999; 22: 157-162.
  13. Thomas S, Jones M, Shutler S, Jones S. Using larvae in modern wound management J of Wound Care; 1996; 5: 60-9.
  14. Boulton AJM. Use of the Scotchcast boot to heal diabetic foot ulcers. Proceedings of the 5th European Conference on Advances in Wound Management. 1996; 199-201.
  15. van Schie CHM, Whalley A, Vileikyte L, Wignall T, Hollis S, Boulton AJM. Efficacy of injected liquid silicone in the diabetic foot to reduce risk factors for ulceration. Diabetes Care 2000; 23: 634-638.
  16. van Schie CHM, Abbot CA, Vileikyte L, Shaw JE, Hollis S, Boulton AJM. A comparative study of the Podotrack, a simple semiquantitative plantar pressure measuring device, and the optical pedobaro-graph in the assessment of pressures under the diabetic foot. Diabetic Medicine 1999; 16: 154-159.
  17. Tentolouris N, Jude EB, Smirnof I, Knowles EA, Boulton AJM Methicillin-resistant staphylococcus aureus: an increasing problem in a diabetic foot clinic. Diabetic Medicine 1999; 16: 767-771.
  18. Boulton AJM. Clinical management of the painful diabetic neuropathies. J of the Royal College of Physicians of London. 2000; 34: 340-343.
  19. Abuaisha BB, Constanzi JB, Boulton AJM. Acupuncture for the treatment of chronic painful neuropathy: a long-term study: Diabetes Research and Clinical Practice 1998; 39: 115-121.
  20. Jude EB, Boulton AJM, Ferguson MWJ, Appleton I. The role of nitric oxide synthase isoforms and arginase in the pathogenesis of diabetic foot ulcers: possible modulatory effects by transforming growth factor beta 1. Diabetologia 1999 42: 748-757.
  21. Blakytny R, Jude EB, Gibson JM, Boulton AJM, Ferguson MWJ. Lack of insulin-like growth factor 1 (IGF1) in the basal keratinocyte layer of diabetic skin and diabetic foot ulcers. J of Pathology. 2000; 190: 589-594.
  22. Vileikyte L Psychological and behavioural issues in diabetic neuropathy. In Boulton AJM, Connor H, Cavanagh P (eds), The Foot in Diabetes. 3rd edition John Wiley & sons Ltd, Chichester, 2000; 121-130.
  23. Vileikyte L Psychological aspects of diabetic peripheral neuropathy. Diabetes Review 1999;7: 387-394.