Stiegler Hubert
Angiologische Abteilung, Klinikum München-Schwabing, München-Schwabing.
Herz. 2004 Feb;29(1):104-15. doi: 10.1007/s00059-004-2534-z.
PATHOGENETIC FACTORS: The decisive factors for the etiology of the diabetic foot syndrome (DFS) are diabetic neuropathy, macroangiopathy and the combination of neuropathy with macroangiopathy. If ischemia prevails, macroangiopathy decisively deteriorates the prognosis and leads, together with local infection, to amputation in almost all cases of DFS. Triggering factors are exogenous trauma by tight shoes, foreign bodies and insufficient foot care combined with a foot deformity, which develops in the context of osteoarthropathy. Pathogenetic factors include the increased collagen deposition and network by advanced glycosylation endproducts, the loss of adipose tissue and the occurrence of edema, which destroy the compensating balance between preventive and damaging factors.
Regular routine inspections by the physician and the patient for hyperkeratosis, fungal infection, skin lesions, control of footwear and foot deformities are as indispensable as the examination of the neurologic and angiologic status. Treatment requires the know-how of a specialized center in collaboration of different medical disciplines, e. g., the diabetologist, the angiologist, the orthopedic and vascular surgeon, the interventional radiologist and assistance by the podiatrist, the orthopedic technician and expert diabetic counseling. Whereas the neuropathic lesion almost always heals under local therapy and pressure release, ischemic lesions demand revascularization. A superimposed infection calls for microbial and resistance testing, since up to six different agents including anaerobic bacteria can be found. This situation needs systemic antibiotic therapy and local treatment.
The amputation rate can be considerably reduced by these measures. Even more important is structured teaching of the patient, which can reduce amputation by 60-70%, which underlines the importance of prophylaxis in DFS. Teaching to the patient must comprise daily inspection of the feet, correct hygiene of the feet and adequate footwear.
发病机制因素：糖尿病足综合征（DFS）病因的决定性因素是糖尿病神经病变、大血管病变以及神经病变与大血管病变的合并存在。若缺血占主导，大血管病变会决定性地恶化预后，并与局部感染一起，在几乎所有DFS病例中导致截肢。触发因素包括紧鞋引起的外源性创伤、异物以及足部护理不足并伴有足部畸形，这种畸形在骨关节病的背景下发展。发病机制因素包括晚期糖基化终产物导致的胶原蛋白沉积增加和网络形成、脂肪组织丢失以及水肿的发生，这些会破坏预防因素和损害因素之间的代偿平衡。
医生和患者定期进行常规检查，检查角质化过度、真菌感染、皮肤病变，控制鞋类和足部畸形，这与检查神经和血管状况同样不可或缺。治疗需要专业中心具备不同医学学科协作的专业知识，例如糖尿病专家、血管专家、骨科和血管外科医生、介入放射科医生，以及足病医生、骨科技术人员的协助和糖尿病专家咨询。虽然神经病变几乎总能在局部治疗和减压下愈合，但缺血性病变需要血管再通。叠加感染需要进行微生物和耐药性检测，因为可能会发现多达六种不同的病原体，包括厌氧菌。这种情况需要全身抗生素治疗和局部治疗。
这些措施可大幅降低截肢率。对患者进行结构化教育更为重要，这可将截肢率降低60 - 70%，这突出了DFS预防的重要性。对患者的教育必须包括每天检查足部、正确的足部卫生和合适的鞋类。
