Stirnemann P, Z'Brun A, Brunner D
Klinik für Herz-, Thorax- und Gefässchirurgie, Kantonsspital Luzern.
Ther Umsch. 1998 Oct;55(10):650-5.
Problems of the diabetic foot are frequent. The magnitude of the clinical picture and morbidity mirrors the severity and complexity of the underlying pathobiology. The three pathogenetic mechanism involved are ischemia, neuropathy and infection. Seldom do these mechanisms work in isolation, rather most foot problems result from a complex interplay among all three. The clinical picture of the diabetic foot reaches from the neuropathic deformity with diminished or absent sensation of pain to limited gangrene or superficial ulcer. The polymicrobial infection leads to extensive tissue destruction (plantarphlegmone) with osteomyelitis. The patients often notes no pain and may become aware of the infection only through the presence of drainage or a foul odor. These infections are usually more extensive than would be predicted by clinical signs and symptoms. These lesions must be debrided and drained promptly and completely. This often requires amputations of one or more toes, combined with an incision along the entire course of the infected track on the plantar or dorsal aspect of the foot. Cultures should be taken from the depth of the wound. Initial treatment should be with broad-spectrum antibiotics, with subsequent adjustment based on culture results. The diabetic foot is a clinical problem that can be solved with a high degree of success when the approached by an interdisciplinary team (specialists in infectious and vascular disease, podiatry and diabetology). Arterial reconstruction should be designed to restore maximum perfusion to the foot. The most effective result can be obtained with infra-inguinal vein bypass with distal anastomosis to the most proximal artery with direct continuity to the ischemic territory. The single most important factor in the achievement of the reduction of amputation is the autologous vein bypass. The overall outcome in the diabetic patient in terms of graft patency and limb salvage is equal to that in the nondiabetic.
糖尿病足问题很常见。临床表现的严重程度和发病率反映了潜在病理生物学的严重性和复杂性。涉及的三种发病机制是缺血、神经病变和感染。这些机制很少单独起作用，相反，大多数足部问题是由这三种机制之间复杂的相互作用导致的。糖尿病足的临床表现从疼痛感觉减退或消失的神经病变畸形到局限性坏疽或浅表溃疡不等。混合微生物感染会导致广泛的组织破坏（足底蜂窝织炎）并伴有骨髓炎。患者通常没有疼痛感，可能仅通过有渗液或恶臭才意识到感染。这些感染通常比临床体征和症状所预示的更为广泛。必须及时、彻底地对这些病变进行清创和引流。这通常需要切除一个或多个脚趾，并在足底或足背沿感染路径全程切开。应从伤口深处采集培养样本。初始治疗应使用广谱抗生素，随后根据培养结果进行调整。糖尿病足是一个临床问题，由跨学科团队（感染性疾病和血管疾病专家、足病学专家和糖尿病学专家）处理时，能够取得很高的成功率。动脉重建应旨在恢复足部的最大灌注。通过腹股沟下静脉搭桥术，将远端吻合至与缺血区域直接相连的最近端动脉，可获得最有效的结果。实现截肢减少的唯一最重要因素是自体静脉搭桥术。就移植物通畅率和肢体保全而言，糖尿病患者的总体结果与非糖尿病患者相当。
