This is the case of a patient with extensive forefoot gangrene, extending almost till the ankle. Patient was a known diabetic and hypertensive. Complete occlusion of below knee vessels was there. Rheologic agents, silver dressing & HBOT were used to treat this patient resulting in complete closure of the wounds and salvage of the foot
Diabetic Foot Ulcers & Growth Factors…
What are growth factors and are they useful in diabetic foot ulcers? Let us try to answer it in non medical lingo.
What are Growth Factors?
Growth factors are substances released by the body to help in wound healing. They get released from various cells once an injury occurs. They help the body to heal a wound. The action of growth factors starts almost from the time you get a wound or injury. Various types of cells release different growth factors based on the type of wound, the duration of the wound etc.
What kind of growth factors are there?
Various growth factors are present in the body like Platelet derived growth factor(PDGF), epidermal growth factor(EGF), Vascular endothelial growth factor, keratinocyte growth factor, transforming growth factors(TGF) etc
Which growth factors are commercially available?
Basically only two growth factors, PDGF & EGF are available for commercial use in the treatment of diabetic foot wounds. Other growth factors are still in the research phase for wound healing.
Can growth factors be applied at anytime to the wound?
No. Growth factors should be used only after thorough cleaning/debridement of the wound has been carried out. If the wound still has pus, dead tissue or gangrenous tissue, the growth factor will not be useful. Therefore cleaning of the wound is of utmost importance before using a growth factor. Growth factors cannot be expected to improve wound healing unless comprehensive wound care is carried out, which addresses the underlying problem of these wounds. Therefore the infection, underlying circulatory problem, blood sugar levels all need to be treated before growth factors will show any improvement in the healing of the wound.
How should growth factors be applied?
Growth factors must be applied as per manufacturer instructions. We prefer to apply them twice daily to a wound. Once growth factor application starts we monitor the wound for progress. If within 15 days of starting the application we find either no difference in the wound or we find that there is less than 50% reduction in wound size, we investigate further as to what is preventing the wound from healing or then we might change the treatment modalities.
SHOES HAVE THE FOLLOWING COMPONENTS
UPPER: Outer layer of shoe material, often leather or canvas.
TOE BOX: Area surrounding the toes.
VAMP: This cradles the area where the toes are connected to the foot, called the metatarsals.
COUNTER: Stiff material on either side of the heel. It is there to prevent forward and backward movement of the foot.
LAST: Shape of the shoe.
What To Look For In A Shoe:
1.SHAPE: Square or Round Toe Shoes are better that Pointed toe shoes.
2.FIT: It should provide ample room in the toe area in both width and Height.
It should fit snugly in the heel .
3. MATERIALS: Leather & Cotton Canvas are the best as they let your feet Breathe.
4.TREAD: Depending on use and what you are using them for, the tread is determined. For example for running outdoors the tread should be rough and grippy but if you run on a Treadmill then the tread should be smooth so as not to damage the belt.
4.CUSHION: More cushioning will absorb impact better.
5.SHOE WEIGHT: Lighter shoes may seem more comfortable initially, but heavier shoes may provide more support.
6.SPECIAL NEEDS: Extra-depth shoes or custom-shoes may be necessary to accommodate for structural foot deformities.
7. Sole : The outer sole in diabetic shoes must not bend & must have a rocker bottom.
A Podiatrist(Foot Doctor) is best suited to answer your questions and needs for special shoes, not a shoemaker.
General Tips on Shoe Purchasing
- Purchase shoes at the end of the day (when your feet are larger) to be certain they won’t be too tight.
- If you can’t wiggle your toes, the shoes are too small. Round or square-toed shoes have the most room, while narrow or pointed-toed shoes have the least and can aggravate conditions such as bunions and hammertoes.
- Measure both feet. One usually is larger and the shoe should fit comfortably on that foot.
- Try on shoes with socks or any special insert you normally wear.
- Walk around the store in the shoes before purchasing. They should feel comfortable. Do not expect shoes to stretch to fit your foot.
- Footwear with adequate cushioning or shock absorption, such as athletic shoes, absorb more stress and protect your feet. This is useful for anyone with heel pain.
- Shoes should have good arch support. Those that bend in the mid-sole area can lead to plantar fasciitis or arch & heel pain.
The following can be eaten freely:
- Vegetables in the form of Salads, Subjis, fillings etc.
- Dark green leafy vegetables eg. Palak, Methi, Coriander, Mint (pudhina) etc.
- High fibre foods like cauliflower, Teenda, Beans, Bajra, etc.
- Spinach, Asparagus, Olives, Mushrooms.
- Eggs in anyway most acceptable…avoid eating the egg yolk.
- Desserts: Custards, jellies, creams (without sugar) & coconuts
- Drinks: Tea or coffee (without sugar), pure water, peptonized milk.
- Any Vegetable soup without thickening agents.
- Pulses-dals, chana, rajma etc
- Multi grain roti—jowar, bajra etc
The following can be eaten in moderate amounts:
- Fats: restrict fried eatables to once a month.
- Cereals- wheat, rice – brown, maize, corn etc.(max.1 bowl 2-3 times per week).
- Fruits – Apple, citrus fruits, pomegranate…these to be titrated against your diabetes medication and blood sugar levels.
- Milk Products-2 small cups of curd or cow’s milk per day
- Organic jaggery(Gud), Desi ghee home made
- Fish of all kinds (dressing should not contain flour)-2 medium pieces (2-3 times per week)
- Chicken 3-4 pieces 2-3 times per week. (all cooked free of flour, potatoes or bread).
The following foods should be avoided:
- Sweets, puddings, chocolates.
- Fried foods eg. Samosas, wafers, vada pav, poories, kulcha etc.
- Dried fruits and nuts.
- Sugar, honey, jams, jellies, cakes and pastries, ice creams.
- Sweetened juices and soft drinks.
- Fruits like mango, Litchis, banana, chikoo, grapes, sitaphal (custard apple), pineapple, guava etc.
- Fried rice, Biryanis, pulaos etc.
- White bread or any other maida item.
- Seafood and shellfish.
- Liver & Red Meat.
- Noodles, spaghetti.
- Strictly avoid mutton, red meats, liver, kidney etc
- Avoid sweets.
- Fats from vegetable sources are better than animal sources.
- Reduce bodyweight if overweight.
- Avoid alcohol.
- Avoid fasting.
- Regulate timing of prescribed medical therapy with the diet.
- Exercise regularly.
- Can use artificial sweeteners instead of sugar but in regulated amounts.
- Take prescribed drugs regularly.
- Low fat
- Vitamins A,B6,B12,C,D(esp after amputation), E, K
- Folic acid
Fruits & Vegetables esp dark green & deep yellow
Meat, poultry & seafood are main sources of B6,B12 & K
Vit E in oil
Vit D in milk products
Zinc, Iron & Copper are found in meats and to a lesser extent in whole grain
Magnesium & Chromium in whole grains
Copper in organ meats, nuts & seeds
Avoid Vitamins C & E and antioxidants in high doses as they reduce vascular permeability and may impair wound healing
Diabetic Foot Problems : Control your sugars…most important. No rise in sugars means no foot problems.
- Inspect your feet daily for blisters, bleeding, and lesions between your toes.
- Use a mirror to see the bottom of your foot and heel.
- Do not soak your feet unless the temperature of the water is lukewarm, not as hot as you can stand it. (95°-100° Fahrenheit).
- Avoid temperature extremes – do not use hot water bottles or heating pads on your feet.
- Wash your feet daily with warm, soapy water and dry them well, especially between the toes.
- Use a moisturizing cream or lotion daily, but avoid getting it between the toes.
- Do not use acids or chemical corn removers.
- Do not perform “bathroom surgery” on corns, calluses, or ingrown toenails.
- Trim your toenails carefully and file them gently. Cut your nails straight across . Have a podiatrist treat you regularly if you cannot trim them yourself without difficulty.
- Contact your podiatric surgeon immediately if your foot becomes swollen or is painful, or if redness occurs.
- Do not smoke.
- Learn all you can about diabetes and how it can affect your feet.
- Have regular foot examinations by your podiatric surgeon.