Diabetic neuropathy and foot complications.
Diabetic neuropathy and foot complications.
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DOI：
10.1016/b978-0-444-53480-4.00008-4
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发表时间：
2014-01-01
影响因子：
--
通讯作者：
Boulton, Andrew J M
中科院分区：
文献类型：
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作者：
Boulton, Andrew J M
足部溃疡和夏科神经关节病 (CN) 是糖尿病周围、躯体和交感自主神经病变的晚期后遗症，已得到广泛认可和记录。然而，神经性足部不会自发溃疡：它是由于神经病变导致感觉丧失以及足部畸形和外部创伤等其他因素的结合，从而导致溃疡甚至 CN。在西方国家，导致神经性足部溃疡的最常见创伤是由不合适的鞋子造成的。糖尿病足部无知觉的治疗方法大部分是从麻风病中学到的，麻风病同样会导致足部无知觉溃疡。不需要昂贵的设备来识别高风险脚，最近开发的测试（例如 Ipswich Touch Test 和 Vibratip）已被证明可用于识别高风险脚。全面的筛查计划以及对高危患者的教育应该有助于降低糖尿病溃疡的高发病率。最近，另一个非常高风险的群体被确定，即透析患者，他们发生足部溃疡的风险极高。这应该是可以预防的。神经性足部溃疡治疗中最重要的特征是减轻负担，因为由于痛觉丧失，患者可以轻松地在活动性足部溃疡上行走。应积极治疗感染，如果有任何周围血管疾病的证据，还需要进行动脉造影和适当的手术治疗。 CN 经常表现为单侧足部发热、肿胀，任何出现已知患有神经病变的这些特征的患者都应按照夏科疗法进行治疗，直到得到其他证明为止。急性 CN 治疗中最重要的是卸载，通常采用全接触石膏。
Foot ulceration and Charcot neuroarthropathy (CN) are well recognized and documented late sequelae of diabetic peripheral, somatic, and sympathetic autonomic neuropathy. The neuropathic foot, however, does not ulcerate spontaneously: it is a combination of loss of sensation due to neuropathy together with other factors such as foot deformity and external trauma that results in ulceration and indeed CN. The commonest trauma leading to foot ulcers in the neuropathic foot in Western countries is from inappropriate footwear. Much of the management of the insensate foot in diabetes has been learned from leprosy which similarly gives rise to insensitive foot ulceration. No expensive equipment is required to identify the high risk foot and recently developed tests such as the Ipswich Touch Test and the Vibratip have been shown to be useful in identifying the high risk foot. A comprehensive screening program, together with education of high risk patients, should help to reduce the all too high incidence of ulceration in diabetes. More recently another very high risk group has been identified, namely patients on dialysis, who are at extremely high risk of developing foot ulceration; this should be preventable. The most important feature in management of neuropathic foot ulceration is offloading as patients can easily walk on active foot ulcers due to the loss of pain sensation. Infection should be treated aggressively and if there is any evidence of peripheral vascular disease, arteriography and appropriate surgical management is also indicated. CN often presents with a unilateral hot, swollen foot and any patient presenting with these features known to have neuropathy should be treated as a Charcot until this is proven otherwise. Most important in the management of acute CN is offloading, often in a total contact cast.