Atlas of the Diabetic Foot Professor Nicholas Katsilambros, MD Directorofthe1st DepartmentofPropaedeuticMedicineandtheDiabeticCentre Athens UniversityMedicalSchool LaikoGeneralHospital Athens,Greece Eleftherios Dounis, MD, FACS DirectoroftheOrthopedicDepartment LaikoGeneralHospital Athens,Greece Panagiotis Tsapogas, MD SeniorRegistrarinInternalMedicineandDiabetes LaikoGeneralHosptial Athens,Greece Nicholas Tentolouris, MD SeniorRegistrarinInternalMedicineandDiabetes LaikoGeneralHospital Athens,Greece Atlas of the Diabetic Foot Atlas of the Diabetic Foot Professor Nicholas Katsilambros, MD Directorofthe1st DepartmentofPropaedeuticMedicineandtheDiabeticCentre Athens UniversityMedicalSchool LaikoGeneralHospital Athens,Greece Eleftherios Dounis, MD, FACS DirectoroftheOrthopedicDepartment LaikoGeneralHospital Athens,Greece Panagiotis Tsapogas, MD SeniorRegistrarinInternalMedicineandDiabetes LaikoGeneralHosptial Athens,Greece Nicholas Tentolouris, MD SeniorRegistrarinInternalMedicineandDiabetes LaikoGeneralHospital Athens,Greece Copyright2003 JohnWiley&SonsLtd,TheAtrium,SouthernGate,Chichester, WestSussexPO198SQ,England Telephone(+44)1243779777 Email(forordersandcustomerserviceenquiries):[email protected] VisitourHomePageonwww.wileyeurope.comorwww.wiley.com AllRightsReserved.Nopartofthispublicationmaybereproduced,storedinaretrievalsystemor transmittedinanyformorbyanymeans,electronic,mechanical,photocopying,recording,scanningor otherwise,exceptunderthetermsoftheCopyright,DesignsandPatentsAct1988orunderthetermsof alicenceissuedbytheCopyrightLicensingAgencyLtd,90TottenhamCourtRoad,LondonW1T4LP, UK,withoutthepermissioninwritingofthePublisher.RequeststothePublishershouldbeaddressed tothePermissionsDepartment,JohnWiley&SonsLtd,TheAtrium,SouthernGate,Chichester,West SussexPO198SQ,England,[email protected],orfaxedto(+44)1243770620. 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BritishLibraryCataloguinginPublicationData AcataloguerecordforthisbookisavailablefromtheBritishLibrary ISBN0-471-486736 Typesetin10/12ptTimesbyLaserwordsPrivateLimited,Chennai,India PrintedandboundinItaly Thisbookisprintedonacid-freepaperresponsiblymanufacturedfromsustainableforestry inwhichatleasttwotreesareplantedforeachoneusedforpaperproduction. Contents Preface vii Acknowledgments ix Chapter I Who is the Patient at Risk for Foot Ulceration? 1 Chapter II Classification, Prevention and Treatment of Foot Ulcers 23 Chapter III Anatomical Risk Factors for Diabetic Foot Ulceration 41 Chapter IV Some Uncommon Conditions 73 Chapter V Neuropathic Ulcers at Various Sites 85 Chapter VI Neuro-Ischemic Ulcers at Various Sites 105 Chapter VII Gangrene 125 Chapter VIII Infections 151 Chapter IX Neuro-Osteoarthropathy. The Charcot Foot 185 Appendix 1 Anatomy of the Foot 213 Appendix 2 Manufacturers of Preventive and Therapeutic Footwear 217 Index 221 Preface Diabetes mellitus is a common disease all over the world and its frequency is steadily increasing. The availability of a wide variety of treatment options results in improvement or even normalization of hyperglycemia as well as of the accompanying metabolic disorders. However people with diabetes continue to suffer from the complications of the disease. Diabetic foot-related problems occur frequently and may have serious consequences. Amputations at different anatomical levels are the most serious of them. ThepresentAtlas representsasystematicdescriptionofthemanydifferentfootlesions, which are often seen in diabetic patients. Each figure corresponds to a case treated in our Diabetes Centre at the Athens University Medical School. Our patients are evaluated and treated in collaboration with the Orthopedic Department as well as with other specialists depending upon individual needs. A short text, which follows each illustration, describes the history of the patient, the physical signs observed, the approach to treatment, and is followed by a short comment. It is hoped that this Atlas will be of assistance, as a reference guide and a teaching instrument, not only to diabetologists and surgeons, but also to all doctors involved in the treatment of diabetic patients. This book may help them not only to recognize and to treat the diabetic foot lesions, but also to prevent them. On behalf of the authors N.Katsilambros