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Orthopedic complications of diabetes mellitus
Maxim Gurevich
Recommended citation format: Gurevich M: Orthopedic complications of diabetes mellitus. Estetol Med Kosmetol 2012; 2 (Supl. 1): s4.
Type 2 diabetes is now a pandemic and shows no signs of abatement. The estimated worldwide prevalence of diabetes among adults was 285 million (6.4%) in 2010 and this value is predicted to rise to around 439 million (7.7%) by 2030. Type 2 diabetes is the predominant form and accounts for at least 90% of cases. The rise in prevalence is predicted to be much greater in developing than in developed countries (69% vs 20%). The excess global mortality in 2000 attributable to diabetes overall (most of them diabetes 2) was 2.9 million (5.2%) deaths. In 2004, heart disease and stroke were reported on 68% and 16%, respectively, of diabetes related death certificates in the USA. Furthermore, diabetes is leading cause of blindness among adults aged 20-74 years, and leads to around 44% of end-stage renal failure and 60% of non-traumatic lower limbs amputations in the USA.
Diabetic foot (DF) is a major cause of morbidity and mortality for diabetes patient and consumes a great deal of health system resources. Foot problems represent 20 % of total reasons for hospital admission of diabetes patients. DF amputations account of 2/3 of all non-traumatic amputation in all developed countries. Diabetic patient can present wide range of orthopedic problems: neuropathy without infection, macroangiopathy, infectious pathology, neuroarthropathy, tendons ruptures, foot deformities, complications associated with regular orthopedic surgeries (poor operation wounds healing, etc.). Three major mechanisms stand in the base of orthopedic complications of diabetes: neuropathy, vasculopathy, and abnormal mechanical environment. Protective sensation plays the most important role in preventing development of diabetic ulcer. Besides sensory neuropathy there are also other kinds of neuropathies in diabetes patient: diabetic amyotrophy, diabetic
mononeuropathy, motor neuropathy, autonomic neuropathy. Abnormal mechanical environment together with neuropathy and vasculopathy gives rise to diabetic ulcers.
Prevention and early detection of diabetic ulcer helps to save affected limb from deterioration and amputation. There are couples of classification systems for diabetic ulcers (Wagner, Brodsky, and San Antonio). Key points are perfusion, extent (size) of lesion, amount of tissue loss, infection and presence (absence) of sensation. Charcot arthropathy is the special kind of diabetic pathology. Presenting at the diabetic patient, untreated Charcot arthropathy leads to severe deformation of limb, causing non-plantigrade unbootable foot, affected with non healing diabetic ulcer. In most cases the common pathway of untreated Charcot is limb amputation. Good education of patients, early recognition of problems and appropriate treatment include multi-specialist team involvement allow to save the affected limb and patient's life.
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