Maintenance treatment of diabetic patients , associating arterial obstructive tibio-peroneal disease

When a melito-diabetic patient presents trophic infected injury on the limb, it is essential an evaluation of the circulatory conditions for therapeutic procedures orientation. In some circumstances, although arterial pulsation is absent, there is no ischemia of tissues. In these cases, the maintenance treatment, with eventual resection of the necrosed and infected tissues may be adopted. Evolution of 70 diabetic patients with trophic injuries on extremities were submitted to a maintenance treatment.. Age of patients varied from 28 to 88 years, with an average of 56.8. The most occurrence was verified in women, with 42 cases. Diabetes non-dependant on insuline (type II) was observed in 64 patients (91.5%), being the remaining 6 patients of type I. Diabetic retinopathy was observed in 14 (20%) of the patients, neuropathy in 22 (31%) and nephropathy in 8 patients (11.4%). All the patients presented arterial pulsation until the popliteal region. They were divided in 2 groups, considering trunk arteries of legs: Group I, perviallegs arteries, composed by 48 patients; Group II, occluded legs arteries, with 22 patients. In what refers to the anatomic local Gfthe injuries, patients were classified in three groups: Group A, formed by 32 patients (45.70/0), presenting injuries in one or two toes only, without affecting the metatarsic region; Group B, formed by 16 patients (22.9%), trophic injuries affecting the metatarsic region and Group C, formed by 22 patients (31.40/0),injuries affectifl9 the calcaneous region. Injuries in both of the groups were caused by mechanical traumatism. Duration of the injury in the inferior member varied from 7 to 48 days, resulting in a 12 days average. Analyzing pervicacity in trunk arterias and evolution of patients, it may be observed that there has been a significantly better result in those with all the pulses present (81.30/0x 45.5%)(p<0,01). Studying the injury locals associated to the evaluation of the cases, we may observe that for injuries in the extreme digital, result is significantly better than in locals more nearly. When distal pulses are absent, there is no significant difference in the result of the treatment, being performed in distal injuries or in the more near ones (p>0,05)(Table IV).


INTRODUCTION W
hen a melito-diabetic person presents trophic infected injury on the limb, it is essential an evaluation of the circulatory conditions, in order to orient the therapeutic procedure (13,14).In the

Address for correspondence:
Nelson Wolosker Rua Esperia, 30 Sao Paulo -SP -Brasil-CEP 0143-060 Berilo Langer (~) -deceased absence of trunk arterial disease, maintenance treatment without amputation next to the metatase, with eventual resection of the necrosed and infected tissues, is .consideredas being the first procedure (3,8,16).When the leg arteries are occluded, perfusion conditions of the member must be carefully evaluated.In certain circumstances, although arterial pulsation is not present, there is no ischemia of tissues.In these cases, the same procedure may be taken (11).
Some patients presented trophic injuries, showing rapid installation and evolution and, therefore, needed urgently care.

Table 1 Distribution of the results obtained in accordance with the presence of arterial pulsation
In patients pertaining to Group I, results showed as being satisfactory in 39 patients (81.3%) and in the group II, it showed satisfactory in 10 patients.
Analyzing pervicacity in trunk arteria and patient evolution, it may be observed that there has been a significantly better result in those .allpulses were present (p<O,OI) (Table I) Studying the local of the injury associated t? the prognosti'c of the cases, we may observe that for the injuries in digital extremities, result is significantly better than in the more near ones (p<O,Ol)(table II).It shows' even much better when we associate the variable "pulse present", being or tibial ant~rior, or posterior or of the foot itself (p<O,Ol)(Table III) .. All the patients were submitted to a general support treatment, antibyothicotherapy of large spectrum and resection of the necrosed and infected tissues.
Statistical analysis was done based on the Fisher exact test, mono modal, using value 0.05 as the critical level.
Evaluation of the results ~as based in the study of' the general clinical conditions of the patients and of the leg affected, when they retired from nospital.
Satisfactory result (S) was considered in the cases where the amputation near the metatarsic region was not necessary.Unsatisfactory result (NS) was the one where the amputation above the metatarsic region was necessary.
Evolution of 70 diabetic patients presenting infection and necrose in the inferior members, treated at the First Aid Unity of the Hospital das Clfnicas da Faculdade de Medicina da Universidade de Sao Paulo from January, 1987 till January, 1990.
Age of patients varied from 28 to' 88 years, with a 56.8 of average.Women were the most attacked, with 42 cases.
Diabetes non-insuline dependent (type II) was observed in 64 of the patients (91.5 %), being the other 6 of type I.
All. the patients pres~nted arterial pulsation till the popliteal region.They were divided in two groups with relation to the trunk arteria of the legs: Group I -Perviallegs arteries, formed by 48 pacients, average of 55 years Group II -Occluded legs arteries, formed by 22 patients with absence of arterial pulsation in the posterior tibial arteries, anterior and dorsal, of the leg.Although with arterial obstructive tibio-peroneal disease, patients presented an apparently good periferic perfusion.Average was of 60.1 years.
In what concerns to the anatomic localization of the injuries, patients were divided in three groups: Group A -Formed by 32 patients (45.7%), with one or two toes affected only, without reaching the metatarsic region Group B -Formed by 16 patients (22.9%), with trophic injuries, affecting the metatarsic region Group C -Formed by 22 patients (31.4%), with injuries affecting calcaneous region Injuries in both of the groups were caused by mechanical traumatism.No patient pertaining to Group I. presented vascular claim before the trauma, while 7 of the patients pertaining to group II reported previous intermitent clumsiness, not limitating.
Time of the injury presence in the inferior member varied from 7 to 48 days, representing a 12 days average'.

CASUISTIC AND METHOD
Evolution of the diabetic patients with trophic injuries in extremeties was studied, and patients were submitted to maintenance treatment.

DISCUSSION
When the distal pulses are absent, there are not significant differences in the results of treatment, being performed in digital injuries or in more nearly ones (p>O,05) (table IV).
Relation between diabetes mellitus and loose of trophic integrity of the inferi~r members due to ischemia and/or infection, are ve~y frequent (4).
Until few years ago, it was accepted that, with the evolution of diabetes, obstruction of the leg aiteries was considered the diabetic microangiopathy (9).Today, this A 1 -Group of patients with normal arterial pulsation and trophic injury affecting only the toes A2 -Group of patients with normal arterial pulsa~ion and trophic injury affecting the metatarsic region A3 -Group of patients with normal arterial pulsation and trophic injury affecting calcaneous region S = Satisfactory / NS = Unsatisfactory affirmation, more than questioned, is being left aside (12).Microangiopathy is the modification at capilar level and the tibio-peroneal obstruction is not its .nearerextension.Before the obstruction of the -leg arterias and before reaching the capilar microcirculation, there are small trunk arterial segments, mainly in the foot, that may be pervial and, therefore, reachable by the new techniques of arterial restoration (1,7,15).So, there is an arterial obstructive tibio-peroneal diseasse distinguished from the diabetic microangiopathy and different from the obliterating periferic aterioesclerosis observed in non-diabetics.Discussion is to know if the arterial obstructive tibio-' peroneal DISEASE corresponds to an arterial injury caused by the di~betes mellitus or if it is a variance more distal of the obliterating periferic aterioesclerosis that appears specifically in diabetics.
Maintenance treatment was studied in diabetic patients with trophic infected injuries of the inferior members that were not submitted to revascularization as presenting good perfusion conditions.Even patients presenting absence of trunk arterial pulses were tre~ted ' this same way, as the clinical evaluation presented good periferic perfusion, suggesting presence of high colateral circulation.This situation, theorically, enables perforrriance of local debridements, without need of periferic revascularization.The most crll:cial problem at the moment of hospitalization seemed to be infection, with its local systemic manifestations, and not the ischemia of the inferior member as a whole.

In step Heel
All the patients of this serial were submitted to immediate treatment of the infected injuries, with antiobyothicotherapy and surgical debridement.Functional prevention of the member was described as the final condition of the treatment in which debridement, including amputation limited to the toes or instep, enable patient to walk without the help of a substitutive prothesis.
In patients without trunk periferic arterial obstruction, functional preservation levels were significantly higher than in the patients with arterial obstructive tibio-peroneal disease (83.1 % against 45.5%).It keeps evident the importance of the pervicacity of the high volume vases in situations of ischemia and periferic tissue infection.Based on this data, we began to do arteriography in all the patients with trophic injuries of trunk arteria obstruction, with the purpose of finding some small arteria segments for possible distal revascularization in our unity as in other centers (2,5,6).
In the trophic injuries limited to the toes, functional preservation of the inferior member was higher than in other anatomic localizations.In patients with all the arterial periferic pulses detected and distal injuries, result is better than the one of the other groups.

CONCLUSIONS
1. Necrotic and infectious injuries in the inferior members of patients with arterial obstructive tibio-peroneal DISEASES have a more serious evolution than the patients with the same type of injuries, but presenting arterial distal pulses.
2. When these injuries are localizated in the toes of the feets, evolution is significantly better than in the more near injuries, specially when there is no arterial obstru~tive tibio-peroneal disease.