1. by Gregory P. Guyton, and Charles L. Saltzman
The Diabetic Foot
by Gregory P. Guyton, and Charles L. Saltzman
J Bone Joint Surg Am
Volume 83(7):
July 1, 2001
©2001 by The Journal of Bone and Joint Surgery, Inc.

2. Diabetic neuropathy can present in a wide variety of patterns.
Diabetic neuropathy can present in a wide variety of patterns. An individual patient may have any combination of the general syndromes listed above.
Gregory P. Guyton, and Charles L. Saltzman J Bone Joint Surg Am 2001;83:
©2001 by The Journal of Bone and Joint Surgery, Inc.

3. The results of the Diabetes Control and Complications Trial (DCCT) indicated that the percentage of patients in whom abnormalities developed was significantly lower in association with intensive glucose control, according to the findings of both neurologic ...
The results of the Diabetes Control and Complications Trial (DCCT) indicated that the percentage of patients in whom abnormalities developed was significantly lower in association with intensive glucose control, according to the findings of both neurologic examination and objective nerve-conduction studies. (Adapted, with permission, from: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993;329:982. Copyright ” 1993 Massachusetts Medical Society. All rights reserved.)‏
Gregory P. Guyton, and Charles L. Saltzman J Bone Joint Surg Am 2001;83:
©2001 by The Journal of Bone and Joint Surgery, Inc.

4. Photograph of the foot of a patient with neuropathic claw toes, showing ulcerations over the prominent dorsal aspects of the proximal interphalangeal joints where the toes rubbed against the shoe.
Photograph of the foot of a patient with neuropathic claw toes, showing ulcerations over the prominent dorsal aspects of the proximal interphalangeal joints where the toes rubbed against the shoe.
Gregory P. Guyton, and Charles L. Saltzman J Bone Joint Surg Am 2001;83:
©2001 by The Journal of Bone and Joint Surgery, Inc.

5. Figs. 4-A and 4-B A radiograph and clinical photograph of the foot of a patient with a midfoot ulceration from Charcot arthropathy with subsequent collapse.
Figs. 4-A and 4-B A radiograph and clinical photograph of the foot of a patient with a midfoot ulceration from Charcot arthropathy with subsequent collapse. Osseous deformity resulting from neuroarthropathy is one of the strongest risk factors for the development of ulceration.
Gregory P. Guyton, and Charles L. Saltzman J Bone Joint Surg Am 2001;83:
©2001 by The Journal of Bone and Joint Surgery, Inc.

6. Figs. 4-A and 4-B A radiograph and clinical photograph of the foot of a patient with a midfoot ulceration from Charcot arthropathy with subsequent collapse.
Figs. 4-A and 4-B A radiograph and clinical photograph of the foot of a patient with a midfoot ulceration from Charcot arthropathy with subsequent collapse. Osseous deformity resulting from neuroarthropathy is one of the strongest risk factors for the development of ulceration.
Gregory P. Guyton, and Charles L. Saltzman J Bone Joint Surg Am 2001;83:
©2001 by The Journal of Bone and Joint Surgery, Inc.

7. A patient with diabetic cheiropathy (limited joint mobility) exhibits the “prayer sign.” Subtle contractures at the interphalangeal and metacarpophalangeal joints prevent the fingers from fully opposing each other.
A patient with diabetic cheiropathy (limited joint mobility) exhibits the “prayer sign.” Subtle contractures at the interphalangeal and metacarpophalangeal joints prevent the fingers from fully opposing each other. A space is visible between the fingers when a praying posture is attempted.
Gregory P. Guyton, and Charles L. Saltzman J Bone Joint Surg Am 2001;83:
©2001 by The Journal of Bone and Joint Surgery, Inc.

8. The hallux of a patient with severe autonomic neuropathy.
The hallux of a patient with severe autonomic neuropathy. In this disorder, the normal sweat function is disrupted, resulting in dry, cracked skin that can serve as a portal for infection.
Gregory P. Guyton, and Charles L. Saltzman J Bone Joint Surg Am 2001;83:
©2001 by The Journal of Bone and Joint Surgery, Inc.

9. A diagram representing a partial explanation of the pathogenesis of microangiopathy.
Gregory P. Guyton, and Charles L. Saltzman J Bone Joint Surg Am 2001;83:
©2001 by The Journal of Bone and Joint Surgery, Inc.

10. Diabetic patients with autonomic dysfunction often have engorged vasculature when the foot is dependent (left).
Diabetic patients with autonomic dysfunction often have engorged vasculature when the foot is dependent (left). Disordered autoregulation allows the blood to drain rapidly when the foot is elevated, and the color of the leg fades (right). This phenomenon of “dependent rubor” is especially common in patients with neuroarthropathy.
Gregory P. Guyton, and Charles L. Saltzman J Bone Joint Surg Am 2001;83:
©2001 by The Journal of Bone and Joint Surgery, Inc.

11. Mönckeberg sclerosis (medial arterial calcification) is readily apparent on radiographs and is strongly associated with autonomic failure and Charcot arthropathy, as it was in this patient.
Mönckeberg sclerosis (medial arterial calcification) is readily apparent on radiographs and is strongly associated with autonomic failure and Charcot arthropathy, as it was in this patient. Note the smooth, diffuse pattern of calcification (arrows) instead of the irregular intimal calcifications characteristic of common atherosclerosis.
Gregory P. Guyton, and Charles L. Saltzman J Bone Joint Surg Am 2001;83:
©2001 by The Journal of Bone and Joint Surgery, Inc.