• Users Online: 445
  • Print this page
  • Email this page


 
 
Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 2  |  Page : 215-220

Arteriopathy by doppler ultrasound study and neuropathy by electromyography and nerve conduction study in diabetic foot


1 Department of Surgery, Almahweel General Hospital, Babil Health Directorate, Babylon Province, Iraq
2 Department of Obstetrics and Gynecology, Babil Obestetric, Pediatric Teaching Hospital, Babil Health Directorate, Babylon Province, Iraq

Date of Submission02-Mar-2020
Date of Acceptance26-Apr-2020
Date of Web Publication17-Jun-2020

Correspondence Address:
Sahar Abdl Hussein Jupori
Department of Obstetrics and Gynecology, Babil Obestetric, Pediatric Teaching Hospital, Babil Health Directorate, Babylon Province
Iraq
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJBL.MJBL_14_20

Get Permissions

  Abstract 


Background: Diabetic foot ulcer is a common surgical problem in the surgical population. Objectives: This study evaluates some of the risk factors which are thought to play a role in the development of diabetic foot ulcer by using (color Doppler sonography, electromyography, and nerve conduction study). Materials and Methods: This was a prospective study on patients admitted to the surgical, medical, and orthopedic wards in the Almahweel General hospital in Babylon for a period from December 15, 2016, to December 15, 2018. Data were collected by history, clinical examination, investigation, and Doppler ultrasound for all patients. Results: Sixty-one patients (47 males and 14 females) were included in our study admitted to the Almahweel General Hospital in Babylon, Iraq. All patients showed different degree of peripheral arteriopathy, retinopathy, osteomyelitis, and different degree of neuropathy. Smoking increases the risk of diabetic foot. Conclusions: Smoking increases the severity of peripheral arteriopathy and neuropathy so increases the severity of diabetic foot ulcer. The severity of peripheral arteriopathy and neuropathy increased with increase the duration of diabetes mellitus. Diabetic foot ulcer is due to the coexistence of peripheral arteriopathy and neuropathy.

Keywords: Arteriopathy, color Doppler ultrasound/S, diabetes mellitus, electromyography, nerve conduction study, neuropathy


How to cite this article:
Dawood IS, Jupori SA. Arteriopathy by doppler ultrasound study and neuropathy by electromyography and nerve conduction study in diabetic foot. Med J Babylon 2020;17:215-20

How to cite this URL:
Dawood IS, Jupori SA. Arteriopathy by doppler ultrasound study and neuropathy by electromyography and nerve conduction study in diabetic foot. Med J Babylon [serial online] 2020 [cited 2020 Jul 7];17:215-20. Available from: http://www.medjbabylon.org/text.asp?2020/17/2/215/287044




  Introduction Top


Diabetic foot is a term referring to any pathology in the foot that results directly from diabetes or its long-term complications.[1],[2] The basic pathophysiologic processes that lead to these foot problems are unknown, but vasculopathy, neuropathy, and deformity caused by mechanical imbalance are believed to contribute.[3]

The factors affecting the diabetic foot include (1) a predisposition to peripheral vascular diseases, (2) damage to the peripheral nerves, (3) reduced resistance to infection, and (4) osteoporosis.[4]

This results in the loss of protective sensation, in which the areas of increased mechanical stress are not perceived and may lead to skin breakdown. The sensory neuropathy can be quantified using sophisticated and expensive evaluation techniques are available and include vibratory (or) nerve conduction velocity testing.[3] Motor neuropathy is characterized by intrinsic muscle atrophy that results in motor imbalance and fool deformity.[5]

Diabetes mellitus (DM) is the most common cause of autonomic neuropathy.[2] It is first recognized in 1945 and found to be closely associated with diffuse peripheral neuropathy, especially in long-term diabetics.[6] Autonomic neuropathy in diabetes affects parasympathetic autonomic nervous system earlier than sympathetic system, where cardiodenervation occurs before postural hypotension.[7]

This results in fragmentation, destruction, and dislocation of the bones of foot and ankles. The incidence of Charcot osteoarthepathy in this population is reported at 1%–2.5% with the average interval between the onset of diabetic and occurrence averaging 15 years, Charcot disease does not occur with ischemia; presumably blood flow must be present to support the inflammatory process that result in bone destruction.[3]

The pathogenesis of atherosclerosis and vascular thrombosis in patients with diabetes is similar to that in persons without diabetes except the process is markedly accelerated.[1] The arteriolar lesion of DM is a hyaline arteriolosclerosis (the hyaline intimal material has high glycoprotein content, and therefore, stains strongly with the Periodic-Acid-Schiff method).[8]

A Fontaine classification of chronicles ischemia included Stage 1 asymptomatic; Stage II intermittent claudication; Stage III ischemic rest pain; and finally, Stage IV ulceration or gangrene, or both.[9]

Atherosclerosis affects mainly the medium-sized vessels below the knee; Doppler Studies should corroborate the clinical findings. Superficial ulceration occurs on the toes, deep ulceration typically under the heel. Unlike neuropathic ulcers, these are painful and tender. Digital vessels occlusion may cause dry gangrene of one or more toes. Proximal vascular occlusion is less common but more serious, sometimes resulting in extensive wet gangrene.[3]

Diabetes is associated with hypercoagulability; platelets angregation is enhanced; fibrinogen level are increased; natural anticoagulants in the blood such as protein C are increased, and there is increased plasminogen activator and fibrinolysis, combined with hypercoagulable state contribute to the high incidence of thrombotic complications in diabetic patients.[10]

The aim of this study was to evaluate the risk factors using (Doppler U/S, electromyography [EMG], and nerve conduction) that thought to play a role in the development of diabetic foot ulcer in patients admitted to the surgical, medical, and orthopedic wards in Al-Mahweel General Hospital in Babylon, Iraq.


  Materials and Methods Top


Patients and study design

Sixty-one patients with diabetic food ulcer were admitted in the surgical, orthopedic, and medical wards in Almahaweel General Hospital in Babylon in the period from December 1, 2016, to December 1, 2018.

History taking which includes age, sex, occupation, duration of DM, history of trauma, history of smoking, previous history of diabetic foot, family history, and history of concomitant disease such as hypertension and ischemic heart disease. Clinical examination has done include general examination to exclude any concomitant disease, peripheral pulses in lower limb to correlate with the result of color Doppler US examination. Pin-prick sensation and motor examination correlate with the result of EMG and nerve conduction study (NCS).

Some investigations were done that include X-ray of the foot to confirm and extent of bone involvement. ECG was done to exclude myocardial ischemia.

Ophthalmological examination by ophthalmologist was done to assess the presence of diabetic retinopathy. Clinical classification of diabetic patient according to the Wagner classification was done. Color Doppler U/S examination has been done for all patients to visualize and assess the changes that occur in peripheral vessels as a result of diabetes. EMG and NCS done for all patients to detect and assess the severity of neuropathy.

Ethical approval

The present study was conducted in accordance with the ethical principles that have their origin in the declaration of Helsinki. It was carried out with patients verbal and analytical approval before the sample was taken. The study protocol and the subject information and consent form were reviewed and approved by a local ethics committee.


  Results Top


Sixty-one patients were studied, of which 47 (54.83%) were male and 14 (45.16%) were female. Doppler ultrasound and (EMG and NCV) were done for them during the study period. All patients were NIDDM.

The mean age of the patients was 61. 9 years old (range from 40 to 80 years old) [Table 1].
Table 1: The percentage of diabetic foot in relation to the age

Click here to view


Forty patients (64. 51%) were smokers, of them 12 patients (30%) had a moderate degree of peripheral arteriopathy and 22 patients (55%) had severe degree of arteriopathy, and six patients (15%) had very severe degree of arteriopathy confirmed by color-Doppler U/S.

Eight patients (20%) had mild neuropathy; 16 patients (40%) had moderate neuropathy; and 16 patients (40%) had severe neuropathy.

Twenty-one patients were nonsmokers; three patients (18.18%) had mild degree arteriopathy; 10 patients (45. 45%) had average degree arteriopathy; and 8 patients (36. 36%) had severe degree arteriopathy.

Five patients (27. 27%) had of nonsmoker patients had mild degree neuropathy, 14 patients (63. 63%) had moderate neuropathy, and two patients (0. 09%) had severe neuropathy [Table 2] and [Table 3].
Table 2: The percentage of arteropathy in relation to the smoking

Click here to view
Table 3: The percentage of neuropathy in relation to the smoking

Click here to view


In all patients, the duration of DM range from 1 to 30 years, 11 patients (19.35%) from 1 to 10 years, of whom four patients (33.3%) had mild degree arteriopathy and seven patients (66.7%) had moderate degree arteriopathy.

Three patients (50%) had mild degree neuropathy and three patients (50%) had moderate degree neuropathy. Thirty-four patients (54. 84%) from 11 to 20 years, of whom four patients (11.76%) had mild arteriopathy, 16 patients (5249%) had moderate arteriopathy, 12 patients (3. 3%) had severe arteriopathy, and two patients (5.9%) had very severe arteriopathy. Four patients (F1.76%) had mild neuropathy, 18 patients (52.9%) had moderate neuropathy, and 12 patients (35.3%) had severe neuropathy.

Sixteen patients (25.81%) the duration of disease was from 21 to 30 years, of whom 10 patients (62.5%) had severe degree arteriopathy and six patients (37.5%) had very severe arteriopathy, eight patients (50%) had moderate neuropathy, and eight patients had severe neuropathy [Table 4] and [Table 5].
Table 4: The percentage of arteriopathy in relation to the duration of diabetes mellitus

Click here to view
Table 5: The percentage of neuropathy in relation to the duration of diabetes mellitus

Click here to view


Sixteen patients had hypertension, 10 patients had ischemic heart disease, eight patients had both and 27 patients had no concomitant disease (25. 80%, 16.13%, 12.9%, and 45.16%, respectively) [Table 6].
Table 6: Percentage of diabetic foot in relation to concomitant diseases

Click here to view


Forty-two patients (67. 74%) had retinopathy according to color-Doppler ultrasound examination, of them 14 patients (33. 33%) show moderate degree of peripheral arteriopathy, 22 patients (52. 38%) had severe degree of peripheral arteriopathy, and six patients (14. 28%) had very severe degree of peripheral arteriopathy [Table 7].
Table 7: Percentage of retinopathy in relation to arteriopathy

Click here to view


Nine patients (32. 25%) show no retinopathy, according to color-Doppler examination, four patients (20%) had mild degree of peripheral arteriopathy, 10 patients (50%) had moderate degree of peripheral arteriopathy, and five patients (30%) had severe degree of peripheral arteriopathy.

Common site involved by ulcer was big toe (25; 41.91%), little toe (18; 29.03%), and other sites (18; 29. 03%) [Table 8].
Table 8: Percentage of diabetic foot to the site of ulcer

Click here to view


Sixteen patients (25.8%) had bone involvement by X-ray of the foot, according to color-Doppler study, four patients (25%) had moderate degree of peripheral arteriopathy, eight patients (50%) had severe degree of peripheral arteriopathy, and four patients (25%) had very severe degree of arteriopathy.

According to EMG, NCV four patients (25%) had moderate degree neuropathy and 12 patients (75%) had severe degree of neuropathy.

Forty-five patients (74.19%) had no bone involvement by X-ray of foot, five patients (13.04%) had mild degree of peripheral arteriopathy, 20 patients (43.47%) had moderate degree of peripheral arteriopathy, 18 patients (39.13%) had severe degree of arteriopathy, and two patients (4.35%) had very severe degree of arteriopathy. Four patients (8.69%) had neuropathy, 30 patients (62.08%) had moderate neuropathy, and 11 patients (26.08%) had severe neuropathy.

According to Wagner classification, six patients (9.68%) presented with Grade 0, of whom four patients (66.66%) had mild degree of peripheral arteriopathy and two patients (33.33%) had moderate degree of peripheral arteriopathy confirmed by color-Doppler study. Two patients (33.33%) had mild neuropathy and four patients (66.66%) had moderate neuropathy this confirmed by EMG and NCV.

Seventeen patients (29.03%) presented with Grade 1: according to color-Doppler study, five patients (33.33%) had mild degree of peripheral arteriopathy, eight patients (44.44%) had moderate degree of peripheral arteriopathy, and four patients (22.22%) severe degree of peripheral arteriopathy. According to EMG and NCV, four patients (22.22%) had mild degree of neuropathy and 13 patients (77.77%) had moderate neuropathy.

Twenty-six patients (41.93%) presented with Grade II: according to color Doppler study: 16 patients (61.54%) had moderate degree of peripheral arteriopathy, eight patients (30.77%) had severe degree of peripheral arteriopathy, and two patients (7.7%) had very severe arteriopathy. According to EMG and NCS, 12 patients (46.15%) had moderate peripheral neuropathy and 14 patients (53.85%) had severe neuropathy.

Twelve patients (19.35%) presented with Grade III: according to color Doppler study: four patients (33.33%) had moderate peripheral arteriopathy, two patients (16.67%) had, severe peripheral arteriopathy and six patients (50%) had very severe peripheral arteriopathy. According to EMG and NCS, two patients (16.67%) had moderate neuropathy and 10 patients (83.33%) had severe neuropathy.

Clinically, 37 patients (61.29%) were (−ve) dorsalis pedis arter pulsation. According to color Doppler study, of whom four patients (10.52%) had moderate peripheral arteriopathy, 27 patients (73.68%) has severe arteriopathy, and six patients (15.79%) had very severe arteriopathy. 24 patients (38.7%) presented with (+ ve) dorsalis pedis artery pulsation. According to color Doppler study, four patients (16.67%) had mild peripheral and 30 patients (83.33%) had moderate arteriopathy.

In distal arteries (below the knee), color Doppler study show 4 patients: (6.4%) had mild arteriopathy, 19 patients (32.25%) had moderate arteriopathy, 32 patients (51.61%) had severe arteriopathy and six patients (9. 6%) had very severe arteriopathy.

In proximal arteries (above the knee with popliteal artery) color Doppler study show: 14 patients (22.58%) had mild arteriopathy, 39 patients (64. 51%) had moderate arteriopathy, six patients (9. 6%) had severe arteriopathy, and two patients (3. 2%) had very severe arteriopathy.

Clinically, all patients show the sensory loss by pin-prick examination. EMG and NCS examination show that seven patients had mild degree of motor peripheral neuropathy (12.91%), 32 patients (51.61%) had moderate degree of motor peripheral neuropathy, and 22 patients (35.48%) had severe degree of motor peripheral neuropathy.


  Discussion Top


Only a few studies have investigated the effect of arteriopathy and neuropathy in diabetic foot by using (color Doppler U/S and EMG, NCS).[11]

In our study, 70% of smoker patients had severe degree of arteriopathy by color Doppler sonography [CDS] and 40% of smoker patients had severe degree of neuropathy by EMG and NCS which more than nonsmoker patients in whom (36%) had severe degree of arteriopathy by CDS, and 9.09% had severe degree of neuropathy (EMG, NCS) that mean smoking increase the severity of arteriopathy and neuropathy.[12]

In our study, all patients had arteriopathy by CDS and neuropathy (EMG and NCS) but in different degree of severity, which increase by increase the duration of DM.

During the first 10 years of duration of DM, there are no patients had severe degree arteriopathy and no patients had severe neuropathy, but 33.3% had mild degree arteriopathy (66.7%) had moderate degree arteriopathy, 50% had mild degree neuropathy, and 50% had moderate degree of neuropathy.

During the second 10 years of duration of DM and above 60% of patients had severe degree arteriopathy and 40% of patients had severe degree neuropathy.

In our study, 45.16% of patients had severe-very severe degree of arteriopathy (CDS) had retinopathy and 6.9%) had severe arteriopathy (CDS) and no retinopathy that mean the longer the duration the more the severity of arteriopathy (CDS) the more incidence to develop retinopathy, so there are strong correlation between severe and very severe degree of peripheral arteriopathy (CDS) and retinopathy.[5]

Bone involvement is correlated with severity of peripheral arteriopathy (CDS) and peripheral motor neuropathy (EMG, NCS), the more the severity of peripheral arteriopathy and neuropathy the higher the incidence of osteomyelitis (bone focus). In our study, (87.5%) patients had severe-to-very severe peripheral arteriopathy show bone involvement by X-ray Seventy-five percent patients had severe neuropathy shows that bone involvement (43.48%) patients had severe-very severe peripheral arteriopathy show no bone involvement by X-ray (26.08%). Patients had severe neuropathy show no bone involvement by X-ray.

The severity of arteriopathy (CDS) and neuropathy (EMG and NCS) are proportionally related to grade of diabetic foot ulcer by Wagner classification, the more the severity the higher the grade, in our result, there are no severe degree of arteriopathy and neuropathy in Grade 0, 1. While there are 38.5% patients with severe arteriopathy, and (53.8%) severe neuropathy in Grade II (66.7%) patients had severe arteriopathy and (83.3%) patients had severe neuropathy in Grade III. That means the higher the severity of a rteriopathy confirmed by CDS and neuropathy confirmed by (EMG, NCS) the more the depth of diabetic ulcer [Table 9] and [Table 10].
Table 9: Percentage of arteropathy in relation to Wagner classificatio

Click here to view
Table 10: Percentage of neuropathy in relation to Wagner classification

Click here to view


In our study clinically (61.29%) patients had (−ve) dorsalis pedis artery pulsation, (89.4%) of them show severe-very severe degree of arteriopathy by CDS, realy only (15.7%) of them with no flow ([100%]: stenosis), all of them (89.4%) cannot be detected clinically but can be detected by CDS. U/S equipment are very sensitive type of stethoscope at site where arterial pulse cannot be palpated [Table 11].[13],[14]
Table 11: Percentage of dorsalis pedis artery pulsation in relation to arteriopathy

Click here to view


In our study (61.3%) patients show severe-very severe degree of arteriopathy in distal arteries by CDS and (9.7%) - patients show severe degree of arteriopathy in proximal arteries. That mean atherosclerosis effect all arteries of lower extremities but differ in severity in which the incidence of severity is more in distal arteries than in proximal arteries in opposite to Louis Solomon study [Table 12].[4]
Table 12: Percentage of arteriopathy in color Doppler examination

Click here to view


In our study all patients had atherosclerosis in different degree by (CDS) and all had neuropathy in different degree (by EMG and NCS), that mean there must be arteriopathy and neuropathy coexist to cause diabetic foot ulcer, in opposite to Allan Chain, state that it is often difficult to decide whether afoot lesion in a diabetes is due to arteropathy, neuropathyor both.[15]


  Conclusions Top


Color Doppler study and (electromyography and NCS) highly sensitive to detect arteriopathy and neuropathy in diabetic foot. Smoking increases the severity of peripheral arteriopathy by (Doppler U/S study) and neuropathy by (EMG, NCS) so increases the severity of diabetic foot ulcer. The severity of peripheral arteriopathy by (Doppler U/S study) and neuropathy by (EMG, and NCS) increased with increase the duration of DM. The incidence of retinopathy increases with increase the severity of peripheral arteriopathy by Doppler U/S study. The more the severity of peripheral arteriopathy by Doppler U/S study and neuropathy by (EMG, NCS) the higher the grades of diabetic foot ulcer. Diabetic foot ulcer due to coexistence of peripheral arteriopathy by Doppler U/S study and neuropathy by (EMG and NCS).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Andoreoli TE, Carpenter CC, Griggs RC, Loscalzo J. Cecil Essential of Medicine. Diabetes Mellitus. 5th ed. Mashecan University, W.b Saunders; 2001. p. 583, 598, 987.  Back to cited text no. 1
    
2.
Ajm Boulton. The diabetic foot. Med Int 1993;21:271-4.  Back to cited text no. 2
    
3.
Beaty JH. Orthopedics, Knowledge Update, Home Study Syllabus; Diabetic Foot. 6th ed. Amer Academy of Orthopaedic; 1999. p. 624-5.  Back to cited text no. 3
    
4.
Solomon L, Warwick D, Nayagam S. Appley's System of Orthopedics and Fractures. 8th ed. Arnold, University of Bristol, Liverpool: 2001. p. 507-9.  Back to cited text no. 4
    
5.
Haslett C. Davidson's Principle and Practice of Medicine. 22nd ed. Churchill Living Stone British Medical Journal; 1999. p. 501.  Back to cited text no. 5
    
6.
Foster DW. Pinciples of Internal Medicine, Diabetes Mellitus (Harrison's). Millers, Elsevier Health Sciences: 1991. p. 1759.  Back to cited text no. 6
    
7.
Sobel BE, Roberts R. Hypotension and syncope. In: b-e sobel.r.roberts: Bravnwald, editor. Heart Disease. Almquista, N Eng J Med; 1988. p. 485.  Back to cited text no. 7
    
8.
Walter JB, Israel MS. Atieresclerosis General Pathology. 6th ed. Churchill Living Stone, Edinburgh; 1987. p. 335.  Back to cited text no. 8
    
9.
Jonasson Dr. Surgical aspect of diabetes mellitus. In: Sabiston DC, editor. Sabiston Textbook of Surgery. 15th ed. England medical journal: W- B Saunders Company; 1997. p. 176-84.  Back to cited text no. 9
    
10.
Boulton AJ. The diabetic foot. J Med Clin North Am 1988;72:1513-30.  Back to cited text no. 10
    
11.
Sapico FL, Witte JL, Canawati HN, Montgomerie JZ, Bessman AN. The infected foot of diabetic patients, Quantitative microbiology and analysis of clinical feature. Rev Infect Dis 1984;6 Suppl 1:S171-6.  Back to cited text no. 11
    
12.
Hofer M. Doppler of Peripheral Arteries in Lower Limb. Teaching Manual of Color Doppler Sonography (CDS). 1st ed. Hofer, West Indian Med J; 2001. p. 10-71.  Back to cited text no. 12
    
13.
Payan I. Clinical Electromyography, Medicine Middle East. Payan, Oxford University; 1981. p. 1040-3.  Back to cited text no. 13
    
14.
Victor AM. Principle of Neurology. New York: C, V, A.; 1998.p.737.  Back to cited text no. 14
    
15.
Kand R, Lee L. The Electromyographer's Hand Book. 2nd ed. Little Brown, Journal of Neurophysioiogy Usa; usa: 1990. p. 9-15.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusions
References
Article Tables

 Article Access Statistics
    Viewed77    
    Printed0    
    Emailed0    
    PDF Downloaded10    
    Comments [Add]    

Recommend this journal