МИНИСТЕРСТВО ОБРАЗОВАНИЯ РОССИЙСКОЙ ФЕДЕРАЦИИ Федеральное агентство по здравоохранению и социальному развитию ГОУ ВПО Челябинская государственная медицинская академия Кафедра хирургических болезней и урологии
Н. М. Грекова, В. Н. Бордуновский, И. В. Гурьева
ДИАГНОСТИКА И ХИРУРГИЧЕСКОЕ ЛЕЧЕНИЕ СИНДРОМА ДИАБЕТИЧЕСКОЙ СТОПЫ
Учебное пособие для системы послевузовского профессионального образования врачей
Рекомендовано учебно-методическим объединением по медицинскому и фармацевтическому образованию ВУЗов России
в качестве учебного пособия для системы послевузовского профессионального образования врачей
Гриф УМО –17—29/146 от 13.04.2009
УДК 616.379–008.64–06:617.58 ББК 54.15
Профессор кафедры хирургических болезней и клинической ангиологии Московского государственного Медико-стоматологического университета, Заслуженный деятель науки РФ, доктор медицинских наук Б. С. Брискин
Ведущий научный сотрудник отдела эндокринологии ФГУ «Федеральный центр сердца, крови, и эндокринологии им. В. А. Алмазова ФА по оказанию высокотехнологичной медицинской помощи», доктор медицинских наук В. Б. Бреговский
Профессор кафедры торакальной хирургии Российской Медицинской академии последипломного образования, доктор медицинских наук
Грекова Н. М. – ассистент кафедры хирургических болезней и урологии ЧелГМА, кандидат медицинских наук;
Бордуновский В. Н. – заведующий кафедрой хирургических болезней и урологии ЧелГМА, доктор медицинских наук, профессор.
Гурьева И. В. — директор центра «Диабетическая стопа» ФБМСЭ, доктор медицинских наук, профессор каф. эндокринологии РМАПО, Представитель России в Международной рабочей группе по Диабетической стопе — консультативной секции Международной Федерации Диабета.
Учебное пособие отражает современные взгляды на этиологию, патогенез, классификацию, диагностику синдрома диабетической стопы. Представленная лечебная тактика соответствует принципам доказательной медицины. Подробно освещена хирургическая тактика и техника, наиболее часто производимых хирургических вмешательств на нижней конечности. Рассматриваются вопросы, касающиеся органосохраняющих вмешательств на стопе. Приведен список литературы для углубленного изучения темы. Пособие предназначено врачам, обучающимся в системе последипломного образования, – хирургам, эндокринологам, ортопедам. Учебное пособие соответствует типовой учебной программе дополнительного профессионального образования врачей по специальности 040126 – «Хирургия», утвержденной МЗ РФ, Москва, 2002 г.
Учебное пособие утверждено на заседании Ученого Совета ГОУ ВПО «ЧелГМА» (протокол № 3 от 24 октября 2008)
1. Определение, патогенез, классификация синдрома диабетической
1.1. Определение синдрома диабетической стопы .
1.2. Хирургическая анатомия стопы.
1.3. Патогенез синдрома диабетической стопы.
1.4. Классификация синдрома диабетической стопы.
2. Клиника, диагностика гнойно-некротических поражений стопы
у больных сахарным диабетом .
2.1. Диагностика диабетической нейропатии.
2.2. Диагностика диабетической макроангиопатии.
2.2.1. Физикальные методы обследования артерий нижних конечностей.
2.2.2. Ультразвуковые методы обследования артерий нижних конечностей.
2.2.3. Другие неинвазивные методы визуализации артерий нижних
2.2.4. Рентгенконтрастная ангиография нижних конечностей.
3. Лечение гнойно-некротических поражений стопы при сахарном
3.1. Реваскуляризация конечности при критической ишемии на фоне
синдрома диабетической стопы.
3.2. Тактика хирурга при лечении гнойно-некротических поражений
стопы больных сахарным диабетом.
3.3. Оперативные вмешательства при синдроме диабетической стопы.
3.4. Вакуумная терапия гнойных ран при синдроме диабетической
3.5. Пластическое закрытие ран при синдроме диабетической стопы.
3.6. Медикаментозная терапия гнойно-некротических поражений стопы
при сахарном диабете.
4. Принципы профилактики гнойно-некротических поражений при
синдроме диабетической стопы.
Список рекомендуемой литературы.
ГБО – гипербарическая оксигенация ДАП – диабетическая ангиопатия ДНП – диабетическая нейропатия ДОАП – диабетическая остеоартропатия КИ – критическая ишемия
КИН – контраст-индуцированная нефропатия КТА – компьютерно-томографическая ангиография ЛПИ – лодыжечно-плечевой индекс МРА – магнитно-резонансная ангиография
МСКТА – мультиспиральная компьютерно-томографическая ангиография ОПН – острая почечная недостаточность ОРИТ – отделение реанимации и интенсивной терапии
ПСП – пероральные сахароснижающие препараты ПТФЭ – политетрафторэтилен
РАСХИ – российская ассоциация специалистов по хирургическим инфекциям СД – сахарный диабет СДС – синдром диабетической стопы
УЗДГ – ультразвуковая допплерография ХОЗАНК – хроническое облитерирующее заболевание артерий нижних
конечностей ЦДК – цветовое доплеровское картирование
ЦДКЭ – цветовое доплеровское картирование по энергии DFSG – рабочая группа по изучению диабетической стопы EASD – Европейская ассоциация сахарного диабета MRSAМетициллин резистентный золотистый стафилококк
ТсрО 2 – Чрескожное парциальное напряжение кислорода в тканях
Качество жизни пациента, страдающего сахарным диабетом, и сама его жизнь нередко подвергаются серьезной опасности. Вместе с поражением сердца, головного мозга, почек и глаз заметную роль в этом играет синдром диабетической стопы.
История изучения гнойно-некротических поражений стопы у больных сахарным диабетом в России, имеющая отражение в фундаментальных трудах, имеет чуть более чем 20летнюю историю. В отечественной литературе понятие «Диабетическая стопа» и первое определение этой патологии появилось в 1987 году в переводе с английского, в докладе исследовательской группы ВОЗ по сахарному диабету.
Особенностям течения раневого процесса при сахарном диабете посвящен раздел капитального труда «Раны и раневая инфекция» под редакцией М. И. Кузина, Б. М. Костюченок, (1990). Здесь впервые было отвергнуто господствующее в то время негативное отношение к радикальному иссечению гнойно-некротического очага у больных сахарным диабетом. В работе подверглось критике общепринятое положение о том, что при сахарном диабете после иссечения очага инфекции нецелесообразно ушивание раны и ее пластическое закрытие. Были сформулированы основы активной хирургической тактики при гнойно-некротических процессах у больных сахарным диабетом (СД).
В 1991 году вышла в свет монография Б. М. Газетова и А. П. Калинина «Хирургические заболевания у больных сахарным диабетом». Здесь было раскрыто понятие «диабетическая стопа» и несколько разделов посвящены патологии стопы при сахарном диабете.
Е. В. Кулешов, и С. Е. Кулешов (1996) в монографии «Сахарный диабет и хирургические заболевания» опубликовали, в частности, результаты изучения заживления ушитых и гнойных ран при СД. Авторы, измеряя парциальное напряжение кислорода в тканях, составили «оксиметрическую карту гнойного очага и инфильтрата». Здесь же представлено подробное описание клинических форм диабетической стопы и, что особенно
важно, диабетической остеоартропатии с известными в то время теориями патогенеза этого проявления Синдрома диабетической стопы (СДС).
Первая классическая отечественная монография «Синдром диабетической стопы» (Дедов И. И., Анциферов М. Б., Галстян Г. Р., Токмакова А. Ю.) вышла в 1998 году. В этом труде впервые подробно рассмотрены все без исключения аспекты этой сложнейшей патологии. До сих пор — это единственная книга, где освещены вопросы хирургической тактики при СДС.
Переломным моментом в организации помощи больным синдромом диабетической стопы в России является выход в свет русского перевода «Международного соглашения по диабетической стопе», составленного Международной рабочей группой по диабетической стопе (перевод И. В. Гурьевой, 2000). С этого времени междисциплинарная помощь больным синдромом диабетической стопы в России стала подчиняться требованиям мировых стандартов.
Высока практическая и теоретическая значимость двух последних монографий, посвященных синдрому диабетической стопы. Это «Поражение нижних конечностей при сахарном диабете» (В. Б. Бреговский, А. А. Зайцев, А. Г. Залевская, О. И. Карпов, И. А. Карпова, Т. Л. Цветкова, 2004) и «Диабетическая стопа» (И. И. Дедов, О. В. Удовиченко, Г. Р. Галстян, 2005). Эти книги являются настольными и служат «руководством к действию» эндокринологов, терапевтов, клинических фармакологов, ортопедов, лучевых диагностов и других специалистов, занимающихся этой сложной патологией.
Основными клиническими проявлениями синдрома диабетической стопы являются хронические язвы, критическая ишемия и неинфекционная деструкция костей и суставов – диабетическая нейроостеоартропатия или стопа Шарко. Именно язвы являются наиболее распространенным и угрожающим потере конечности состоянием диабетической стопы вследствие присоединения вторичной инфекции и развития гнойнонекротического процесса, гангрены, сепсиса.
Гнойный процесс любой локализации в условиях гипергликемии и абсолютной или относительной инсулиновой недостаточности сопровожда-
ется прогрессирующим некрозом тканей. В гнойной ране, на фоне синдрома диабетической стопы, деструкция развивается быстрее, чем где–либо и сопровождается распространением гноя в глубокие ткани и в проксимальные отделы стопы и голени. Именно поэтому в мире каждый час происходит 55 ампутаций нижних конечностей у больных сахарным диабетом.
В настоящее время специальности подиатр (от английского слова podiatrist), не существует в нашей стране, и проблемами этого, весьма распространенного синдрома, занимаются хирурги и эндокринологи.
К сожалению, тиражи специальных и общих руководств для хирургов, монографий, справочников, учебников, в которых отражены практические рекомендации по диагностике и лечению гнойно-некротических поражений стопы у больных сахарным диабетом, недостаточны. Эти книги не имеют должного распространения в научно-медицинских библиотеках и розничной книжной сети.
В предлагаемом пособии отражены этиология, патогенез и наиболее распространенные классификации синдрома диабетической стопы, которые имеются в отечественной и зарубежной литературе последних лет. Освещены вопросы диагностики и дифференциальной диагностики форм синдрома диабетической стопы.
Значительная часть пособия посвящена хирургической тактике, оперативному лечению и медикаментозной терапии гнойно-некротических поражений стопы у больных сахарным диабетом.
В пособии имеются ситуационные задачи и тест-контроль.
Пособие предназначено хирургам системы послевузовского профессионального образования врачей, а также может быть полезно интернам и клиническим ординаторам хирургических специальностей, может заинтересовать эндокринологов, врачей кабинета «Диабетическая стопа».
1. Определение, патогенез, классификация синдрома диабетической стопы
Нижняя конечность представляет собой сложный аппарат для опоры и движения. При нагрузке вся тяжесть тела через голень передается на своды стопы, сформированные костями, суставами, мышцами и фиброзными образованиями. Поэтому при сочетании патологии нервов, сосудов, костей, суставов, вызванных сахарным диабетом, стопа особенно подвержена различным деформациям и поражениям.
1.1. Определение синдрома диабетической стопы
Согласно ВОЗ, понятие «Синдром диабетической стопы» определяется, как самостоятельное осложнение СД, наряду с диабетическим поражением глаз, почек, нервной и сердечно-сосудистой систем. Это «комплекс анато- мо-функциональных изменений стопы, связанный с диабетической нейропатией, микро- и/или макроангиопатией, на фоне которых развиваются тяжелые гнойно-некротические процессы». Любой из этих факторов может играть ведущую роль, хотя, обычно, все они присутствуют в той или иной степени.
На основе этого определения ВОЗ Международное соглашение по диабетической стопе дает следующее определение этого синдрома:
«Инфекция, язва и/или деструкция глубоких тканей, связанная с неврологическими нарушениями и снижением магистрального кровотока в артериях нижних конечностей различной степени тяжести».
Целью практического хирурга в лечении синдрома диабетической стопы является сохранение опорной и рессорной функции стопы в условиях острой хирургической патологии, которая чаще всего является гнойным и/или некротическим поражением различной локализации, распространенности, глубины.
1.2. Хирургическая анатомия стопы
Стопа – это дистальный отдел нижней конечности, которая служит опорным и пружинящим аппаратом при стоянии, ходьбе, беге.
На тыльной поверхности стопы под кожей расположена поверхностная фасция. Далее — тонкий слой подкожной жировой клетчатки и собствен-
ная фасция стопы, под которой лежат сухожилия длинных разгибателей. Непосредственно под ними – a. dorsalis pedis (проекционная линия – от середины расстояния между лодыжками до первого межпальцевого проме-
жутка), a. arcuata с ветвями и n. peroneus profundus.
Еще глубже расположены короткие разгибатели пальцев, которые начинаются от пяточной кости. Фасциальный мешок для сухожилий длинных разгибателей с их синовиальными влагалищами и коротких мышц стопы образуется из собственной фасции тыла и из глубокой фасции, покрывающей кости предплюсны, плюсны и межкостные мышцы. На подошве собственная фасция сильно утолщена и образует в средней своей части сухожильно-блестящий подошвенный апоневроз, натягивающийся от пяточного бугра до основания пальцев.
На уровне головок плюсневых костей, при помощи поперечных волокон, образуется 3 комиссуральных отверстия, через которые глубокое ложе подошвы сообщается с клетчаткой межпальцевых промежутков. От апоневроза вглубь, к длинной связке подошвы и к глубокой подошвенной фасции идут фиброзные перегородки, разделяющие подапоневротическое пространство на четыре ложа. Медиальное, латеральное ложе и среднее.
При синдроме диабетической стопы особое значение имеет выделение задних ее отделов – пяточной и надпяточной областей.
Пяточная область содержит бугор пяточной кости, покрытый надкостницей. От его нижней передней поверхности начинается мощная подошвенная связка, являющаяся верхней стенкой подошвенного канала. Более поверхностно, от его надкостницы берут начало короткие мышцы подошвы. И, ближе всего к коже, от пяточного бугра начинается подошвенный апоневроз.
К задней поверхности пяточного бугра прикрепляется ахиллово сухожилие. Пяточный бугор окружен подкожной клетчаткой, пронизанной мощными фиброзными пучками, соединяющими надкостницу и кожу. Эти тяжи разделяют жировую ткань на дольки. Всвязи с этим, гнойнонекротический процесс в мягких тканях пяточной области быстро распространяется вглубь, и поражает надкостницу и кость. Надпяточная область
содержит в себе ахиллово сухожилие с окружающим его влагалищем, сухожилие подошвенной мышцы и синовиальную сумку.
Под ахилловым сухожилием, между его передней поверхностью и глубоким листком собственной фасции голени, покрывающим заднюю поверхность большеберцовой кости, расположен слой жировой клетчатки (рис. 1-А, 1-Б). В это пространство гной может попадать при флегмоне пяточной области, из клетчатки, окружающей пяточный бугор. Причина таких флегмон у больных СД – ссадины, мозоли, трещины, трофические язвы в местах повышенного давления при нарушенной статикодинамической функции стопы, связанной с диабетической остеоартропатией и нейропатией.
Среди дистальных отделов стопы выделяют межпальцевые промежутки. При СДС их строение имеет особое значение, т. к. именно здесь расположены начальные отделы собственных пальцевых артерий, просвет которых часто оказывается сужен или полностью облитерирован при диабетической макроангиопатии. С развитием изолированной межпальцевой флегмоны или при распространении гноя в эту область из других отделов стопы, кровоснабжение пальца резко нарушается. Возможно развитие вторичной гангрены пальца.
Практическое значение в гнойной хирургии стопы имеет сообщение клетчаточных пространств подошвы и тыла друг с другом и возможные пути распространения гноя. Срединное клетчаточное пространство, в котором находится подошвенная артериальная дуга, вдоль клетчатки, окружающей этот сосуд, а также по сухожилиям сгибателей пальцев сообщается с лодыжечным каналом и с глубоким ложем голени. Сухожилие длинного сгибателя 1 пальца на своем пути через лодыжечный канал тесно прилежит к задним отделам капсулы голеностопного сустава, которая здесь особенно тонка. Гной, распространяющийся по сухожилию, может вызвать деструкцию капсулы сустава и попасть в его полость, вызвав гнойный артрит. Срединное ложе подошвы через комиссуральные отверстия в подошвенном апоневрозе имеет связь с подкожной клетчаткой подошвы, межпальцевыми промежутками, боковыми и тыльными сторонами пальцев. Вдоль глубокой подошвенной ветви тыльной артерии стопы и по
Эндоваскулярное лечение диабетической стопы
Диабетическая стопа — страшное заболевание.
Спасти ногу – спасти жизнь.
Синдром диабетической стопы (СДС) – одно из самых страшных осложнений сахарного диабета (СД). При нем развиваются язвенные, гнойно-некротические процессы, гангрена – нога начинает буквально гнить. Человек теряет навыки самообслуживания, от постоянного дискомфорта, постоянных болей, из-за отсутствия надежды на излечение начинается деградация личности — среди таких больных очень высок процент суицидов.
Диабетическая стопа (diabetic foot) – позднее осложнение СД, патологическое состояние стоп в виде гнойно — некротических процессов, язв и костно-суставных поражений, возникающее на фоне изменения периферических нервов, сосудов, кожи и мягких тканей, костей и суставов.
Определение ВОЗ: инфекция, язва и/или деструкция глубоких тканей, связанная с неврологическими нарушениями, снижением магистрального кровотока в артериях нижних конечностей различной степени тяжести.
В течение жизни у 15% пациентов с СД образуются язвы стопы. В 10 раз чаще СДС развивается у лиц со вторым типом сахарного диабета. У больных диабетом каждое увеличение гликированного гемоглобина А1с на 1% приводит к 26% увеличению риска развития заболевании артерий ног. Из общей популяции больных с язвой стопы, 10-24% подвергается ампутации, что, со своей стороны, увеличивает смертность, как в ближайшем, так и в отдаленном периодах. Мрачен прогноз и после ампутации, через 2 года умирает от 30 до 50 процентов пациентов, умирает не столько от самого хирургического вмешательства, сколько от развивающих осложнений и сопутствующих заболеваний.
На сегодняшний день идет постоянный поиск новых методов лечения для сохранения конечностей и заживления трофических поражений.
Все больные с СД и трофическими язвами должны быть обследованы на предмет заболевания артерий нижних конечностей.
При отсутствии клинического улучшения нейропатических язв на фоне лечения более 2 недель показано проведение ангиографии с обязательным контрастированием артерий голени и стопы (Рекомендации TASC 2 (2007)).
Возможно ли лечение?
Трофические язвы при диабете могут быть нейропатические, ишемические и смешанные. В основном в 60-70% случаях язвы нейропатические, в 5- 10% случаях – ишемические, а 20-39% смешанные – нейроишемические. Несмотря на то, что большинство диабетических язв являются нейропатическими, необходимо исключить ишемический генез язвы, который имеет большое влияние на исход. И принципиальное значение приобретает раннее обследование пациентов на предмет поражения магистральных артерии нижних конечностей. До 85% ампутаций могут быть предотвращены при раннем выявлении и надлежащем лечении.
Действительно, участь больных незавидна. Основной метод лечения — это местное лечение и плюс гигиенический уход за "болячками". Но рано или поздно все равно встает вопрос об ампутации. Причем с постепенным повышением уровня ампутации: сначала палец, потом стопа, голень, бедро. Поэтому реваскуляризация (восстановление кровообращения) является жизненно необходимой мерой для сохранения функциональной конечности и обезболивания. Выбор метода реваскуляризации (реконструктивная или эндоваскулярная хирургия) зависит от состояния больного и конечности, а также от оценки риска вмешательства на основании сопутствующих заболеваний и ожидаемых результатов операции.
Непосредственные и отдаленные результаты реконструктивных (шунтирующих) операций артерий голеней оставляют желать лучшего и, к сожалению, из-за многоуровневых поражений артерий нижних конечностей очень часто их проведение невозможно.
Итак, получается, что до недавнего времени основным, самым распространенным методом лечения при диабетической стопе остается ампутация, но потеря конечности в целях спасения жизни сопровождается высокой послеоперационной смертностью. Да и стоимость дальнейшего лечения и реабилитации возрастает втрое.
Размышление по теме: без ног жить можно, но с ногами лучше!
Конечно, если рассуждать, жить без ног можно, особенно при сегодняшнем развитии ортопедической индустрии. Но всегда надо помнить: одно дело травматическая ампутация конечности у молодых без сопутствующих заболеваний (мы же знаем множество героических историй…), а другое – ампутация у больных с синдромом диабетической стопы с множественными сопутствующими заболеваниями. Статистика ужасная — в течение 3 лет умирает каждый второй пациент с ампутированной конечностью. То есть, сохранение конечности напрямую связано с сохранением жизни.
И конечно все: и врачебное сообщество и медицинская индустрия предпринимали и предпринимают огромные усилия для разрешения такой большой социальной задачи.
Появилась надежда — лечение возможно!
Настоящей панацеей стал метод эндоваскулярного лечения диабетической стопы (который также называют ангиопластикой артерий ног при синдроме диабетической стопы). Хирургическое вмешательство производится без наркоза, без разреза через пункцию артерии с минимальной потерей крови. При этом возможно восстановление проходимости не только артерий голеней, но и так называемых путей притока: подвздошных и бедренных артерий.
Этот способ в мире и в России активно разрабатывается в последние 10-15лет. С помощью такого лечения можно избежать ампутации конечностей. Операция состоит в том, что через предварительно сделанные проколы в артерию вводят специальные катетеры. Через эти трубочки с помощью специальных баллонов эндоваскулярные хирурги восстанавливают проходимость и расширяют закрытые сосуды (их сужение или полное закрытие и приводит к некрозу тканей). После этого в восстановленный просвет ставят специальные металлические каркасы – стенты, которые впоследствии не дают сосудам закрываться. Прогресс в развитии методики ангиопластики обусловлен технологическими достижениями: специальный инструментарий позволяет с высокой эффективностью восстанавливать закрытые сосуды, а стенты, особенно с лекарственными покрытиями, позволяют достичь хороших отдаленных результатов. На все эти действия врачам требуется час с небольшим.
Метод, в отличие от шунтирующих операций, не имеет ограничений по возрасту и сопутствующим заболеваниям. Результаты эндоваскулярных вмешательств действительно обнадеживающие. Почти сразу в день операции начинается уменьшение болевых ощущений и начинается довольно долгий процесс заживления трофических изменений. И с этого момента принципиальное значение приобретает медикаментозное лечение СД и других сопутствующих заболеваний и, что самое важное, — правильный медицинский "уход" — местное лечение за диабетической стопой.
Возможность восстановления регионарного кровотока на разных уровнях ноги, малотравматичность операции, быстрая реабилитация, обнадеживающие непосредственные и отдаленные результаты, улучшение качества и прогноза жизни больных, позволяют считать эндоваскулярную хирургию методом выбора при лечении ишемических и нейроишемических форм СДС.
Залог будущих успехов при лечении СДС состоит в междисциплинарном подходе лечения, когда врачи различных специальностей: эндокринолог, общий хирург, подиатр, сосудистый — эндоваскулярный хирург, дерматолог объединяются и совместно действуют на разных этапах лечения СДС. Такой подход был использован при создании службы диабетической стопы в ГКБ № 71 г. Москвы. Такой же подход позволил в скандинавских странах снизить количество "высоких" ампутации в 4 раза, а в США более чем в 8 раз.
Сотрудники отделения сердечно-сосудистой патологии ГКБ №71 г. Москвы имеют самый большой опыт в России (более 800 больных) эндоваскулярного лечения больных с критической ишемией и синдромом диабетической стопы. Как уже было отмечено, возможности эндоваскулярных методов лечения позволяют одномоментное или многоэтапное лечение поражений артерий нижних конечностей всех уровней: подвздошных артерий, бедренных артерий, подколенной артерии, артерий голени и артерий стоп, используя при этом как стандартные, так и оригинальные (ретроградные доступы через подколенную артерию, артерии стопы) доступы и технологии для проведения оперативных вмешательств.
Обладая всеми этими технологическими возможностями, хирургическим опытом и огромным желанием помочь страдающим, на сегодняшний день можно уверенно утверждать, что шанс спасти конечность и улучшить качество жизни, и, в конечном итоге, спасти жизнь, есть почти у всех пациентов. А, как минимум, эндоваскулярная хирургия позволяет уменьшить уровень ампутации, сохранив этим опорную функцию конечности и высокую социальную активность пациента.
Обратитесь вовремя к специалистам…..
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В настоящее время проблема лечения больных сахарным диабетом (СД) приобретает все большую актуальность. Этим заболеванием страдает 5–6% населения развитых стран. Число таких больных постоянно растет и каждые 10–15 лет удваивается [3,4,7]. Гнойно–некротические поражения при синдроме диабетической стопы (СДС) продолжают оставаться наиболее актуальной проблемой современной хирургии [10,13].
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