3BURDEN & MAGNITUDE60 million feet at risk.25% of Diabetes Patient Experience foot Problem in their lifetime.Risk of Amputation 40 times high Compared to Non Diabetics.75% of all lower limb Amputation are Performed in Diabetics.Every 30 sec one Diabetic looseshis/her toes / foot / limb in the world.Prolong Hospitalization & high Cost of Treatment.
8MANAGEMENTMulti disciplinary approach to save maximum number of limbs.Proper timely & adequate management coupled with foot care education can save % Amputation.High sensitivity to the senseless foot of patient is needed by the health care provider.
9COMPONENTS OF MANAGEMENT Metabolic ControlMechanical ControlEducational ControlVascular ControlMicrobiological ControlWound Control
10METABOLIC CONTROLIn all stages tight Glycemic control is important.Hyperglycemia is important Risk factor for development of neuropathy & Occlusive Vascular disease.Hyperglycemia in Ulcerated foot reduces fibroblast proliferation & growth factor impairs protease activity & Hence retard ulcer healing.Hyperglycemia reduces Chemo taxis & Phagocytosis & Humoral antibodies. Tissueglucose is good media for bacterial Proliferation so, for microbiological control in infected ulcer Glycemic control is essential.Tight Glycemic control in infected Patient should be achieved by insulin infusion followed by SC MDI Regime.
11METABOLIC CONTROLBesides Hyper Glycemic Control of BP, Dyslipidemia & Cessations of Smoking is required.For BP Control in Patient with Neuroischemic foot blocker Should be used with CautionStatins & fibrate are effective & safe in Controlling Dyslipidemia.All Patient need antiplatelate Therapy & DVT Prophylaxis with LMWH in Patient needing Prolonged bed rest.Many Patient have associated Renal & Cardiac Failure requiring Proper adjustment in drug dosage.
12MECHANICAL CONTROLHyper Glycemia affects Practically all tissues of the foot. Changes in foot architecture lead to altered biomechanics of foot with development of high planter pressure under Wt.barring points in naturopathic foot.So, naturopathic ulcers are essentially pressure source & offloading is must for their healing.Histological Studies have proven the efficacy of off loading within 48 hrs. where ulcers changes its characteristics from nonhealing to heeling.
13MECHANICAL CONTROLNeuroischemic ulcers also Respond well to off loading.In severely infected foot non weight barring is desirable with use of crutches wheelchair or zimer’s frame.TCC is gold standard for off loading with healing rate as high as 80% but is costly cumbersome & associated with some complicationRemovable cast walkers therapeutics shoes, half shoe ,PRAFO are the other modality of off loading in ambulatory patient.Healing is directly proportional to impulse loading.
14HEALING OF NEUROPATHIC ULCER USING CUSTOMISED AFO Study of 10 patient presented in NNDU 2004 at Singapore.10 patient with 13 weeks neuropathic ulcer (wagnergrade-1) were studied using off loading with Customize AFO.All Patient healed within 6 week time.
15EDUCATIONAL CONTROLRoutine foot care for all diabetics.Prophylactic diabetes foot ware & trauma Prevention education to high risk patient.Education regarding early sign of infection & Immediate reporting .Non weight bearing & off loading in Ulcerated and infected foot.Rehabilitation & Psycho-social support in patient with major Amputation .
16VASCULAR CONTROLVascular assessment with ABPI &transcutaneous o2 tension as marker, is essential in all diabetic patient.ABPI < 0.5, o2 tension < 30 mm hg or TBPI <30 mm hg denote severe ischemia.In severe Neuroischemic foot attempts to improve vascular perfusion by angioplasty or bypass surgery should be done.
17VASCULAR CONTROLAggressive debridement should be avoided when possible in patient with severe ischemia.Infection should be treated very aggressively as it can have disastrous out come.Analgesic may be needed to relieve rest pain.Larva therapy & hyper baric o2 therapy may be useful adjunctive treatment.
18MICROBIOLOGICAL CONTROL Infection occur in both neuropathic & neuro ischemic foot frequently.Symptom & signs of infection are masked by neuropathy.Patient may present with localized infected ulcer, with surrounding erythema with diffuse spreading erythema ,with massive soft tissue infection with systemic features of toxemia shock.With severe infection only 50 % patient have systemic features of fever & toxemia.
19MICROBIOLOGICAL CONTROL 85% of foot ulcers beings as clean wound detection of early infection & adequate microbiological control block road to amputation.Osteomyelitis may be associated with any of the presentation & all cases with exposed bone, ability to probe to the bone, x-ray /MRF evidences of osteomyelitis ,should be treated as osteomyelitis.Most infection are polymicrobial in nature & culture from deep tissue swab from deep curetting should be obtained initially & then weekly if needed.If soft tissue infection is responding well to conservative treatment OM should be treated conservatively.Most patient respond well to conservative Rx.
21ANTIBIOTICS FOR TREATING THE INFECTED FOOT ANTIBIOTIC TREATMENTMICROORGANISMORALIVENTEROCOCCUSANAEROBESCOLIFORMS(E.COLI, PROTEUS,KLEBSIELLA,ENTEROBACTER)PSEUDOMONASAMOXICILLIN 500 MG TDSMETRONIDAZOLE 400 MG TDSCLINDAMYCIN 300 MG TDSCIPROFLOXACIN 500 MG BDCEFADOXIL 1 G BDRIMETHOPRIP 200 MG BDAMOXICILLIN 500 MG TDSVANCOMYCIN 1 G BD(ACCORDING TO LEVELS)METRONIDAZOLE 500 MG TDSCLINDAMYCIN MG QDSCIPROFLOXACIN 500 MG BDCEFTAZIDIME 1-2 G TDSCEFTRIAXONE1-2 G DAILYGENTAMICIN 5 MG/KG/DAYPIPERACILLIN/CLAVULANATE 4.5 G TDSMEROPENEM 500 MG TO 1 G TDSTICARCILLIN/CLAVULANAT 3.2 G TDSCEFTAZIDIME 1-2 G TDS.
22WOUND CONTROL Good wound control can be achieves by : T : tissue debritment may be surgical, chemical, enzymatic or biological.I : control of infection & inflamation & oedema.M: Providing must environment to wound using saline / hydrogel dressing.E : edge control.
23WOUND CONTROLall irritant chemicals & antibiotics damage the granulating tissues and should be avoided.various dressing materials used for diabetes foot wound include saline soaked gauze , foams ,hydrocolloids , hydrogels ,Alginates, hydrophilicfibre dressing.Advanced wound healing products includes dermagraft ,apligraf,PDGF,promogran etc.Supplementary wound healing techniques includes skingraft ,VAC ,maggot therapy, hyperbaric oxygen.
25SURGICAL APPROACH TO DIABETES FOOT CARE Elective & prophylactic surgery for reducing ulcer risk in stage-1&2 patient include correction of hammer& claw toe. well osteotomy, metatarsal resection, cismoidectomy, Akilistendon lengthing, etc. may be considered when conservative treatment failed.Risk of GA should be dually considered as pt. may have cardiac & renal failure.SA & LA may be sufficient for elective procedure emergency surgery for major amputation &urgent IND may necessary in some patient.