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Page 1 Diabetic Foot. Page 2 Diabetic Foot Any foot pathology that results directly from diabetes or its long term complications ( Boulton 2002) The foot.

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Presentation on theme: "Page 1 Diabetic Foot. Page 2 Diabetic Foot Any foot pathology that results directly from diabetes or its long term complications ( Boulton 2002) The foot."— Presentation transcript:

1 Page 1 Diabetic Foot

2 Page 2 Diabetic Foot Any foot pathology that results directly from diabetes or its long term complications ( Boulton 2002) The foot of a diabetic patient that has the potential risk of pathologic consequences including infection, ulceration and or destruction of deep tissues associated with neurologic abnormalities, various degrees of peripheral vascular disease and/or metabolic complications of diabetes in the lower limb

3 Page 3 Diabetic Foot Diabetic foot ulcer Diabetic foot infections Charcot Joints

4 Page 4 Epidemiology DM is the largest cause of neuropathy 50% patients don’t know that they have diabetes Foot ulcerations is most common cause of hospital admissions for Diabetics Expensive to treat, may lead to amputation and need for chronic institutionalized care

5 Page 5 Pathophysiology Combination of factors –Neuropathy –Peripheral arterial disease –Abnormal foot biomechanics –Delayed wound healing

6 Page 6 Diabetic Neuropathy Microvascular complication Occlusion of vasa nervosum Can be –Sensory / motor/ autonomic –Mono / poly / radiculopathy Most commonly distal symmetric sensory neuropathy

7 Page 7 Neuropathy Sensory Neuropathy –Loss of touch and temperature –Minor trauma goes unnotices Disorders of proprioception –Abnormal weight bearing –Callus formation, ulceration Motor and sensory neuropathy –Abnormal foot biomechanics –Structural changes

8 Page 8 Neuropathy Autonomic neuropathy –Anhidrosis in lower limbs –Drying of feet –Fissure formation

9 Page 9 Altered biomechanics Abnormal weight bearing Fixed foot deformities –Hammer toe –Claw toe –Prominent metatarsal heads –Charcot’s joints

10 Page 10 Hammer Toes Claw Toes

11 Page 11 Hallux Valgus

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16 Page 16 Other factors Impaired wound healing –Does not allow resolution of fissures and minor injuries –Increased chances of infection

17 Page 17 Peripheral arterial disease 30 times more prevalent in diabetics Diabetics get arteriosclerosis obliterans or “lead pipe arteries” Calcification of the media Often increased blood flow with lack of elastic properties of the arterioles Not considered to be a primary cause of foot ulcers

18 Page 18 Causal Pathways for Foot Ulcers Neuropathy Deformity ULCER % Causal Pathways Neuropathy: 78% Minor trauma:79% Deformity:63% Behavioral ?   Poor self-foot care Minor Trauma - Mechanical (shoes) - Thermal - Chemical

19 Page 19 Risk Factors for Diabetic Foot Male Sex DM > 10 years duration Peripheral neuropathy Abnormal foot structure Peripheral arterial disease Smoking H/O previous ulceration / amputation Poor glycemic control

20 Page 20 EVALUATION OF A PATIENT WITH DIABETIC FOOT

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22 Page 22 Examination  Neurological examination ◦ Vibration perception ◦ Light pressure ◦ Light touch ◦ Two point discrimination ◦ Pain ◦ Temperature perception ◦ Deep tendon reflexes ◦ Clonus ◦ Babinski test ◦ Romberg test  Vascular Examination ◦ Palpation of pulses ◦ Skin/limb colour changes ◦ Presence of edema ◦ Temperature gradient ◦ Skin changes  Atrothy  Abnormal wrinkling  Absence of hair  Onychodystrophy ◦ Venous filling time

23 Page 23 Examination  Dermatological ◦ Skin appearance ◦ Calluses ◦ Fissures ◦ Nail appearance ◦ Hair growth ◦ Ulceration/infection/ gangrene ◦ Interdigital lesions ◦ Tinea pedis ◦ Markers of diabetes  Musculoskeletal ◦ Biomechanical abnormalities ◦ Structural deformities ◦ Prior amputation ◦ Restricted joint mobility ◦ Tendo Achilles contractures ◦ Gait evaluation ◦ Muscle group strength testing ◦ Plantar pressure assessment

24 Page 24 Investigations Blood investigation –FBS, PPBS –HbA1C –Complete blood counts –ESR –RFT –Urinalysis –Wound / blood culture

25 Page 25 Imaging Plain X-rays –Osteomyelitis –Fractures –Dislocations –Osteolysis –Structural foot abnormalities –Arterial calcification –Tissue gas

26 Page 26 X rays

27 Page 27 Vascular evaluation Non invasive evaluation –Doppler segmental pressure and waveform analysis –Ankle brachial pressure index –Toe blood pressure –Transcutaneous CO2 –Laser doppler velocimetry

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29 Page 29 Interpretation of ABI InterpretationABI Normal Mild obstruction Moderate obstruction Severe obstruction<0.40 Poorly compressible >1.30 2° to medial calcification *Poor ulcer healing with ABI < 0.50 **Further vascular evaluation needed

30 Page 30 Vascular evaluation Invasive evaluation –Arteriography –MR angiography –CT angiography

31 Page 31 CLASSIFICATION OF DIABETIC FOOT ULCERS

32 Page 32 Wagner’s Classification 0 – Intact skin (impending ulcer) 1 – superficial 2 – deep to tendon or ligament 3 - deep abscess, osteomyelitis 4 – gangrene of toes or forefoot 5 – gangrene of entire foot

33 Page 33 Wanger’s stage 0

34 Page 34 Wanger’s Stage 0

35 Page 35 Classification Type 1, type 2

36 Page 36 Classification Type 3

37 Page 37 Type 4

38 Page 38 Treatment  Prevention ◦ Identification of high risk patients ◦ Patient education  Careful selection of foot wear  Daily inspection of feet  Daily foot hygiene  Keep foot clean, moist  Avoidance of self treatment of foot abnormalities and high risk behavior ( walking barefoot)  Prompt consultation with health care provider  Orthotic shoes and devices  Callus management  Nail care

39 Page 39 Identifying at risk patient  History: ◦ Prior amputation or foot ulcer ◦ Peripheral artery disease (PAD)  Exam: ◦ Insensate ◦ Foot deformities ◦ Absent pulses ◦ Prolonged venous filling time ◦ Reduced ABI ◦ Pre-ulcerative cutaneous pathology

40 Page 40 Risk stratification for ulcer risk Risk Level Foot Ulcer %/yr 3: Prior amputation Prior ulcer 28.1% 18.6% 2: Insensate and foot deformity or absent pedal pulses 6.3% 1: Insensate 4.8% 0: All normal 1.7%

41 Page 41 Treatment –Attention to other risk factors Smoking Hypertension Dyslipidemia –Glycemic control

42 Page 42 Treatment Plantar surface of the foot is the most common site Ulcer may be –Primarily neuropathic –a/w surrounding cellulitis/ ostemyelitis Cellulitis without ulceration may occur

43 Page 43 Treatment Offloading Debridement Wound dressing Antibiotics Revascularisation Amputation

44 Page 44 Treatment Wagner 0-2 –Total contact cast –Distributes pressure and allows patients to continue ambulation –Principles of application Changes, Padding, removal –Antibiotics if infected

45 Page 45 Treatment Wagner 0-2 –Surgical if deformity present that will reulcerate Correct deformity exostectomy

46 Page 46 Treatment Wagner 3 –Excision of infected bone –Wound allowed to granulate –Grafting (skin or bone) not generally effective

47 Page 47 Treatment Wagner 4-5 –Amputation ? level

48 Page 48 Indications for Amputation Uncontrollable infection or sepsis Inability to obtain a plantar grade, dry foot that can tolerate weight bearing Non-ambulatory patient Decision not always straightforward

49 Page 49 Treatment After ulcer healed –Orthopedic shoes with accommodative (custom made insert) –Education to prevent recurrence

50 Page 50 Wound Care products Dressings –Gauze pads –Transparent films –Hydrogels –Foam –Hydrocolloid –Alginate –Collagen dressing –Antimicrobial dressings

51 Page 51 Wound care products  Topical agents ◦ Saline ◦ Detergents/antiseptics  Povidone iodine  Chlorhexidine  Hypochlorite ◦ Topical antibiotics  Bacitracin, neomycin  Mupirocin, poly B  SSD, mafenide ◦ Enzymes  Papain urea  collagenase

52 Page 52 Wound care products Growth factors –PDGF –VEGF –FGF Autologoud PRP Bioengineered tissues –Apligraft –Dermagraft

53 Page 53 Wound care Adjunctive modalities –Hyperbaric oxygen –Ultrasound therapy –Vacuum assisted closure

54 Page 54 Charcot Foot More dramatic – less common 1% Severe non-infective bony collapse with secondary ulceration Two theories –Neurotraumatic –Neurovascular

55 Page 55 Charcot Foot Neurotraumatic –Decreased sensation + repetitive trauma = joint and bone collapse Neurovascular –Increased blood flow → increased osteoclast activity → osteopenia → Bony collapse –Glycolization of ligaments → brittle and fail → Joint collapse

56 Page 56 Charcot Foot

57 Page 57 Classification Eichenholtz –1 – acute inflammatory process Often mistaken for infection –2 – coalescing phase –3 – reconstructive

58 Page 58 Classification Location –Forefoot, midfoot (most common), hindfoot Atrophic or hypertrophic –Radiographic finding –Little treatment implication

59 Page 59 Treatment Immobilisation Stress reduction Bisphosphonates Surgery –Exostectomy –Arthodesis

60 Page 60 THANK YOU


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