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Foot and Leg Wound Management: Medical Issues

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1 Foot and Leg Wound Management: Medical Issues
Dr. Todd Yip MSc MD FRCPC Dine and Learn Event Victoria Division of Family Practice January 28, 2014

2 Declaration One Bracing is an orthotic, bracing, and splinting office within Rebalance MD clinic

3 Foot and Leg Ulcer Clinic
RJH Memorial Pavilion 40-50 new referrals per month Nurses, Pedorthist, Orthotist, Physician, Surgeon Not open Mondays, some Friday PM Referrals must be via Central Intake Recommend fax copy of referral to FLUC

4 Peripheral Vascular Disease and Compression
Dr. Todd Yip MSc MD FRCPC Victoria Division of Family Practice Dine and Learn Event January 28, 2014

5 Edema Lower limb edema control is vital to heal wounds and to prevent recurrent ulceration. How much compression would be reasonable? What is a reasonable to compression management?

6 PVD Work-up Arterial Venous **Renal function (eGFR >60)
**Resting arterial doppler U/S (includes ABI) ABI (with doppler study **CTA Abdo Aorta + runoff (preferred) Conventional unilateral angiogram MR Angiography **key items Venous Reflux (valve competence) Deep veins, Superficial veins, perforators

7 Ankle Brachial Index/Doppler Ultrasound
<0.4 Severe disease (rest pain) Mild to moderate disease Normal >1.3 Poorly compressible vessels Age and diabetes – main confounders Doppler Waveform (flattens with disease) Triphasic Normal Biphasic Mild disease Monophasic Severe disease Localizes occlusive disease Eg. Monophasic popliteal, dorsalis pedis, posterior tibial = above knee stenosis Toe pressure >30 mmHg Predicts healing in non-diabetic >50 mmHg Predicts healing in diabetic

8 Ankle Brachial Index Sensitivity: 70-90% Specificity: 65-95%
Lower in elderly or diabetics Specificity: 65-95% Khan TH et al. Critical Review of the Ankle Brachial Index. Current Cardiology Reviews, 2008, 4,

9 ABI/Toe Pressure

10 ABI/Toe Pressure

11 Approach to Compression
Avoid compression (generally) Severe PAD; ABI <0.4 Low compression (8-15 mmHg) ABI >0.5 Pure venous + leg edema +/- significant drainage Needs dressing, not socks Mixed PVD Medium compression (15-20 mmHg) Mixed PVD, if edema control reasonable If tolerating low compression Try adding low compression sock to low compression dressing to graduate

12 Approach to Compression
High compression At least mmHg compression Strong, palpable pulses, normal ABI; No risk factors Pure venous disease, mild edema ?Local dressing + compression sock vs. compression dressing Depends on clinical picture/practical options Trial and (hopefully not) error approach If dressings, change 2 to 3 x per week

13 Practical Considerations
The application of compression dressings (or complex dressing) is highly variable Socks must be hand-washed and hung to dry Socks must be less than 6-8 months old (of total daily use) Socks on in the AM, off in the PM, unless patient sleeps in chair Dressing and sock costs are often not covered in community

14 Some Compression Dressings
Modified Unna’s boot +/- tensor Less than 10mmHg Light options: local dressing + tubifast (blue- or yellow-line, or tubigrip) Coban 2 lite – mmHg Coban 2 – mmHg

15 Some Compression Options
If no ulcer or nearly healed, then compression stockings: 8-15 mmHg (e.g. “Diabetic sensifoot”) 15-20 mmHg intermediate 20-30 mmHg venous insufficiency, some PAD 30-40 mmHg lymphedema 40-50 mmHg young venous insufficiency Some patients can use remarkably high compression safely

16 Compression Stocking Practical Tips
Layered lower level compression stockings for increased compliance/ease of management and cost savings 10 mmHg stocking liner 10 mmHg ankle-high “socklet” Open-toed or zippered socks Sock donning gadgets Home supports as required for dressing

17 Infection Dr. Todd Yip MSc MD FRCPC
Victoria Division of Family Practice Dine and Learn Event January 28, 2014

18 Work-up - Foot X-ray +/- x-ray in 3 weeks CBC, CRP, renal function
Bone scan (debatable role – non-specific) “add infection label if +” WBC label if <3/12 Gallium if >3/12 Indicate duration of ulcer and if patient on antibiotics on requisition MRI - ?debatable role Wound cultures can be helpful or misleading

19 Infection Legs Mostly clinical diagnosis
?Cellulitis vs. ?Stasis dermatitis vs. ?Ostemyelitis Essentially the same work up as feet

20 Diabetic Foot Infections (DFI)
Mostly polymicrobial Aerobic GPC, especially staphylococci Aerobic GNB, if chronic Anaerobes, if ischemic or necrotic Foul odour of necrosis +/- pseudomonas

21 Reasonable Empiric Antibiotics
1st line Keflex (500 mg BID-QID) Clindamycin ( mg TID) 2nd line Clindamycin + cipro ( mg OD-BID) Clavulin (500 mg TID/875 mg BID) If MRSA Clindamycin, Bactrim (1 DS tab BID), or Doxycycline (100 mg BID) Note: clindamycin requires no adjustment for renal function and covers MRSA!

22 Parenteral Antibiotics
Suggested Indications Failed oral antibiotics Abscess or ?abscess (surgical consult pending) Sepsis Dialysis Side effects from oral antibiotics Impaired immune response Past response of frequent flyers ?Non-adherence to oral medications? “No data support the superiority of any specific antibiotic agent or treatment strategy, route, or duration of therapy” Lipsky et. al., 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clinical Infectious Diseases 2012;54(12):

23 Imaging for Osteomyelitis Details
Modality Sensitivity (%) Specificity X-ray 43 to 75 65 to 83 Bone scan Technetium-99m methylene diphosphonate 69 to 100 38 to 82 Gallium-67 citrate scan 25 to 80 67 to 85 WBC Scan Technetium-99m hexamethyl-propyleneamine oxime-labeled 90 80 to 90 MRI 82 to 100 75 to 96 Pineda  C, Vargas  A, Rodriguez  AV.  Imaging of osteomyelitis: current concepts.  Infect Dis Clin North Am.  2006;20(4):789–825. Termaat  MF, Raijmakers  PG, Scholten  HJ, Bakker  FC, Patka  P, Haarman  HJ.  The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis.  J Bone Joint Surg Am.  2005;87(11):2464–2471. Kapoor  A, Page  S, Lavalley  M, Gale  DR, Felson  DT.  Magnetic resonance imaging for diagnosing foot osteomyelitis: a meta-analysis.  Arch Intern Med.  2007;167(2):125–132

24 Dermatology and Diabetes: Something Different?
Dr. Todd Yip MSc MD FRCPC Victoria Division of Family Practice Dine and Learn Event January 28, 2014

25 Skin Manifestations of Diabetes
Type 1 Periungal telangiectasia Necrobiosis lipoidica diabetacorum Bullosis diabeticorum Vitiligo Lichen ruber planus Type 2 Yellow nails Diabetic thick skin Acrochordons (skin tags) Diabetic dermopathy Skin spots and pigmented pretibial papules Acanthosis nigricans Acquired perforating dermatosis Calciphylaxis Eruptive xanthoma Granuloma annulare

26 Skin Manifestations of Drugs
A number of reactions, too many to list Van hattem, Bootsma AH, Thio HB. Cleveland Clinic Journal of Medicine: 75(11):

27 Three Recent Cases




31 My Main Differential Diagnosis
Dry skin (autonomic) Fungus/tinea ??Psoriasis ??Something else that responds to topical steroid If psoriasis, then it is recommended not to debride So, confirming a diagnosis will affect the treatment approach (i.e. it affects management)

32 ?Psoriasis Usually 2-3 referrals per to Dr. Telford, RJH Psoriasis Clinic dermatologist for “?Psoriasis not previously diagnosed?” For estimated >95% of referrals, Dr. Telford agrees psoriasis – may or may agree with foot involvement Prevalence = 2-4% general population Prevalence among patients with diabetes? Disclaimer: Dr. Telford’s consultation is pending for these cases.

33 Recent Literature: Psoriasis-Diabetes Link
Independent risk factor in the development of T2DM Population-based cohort study (n=108132) HR 1.14 (mild psoriasis); 1.30 (severe psoriasis) Arch Dermatol. 2012;148(9): Associated with an increased prevalence and incidence of diabetes Systematic review and meta-analysis 27 Cohort, case-control, and cross-sectional studies from Prevalence OR 1.59 (1.97 if severe psoriasis); Incidence RR 1.27 JAMA Dermatol. 2013; 149(1)84-91.

34 Questions Is the reverse true? That is,
Is the incidence and prevalence of psoriasis higher amongst those with diabetes? Is diabetes and independent risk factor for psoriasis? Is psoriasis more prevalent among those with “severe” diabetes? Or, those who have or at high risk of foot ulcers?

35 Three Recent Cases

36 Simple Treatment Approach
If unsure, consider treat with least potentially harmful agent first Moisturizer Hydrophilic petrolatum Atrac-Tain Anti-fungal Anti-dandruff shampoo foot wash Lamisil 1% OD Steroid ointment Clobetasol 0.05% OD (affected areas only) Dermatology referral

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