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THE DIABETIC FOOT DR.SEIF I M ELMAHI MD, FRCSI University of Khartoum, Sudan.

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Presentation on theme: "THE DIABETIC FOOT DR.SEIF I M ELMAHI MD, FRCSI University of Khartoum, Sudan."— Presentation transcript:

1 THE DIABETIC FOOT DR.SEIF I M ELMAHI MD, FRCSI University of Khartoum, Sudan

2 CONTENT  Definition  Epidemiology  Social & Economic factors  Pathophysiology of foot ulceration  Diabetic Neuropathy  Peripheral Vascular Disease & Diabetes  Biomechanics of Foot Wear  The Diabetic Foot Ulcer Outcome & Management  Neuro-osteoarthropathy  Amputation in Diabetic Patient  Prevention of Foot Problem

3 Diabetic Foot  Definition: Infection, ulceration or destruction of deep tissues associated with neurological abnormalities & various degrees of peripheral vascular diseases in the lower limb Infection, ulceration or destruction of deep tissues associated with neurological abnormalities & various degrees of peripheral vascular diseases in the lower limb ( based on WHO definition) ( based on WHO definition)

4 Epidemiology  40% - 60% of all non traumatic lower limb amputation  85% of diabetic related foot amputation are preceded by foot ulcer  4 out of 5 ulcer in diabetics are precipitated by trauma  4% -10% is the prevalence of foot ulcer in diabetics

5 Epidemiology In Sudan:  Prevalence of DM ? 6 – 12 %  DSF inpatient KTH : 30% - 40% risk of major amputation 30% - 40% risk of major amputation 8% - 20% mortality 8% - 20% mortality

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7 Social & Economic Factors  Diabetic foot complications are expensive : ( cost of healing USD) ( healing with amp USD) ( healing with amp USD) In Khartoum : (4 weeks dressing cost SD)  Intervention of foot care is cost effective in most societies  Scarce information regarding long term prognosis

8 Pathophsiology of Foot Ulceration  Neuropathic  Ischemic  Neuro -ischemic

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10 STAGES OF ULCER DEVELOPMENT

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12 Diabetic Neuropathy  Sensorimotor & peripheral sympathatic neuropathy are major risk factors for ulcer  History & careful foot examination are mandatory to diagnose neuropathy examination  Up to 50%of type2 diabetic patient have significant neuropathy & at risk of foot ulcer

13 Periphral vascular disease& diabetic PVD  PVD is the most important factors related to outcome of diabetic foot ulcer PVD  PVD is diagnosed by simple clinical examination  non invasive vascular test determines probability of healing probability probability  Symptoms of ischemia may be masked by neuropathy  Microangiopathy shouldn't be accepted as primary cause of ulcer  Conservative approach for treatment  Outcome of revascularization is similar to that in non-diabetic revascularization revascularization

14 Biomechanics of foot wear  Biomechanical abnormalities are consequence of neuropathy, they lead to abnormal foot pressure pressure pressure  Foot deformity & neuropathy increase the risk of ulcer ulcer  Pressure relief is essential for ulcer healing and/or prevention Pressure  Frequent inspection of shoes & insoles is mandatory  Appropriate foot wear significantly reduce ulcer recurrence

15 Diabetic Foot Infection  Infection in diabetic foot is limb threatening  Signs of infection may be absent in diabetic pt. with foot ulcer  Superficial infection is usually caused by gram +ve cocci, deep infection is poly microbial  Surgical debridment is essential in acute deep infection  Osteomylitis( diagnoses & treatment) Osteomylitis

16 Neuro-osteoarthropathy  Non- infective pathology  Should be suspected in any swollen hot erythematous foot swollen  Differentiation from infection is important to prevent misdiagnosis & possible amputation  Treatment should aim at preventing severe deformity

17 Diabetic Foot Ulcer Treatment  Multidisciplenary approach approach  Staging dictate the treatment option Staging  Continuity of care & life long observation

18 Amputation in Diabetic Patient  Increased minor\major amputation increased the no. of deformed feet deformed feetdeformed feet  Minor amputation is needed : *Gangrene *Gangrene *As part of debriment *As part of debriment *for correction of foot deformities *for correction of foot deformities  Minor amputation doesn’t significantly compromise walking ability

19 Major Amputation  Risk of loss walking ability  Mortality  Risk of contra-lateral amputation  Strict indication  Careful choice of the level

20 How To Prevent Foot Problems 5 corner stones 5 corner stones  Regular inspection & examination of foot & foot wear  Identification of high risk patient  Education of patient, family & health care providers  Appropriate foot wear  Treatment of non ulcerative pathology

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23 SENSORY NEUROPATHY

24 Diabetic Neuropathy Diabetic Neuropathy

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27 PERIPHRAL VASCULAR DISEASE

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29 Biomechanics of foot wearBiomechanics of foot wearAREAS AT RISK OF ULCERATION Biomechanics of foot wear

30 FOOTFOOT WEAR FOOT

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33 FOOT WEAR

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35 OSTEOMYLITIS

36 Diabetic Foot Ulcer Treatment Diabetic Foot Ulcer Treatment Modalities Diabetic Foot Ulcer Treatment  Microbiological control  Wound control  Vascular control  Mechanical control  Metabolic control  Educational control

37 Staging of Diabetic Foot Stage Clinical condition Stage Clinical condition 1 Normal 1 Normal 2 High risk 2 High risk 3 Ulcerated 3 Ulcerated 4 cellulitic 4 cellulitic 5 Necrotic 5 Necrotic 6 Major amputation 6 Major amputation

38 AssessmentAssessment of Diabetic Foot Assessment  Neuropathy  Ischemia  Deformity  Callus  Swelling  Skin breakdown  Infection  Necrosis

39 NEURO-OSTEOARTHROPATHY( CHARCOT FOOT)

40 NEURO-OSTEOARTHROPATHY( CHARCOT NEURO-OSTEOARTHROPATHY( CHARCOT FOOT)Neuro-osteoarthropathy Neuro-osteoarthropathy NEURO-OSTEOARTHROPATHY( CHARCOTNeuro-osteoarthropathy

41 PODIATRY

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