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MANAGEMENT OF DIABETIC FOOT SYNDROME BY DR AKPOJEVWE E.O. CONSULTANT ORTHOPAEDIC/TRAUMA SURGEON DELSUTH OGHARA NIGERIAN MEDICAL ASSOCIATION, DELTA STATE.

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Presentation on theme: "MANAGEMENT OF DIABETIC FOOT SYNDROME BY DR AKPOJEVWE E.O. CONSULTANT ORTHOPAEDIC/TRAUMA SURGEON DELSUTH OGHARA NIGERIAN MEDICAL ASSOCIATION, DELTA STATE."— Presentation transcript:

1 MANAGEMENT OF DIABETIC FOOT SYNDROME BY DR AKPOJEVWE E.O. CONSULTANT ORTHOPAEDIC/TRAUMA SURGEON DELSUTH OGHARA NIGERIAN MEDICAL ASSOCIATION, DELTA STATE CME SERIES MAY 2014

2 OUTLINE OVERVIEW PATHOPHYSIOLOGY CLINICAL PRESENTATION GRADING INVESTIGATION TREATMENT OPTIONS LOCAL/ REGIONAL CHALLENGES RECENT ADVANCES PREVENTION CONCLUSION

3 OVERVIEW GROUP OF METABOLIC DISEASES CHARACTERISED BY HYPERGLYCAEMIA DEFECTS IN INSULIN SECRETION, INSULIN ACTION OR BOTH LONG TERM DAMAGE AND DYSFUNCTION OF MULTIPLE ORGAN SYSTEMS TYPE 1 DIABETES MELLITUS AND TYPE 2 DIABETES MELLITUS OTHER TYPES- GESTATIONAL, ENDOCRINOPATHIES, DRUG/CHEMICAL INDUCED, IMMUNE-MEDIATED, DISEASES OF THE EXOCRINE PANCREAS IMPAIRED GLUCOSE TOLERANCE IMPAIRED FASTIG GLUCOSE

4 FASTING BLOOD SUGAR <100MG/DL NORMAL MG/DL IMPAIRED FASTING GLUCOSE ≥126MG/DL PROVISIONAL DIAGNOSIS OF DM 2- HOURS POST PRANDIAL GLUCOSE <140MG/DL NORMAL GLUCOSE TOLERANCE MG/DL IMPAIRED GLUCOSE TOLERANCE ≥200MG/DL PROVISIONAL DIAGNOSIS OF DM DIAGNOSIS OF DIABETES MELLITUS FBS ≥ 126MG/DL OR SYMPTOMS OF HYPERGLYCAEMIA + RBS >200MG/DL OR 2-HOURS POST PRANDIAL GLUCOSE ≥ 200MG/DL HbA1c ≥ 6.5%

5 WORLD WIDE EPIDEMIC 171 MILLION CASES OF DM WORLDWIDE IN 2000 (2.8% PREVALENCE) 366 MILLION CASES PROJECTED FOR 2030 (4.4% PREVALENCE) 15% OF DIABETICS DEVELOP DFU THEIR LIFETIME % PREVALENCE OF DFU AMONG DIABETICS IN NIGERIA AMPUTATION RATES UP TO 53% MORTALITY RATES UP TO 29% MEAN COST OF TREATMENT N180,581.60K $28, SPENT PER PATIENT OVER 2 YEARS FOR EACH EPISODE OF DFU LEADING CAUSE OF NON-TRAUMATIC LOWER EXTREMITY AMPUTATIONS IN USA LEADING CAUSE OF LOWER EXTREMITY AMPUTATIONS IN NIGERIA

6 MALE PREPONDERANCE UP TO 85% TYPE 2 DM IN UP TO 88% OF CASES MEAN AGE IS THE 6 TH DECADE OF LIFE 50% NEUROISCHAEMIC, 35% NEUROPATHIC, 15% ISCHAEMIC POLYMICROBIAL CULTURES COMMONEST IN CHRONIC ULCERS STAPHYLOCCOCUS AUREUS AS SINGLE ISOLATE IN 38% ON NON-GANGRENOUS LIMBS ANAEROBES; 16% GAS GANGRENE 60% RESISTANCE TO PENICILLINS

7 HIGHLIGHT ONE LIMB IS AMPUTATED EVERY 20 SECONDS DUE TO DIABETIC COMPLICATIONS

8 PATHOPHYSIOLOGY MULTIFACTORIAL TETRAD OF NEUROPATHY, VASCULOPATHY, DEFORMITY AND INFECTION IMPAIRED IMMUNITY ATHEROSCLEROSIS AND NEUROPATHY OCCUR WITH INCREASED FREQUENCY IN DM NON-ENZYMATIC GLYCOSYLATION OF LIGAMENTS CAUSING STIFFNESS STIFFNESS + NEUROPATHY INCREASES MECHANICAL STRESSES ON FOOT

9 DIABETIC ATHEROSCLEROSIS THICKENED CAPILLARY BASEMENT MEMBRANE ARTERIOLAR HYALINOSIS ENDOTHELIAL PROLIFERATION MONCKEBERG’S SCLEROSIS HIGH AFFECTATION OF INFRAPOPLITEAL AND DIGITAL ARTERIES HIGH LDL, VLDL, ELEVATED PLASMA VON WILLEBRAND FACTOR INHIBITION OF PROSTACYCLIN SYNTHESIS ELEVATED PLASMA FIBRINOGEN INCREASED PLATELET ADHESIVENESS

10 DIABETIC PERIPHERAL NEUROPATHY OCCLUDED VASA NERVORUM ENDONEURAL DYSFUNCTION DIMINISHED Na-K ATPase ACTIVITY CHRONIC HYPEROSMOLARITY CAUSING NERVE TRUNK OEDEMA EFFECTS OF INCREASED SORBITOL AND FRUCTOSE LOSS OF SENSATION – REPETITIVE STRESS, UNNOTICED INJURIES AND FRACTURES STRUCTURAL FOOT ABNORMALITIES UNNOTICED EXCESSIVE HEAT/COLD PRESSURE FROM ILL FITTING SHOES

11 COMMON PRECIPITATING FACTORS TRAUMA BLISTERING ILL FITTING/NEW SHOES NAIL CUTTING BURNS TINEA PEDIS FURUNCLES

12 RISK FACTORS FOR FOOT ULCERATION PREVIOUS HISTORY OF FOOT ULCERATION OR AMPUTATION VISUAL IMPAIRMENT DIABETIC NEPHROPATHY POOR GLYCAEMIC CONTROL CIGARETTE SMOKING MALESEX LOW SOCOECONOMIC STATUS POOR EDUCATION POOR ACCESS TO HEALTH CARE

13 CLINICAL PRESENTATION PRESENT AS INFECTION, ULCER, ABSCESS OR GANGRENE 4% -13.1% NEWLY DIAGNOSED AS DIABETIC AT PRESENTATION 11.7% % OF DIABETIC ADMISSIONS IN NIGERIA MEAN DURATION OF DM 7-12 YEARS ONSET OF SYMPTOMS TO PRESENTATION AVERAGELY 6 WEEKS

14 SYMPTOMS SYMPTOMS OF DM POLYURIA POLYDIPSIA POLYPHAGIA WEIGHTLOSS SYMPTOMS OF PERIPHERAL NEUROPATHY HYPERESTHESIA HYPOESTHESIA PARAESTHESIA DYSESTHESIA ANHYDROSIS RADICULAR PAIN

15 SYMPTOMS OF PERIPHERAL ARTERIAL INSUFFICIENCY INTERMITTENT CLAUDICATION REST PAIN NON-HEALING ULCERATION OF FOOT FRANK ISCHAEMIA SYMPTOMS OF INFECTION GANGRENE SEPSIS: LOCAL, GENERALISED SYMPTOMS REFERRABLE TO OTHER ORGAN SYSTEMS RETINOPATHY, NEPHROPATHY, HYPERTENSION

16 PHYSICAL EXAMINATION GENERAL EXAMINATION – FEVER, PALLOR, JAUNDICE, DEHYDRATION, REGIONAL LYMPH NODES, LEG SWELLING, WEIGHT LOSS FULL SYSTEMIC EXAMINATION MANDATORY EYE EXAMINATION MUSCULOSKELETAL SYSTEM EXAMINATION FOOT/ULCER POWER SENSATION REFLEXES PULSES

17 EXAMINATION OF THE ULCER LOCATION, SIZE, DEPTH DETERMINE TYPE- NEUROPATHIC, ISCHAEMIC OR NEUROISCHAEMIC MUSCULOSKELETAL SYSTEM ABNORMALITIES COLOUR AND STATE OF WOUND EXPOSED BONE NECROSIS OR GANGRENE INFECTION: LOCAL AND SYSTEMIC MALODOROUS LOCAL PAIN EXUDATE WOUND EDGE : CALLUS, MACERATION, OEDEMA CLINICAL PHOTOGRAPHS

18 DFU FEATURES ACCORDING TO AETIOLOGY FEATURENEUROPATHICISCHAEMICNEUROISCHAEMIC SENSATIONSENSORY LOSSPAINFULDEG OF SENSORY LOSS CALLUS/ NECROSISOFTEN THICK CALLUSNECROSIS COMMONMINIMALCALLUS PRONE TO NECROSIS WOUND BEDPINK, GRANULATING, SURROUNDING CALLUS PALE, SLOUGHY, POOR GRANULATION POOR GRANULATION FOOT TEMP/ PULSES WARM, BOUNDING PULSESCOOL, ABSENT PULSES OTHERDRY SKIN, FISSURINGDELAYED HEALINGHIGH RISK OF INFECTION TYPICAL LOCATIONWEIGHT BEARING AREAS OF FOOT TIPS OF TOES, NAIL BEDS, B/W TOES, LATERAL BORDER OF FOOT MARGIN OF FOOT AND TOES PREVALENCE35%15%50%

19 GRADING SYSTEMS SEVERAL SYSTEMS IN USE OLDER CLASSIFICATIONS WAGNER-MEGGIT UNIVERSITY OF TEXAS CLASSIFICATION GIBBONS FORREST FRYKBERG AND COLEMAN’S NEWER CLASSIFICATIONS PEDIS KINGS KOBE’S AMIT JAIN’S SAD

20 WAGNER-MEGGIT CLASSIFICATION OF DIABETIC FOOT DEVELOPED IN 1977 WIDELY ACCEPTED, UNIVERSALLY USED,SIMPLE DOES NOT ADDRESS DIABETIC ULCERATIONS AND INFECTION ADEQUATELY LIMITED IN IDENTIFYING/DESCRIBING VASCULAR DISEASE GRADE 0FOOT AT RISK GRADE 1SUPERFICIAL ULCER GRADE 2DEEP ULCER GRADE 3ULCER WITH BONE INVOLVEMENT GRADE 4FOREFOOT GANGRENE GRADE 5FULL FOOT GANGRENE

21 UNIVERSITY OF TEXAS CLASSIFICATION VALIDATED, GENERALLY PREDICTIVE OF OUTCOME INCREASING USE IN CLINICAL TRIALS AND DIABETIC FOOT CENTERS GRADE 0GRADE 1GRADE 2GRADE 3 STAGE APRE- OR POST ULCERATIVE LESION,FULLY EPITHELISED SUPERFICIAL WOUND, NIL TENDON, CAPSULE OR BONE INVOLVED WOUND PENETRATING TO CAPSULE OR TENDON WOUND PENETRATING TO BONE OR JOINT STAGE BINFECTION STAGE CISCHAEMIA STAGE DINFECTION AND ISCHAEMIA

22 DIABETIC FOOT SEVERITY SCORE(DFSS)- UMEBESE AND OGBEMUDIA BEING VALIDATED GRADES ULCER, PULSES, SENSATION, COLOUR, AGE AND RADIOGRAPHS OF THE FOOT PREDICTS LIMB SALVAGEABILITY ≤ 11 UNSALVAGEABLE 21 BEST PROGNOSTIC INDEX 6 WORST PROGNOSTIC INDEX COMPLEX DIFFICULT TO MEMORISE

23 COLOUR OF FOOT NORMAL3 DARKER DISCOLOURATION2 BLACK1 PERIPHERAL PULSES DORSALIS PEDIS AND POSTERIOR TIBIAL PALPABLE4 POSTERIOR TIBIAL ONLY3 DORSALIS PEDIS ONLY2 NONE1 SENSATION NORMAL LIGHT TOUCH AND PIN PRICK3 DIMINISHED HYPOESTHESIA2 INSENSIBILITY TO INSENSATE1

24 ULCER GRADING GANGRENE LIMITED TO 1 OR 2 TOES5 FULL THICKNESS ULCERATION OF DORSALSKIN4 ULCER INVOLVEMENT OF >2 TOES OR BALL OF FOOT3 OPEN PENETRATING ULCER >50% OF SOLE2 WHOLE FOOT GANGRENE + SUPRAMALLEOLAR 1 NECROTISING CELLULITIS AGE 40 YEARS YEARS2 > 61 YEARS1 RADIOGRAPH OF FOOT NORMAL 3 COM OR CALCIFIED PERIPHERAL VESSELS2 COM + CPV1

25 DIFFERENTIAL DIAGNOSES DIABETIC DERMOPATHY ERUPTIVE XANTHOMAS NECROBIOSIS LIPOIDICA ARTHRITIS MUSCLE PAIN THROMBOPHLEBITIS RADICULAR PAIN MYEXDEMA VASCULITIC NEUROPATHIES METABOLIC NEUROPATHIES AUTONOMIC NEUROPATHY

26 INVESTIGATIONS ESTABLISH DIAGNOSIS/ GLYCAEMIC CONTROL FASTING BLOOD SUGAR 2-HOUR POST PRANDIAL GLUCOSE HbA1c ASSAY BASELINE FULL BLOOD COUNT ERYTHROCYTE SEDIMENTATION RATE C-REACTIVE PROTEIN ASSAY ELECTROLYTE/UREA/CREATININE URINALYSIS 24-HOUR URINE FOR PROTEIN ESTIMATION

27 DIABETIC FOOT DEEP TISSUE CULTURE/HISTOLOGY ASPIRATE M/C/S PULSE VOLUME RECORDING(PVR) ANKLE-BRACHIAL INDEX PLAIN RADIOGRAPHS DOPPLER/DUPLEX ULTRASOUND SCANS MONOFILAMENT TESTING BIOTHESIOMETER CONTACT THERMOGRAPHY

28 CT SCAN/MRI BONE SCANS ANGIOGRAPHY TRANSCUTANEOUS TISSUE OXYGEN STUDIES INVESTIGATE FOR RETINOPATHY, NEPHROPATHY, CARDIAC DISEASE ETC

29 TREATMENT NON-SURGICAL SURGICAL

30 APPROACH CONSIDERATIONS FOR TREATMENT OFFLOAD THE WOUND WITH APPROPRIATE FOOT WEAR DEBRIDEMENT DAILY WOUND DRESSING ANTIBIOTICS OPTIMAL CONTROL OF GLUCOSE, HYPERTENSION AND HYPERLIPIDAEMIA EVALUATE/ CORRECT PERIPHERAL VASCULAR INSUFFICIENCY MULTIDISCIPLINARY ENDOCRINOLOGISTINFECTIOUS DISEASE SPECIALIST CARDIOLOGISTPLASTIC SURGEON NEPHROLOGISTPROSTHETIST/ ORTHOTIST PODIATRISTNUTRITIONIST ORTHOPAEDIC SURGEONWOUND CARE SPECIALIST VASCULAR SURGEON

31 NON-SURGICAL TREATMENT WOUND DRESSING AUTOLYTIC DEBRIDEMENT ENZYMATIC DEBRIDEMENT LARVAL THERAPY VACUUM ASSISTED CLOSURE HYDROTHERAPY HYPERBARIC OXYGEN THERAPY OFFLOADING THE FOOT: TCC, RCW, ITCC, CRUTCHES, WHEEL CHAIR

32 ANTIBIOTICS HEMORRHEOLOGIC AGENTS: PENTOXIFYLLINE, CILOSTAZOL ANTIPLATELET AGENTS: CLOPIDOGREL, SOLUBLE ASPIRIN WOUND HEALLING AGENTS: BECAPLERMIN GEL(REGRANEX) SUPPORTIVE THERAPY: ANALGESIA, FLUID AND ELECTROLYTE CORRECTION, BLOOD TRANSFUSION, GLYCAEMIC CONTROL

33 DRESSING AGENTS WET TO DAMP DRESSINGS ABILITY TO ABSORB EXUDATE AND PROTECT HEALTHY SKIN OPSITE; TEGADERM NORMAL SALINE ISOTONIC SALINE GEL(NORMGEL) HYDROCOLLOIDS: DUODERM, INTRASITE – DRY WOUNDS CALCIUM ALGINATES: KALTOSTAT, CURASORB – EXUDATIVE WOUNDS IMPREGNATED GAUZE (MESALT) – VERY EXUDATIVE WOUNDS HYDROFIBRES (AQUACEL) – VERY EXUDATIVE WOUNDS

34 DERMAZINE, BACITRACIN, NEOSPORIN – INFECTED WOUNDS DRY DRESSING + BETADINE – ESCHAR HONEY – INFECTED WOUNDS CYTOTOXIC AGENTS: NOT ADVISED EXCEPT IN INFECTED WOUNDS HYDROGEN PEROXIDE POVIDONE IODINE SODIUM HYPOCHLORITE ACETIC ACID EUSOL

35 SURGICAL TREATMENT SHARP DEBRIDEMENT REVISION SURGERIES VASCULAR RECONSTRUCTION SOFT TISSUE COVERAGE AMPUTATION

36 SHARP DEBRIDEMENT MUST PRECEDE NON-SURGICAL TREATMENT REMOVE INFECTED AND NON-VIABLE TISSUES REMOVE EXCESS CALLUS CURETTAGE OF UNDELYING OSTEOMYELITIC BONES REDUCES PRESSURE ALLOWS FULL INSPECTION OF UNDERLYING TISSUES HELPS DRAINAGE OF SECRETIONS AND PUS HELPS OPTIMSE EFFECTIVENESS OF TOPICAL PREPARATONS STIMULATES HEALING

37 VASCULAR RECONSTRUCTION EARLY REFERRAL TO THE VASCULAR SURGEON INTRACTABLE REST OR NOGHTPAIN INTRACTABLE FOOT ULCERS IMPENDING GANGRENE FEMORO-POPLITEAL BYPASS

38 REVISION SURGERIES FOR BONY ARCHITECTURE REMOVE PRESSURE POINTS RESECTION OF METATARSAL HEADS, OSTECTOMY

39 SOFT TISSUE COVERAGE SKIN GRAFTING AUTOGRAFT CADAVERIC TISSUE CULTURED SKIN SUBSTITUTES DERMAGRAF APLIGRAF XENOGRAFT

40 AMPUTATION 85% OF AMPUTATIONS ARE PRECEDED BY ULCERS AMPUTATION RATES AVERAGELYBETWEEN 5-24% 53% AMPUTATION RATES HAVE BEEN QUOTED 26% RE-AMPUTATION RATE PREDICTORS FOR MAJOR AMPUTATION SMOKINGLIMB ISCHAEMIA OSTEOMYELITISULCER SIZE ELEVATED WBC,ESR,CRPREDUCED Hb, ALBUMIN LOCAL OR DIFFUSE GANGRENE

41 INDICATONS FOR AMPUTATION ISCHAEMIC REST PAIN THAT CANNOT BE MANAGED BY ANALGESIA OR REVASCULARISATION LIFE THREATENING FOOT INFECTION THAT CANNOTBE MANAGED BY OTHER MEASURES NON-HEALING ULCER ACCOMPANIED BY HIGHER BURDEN OF DISEASE THAN WOULD RESULT FROM AMPUTATION

42 TYPES OF AMPUTATION RAY AMPUTATION FOOT CONSERVING AMPUTATIONS: TRANSMETATARSAL, LISFRANC’S BELOW KNEE AMPUTATION ABOVE KNEE AMPUTATIONS DISARTICULATIONS

43 STEPS TO AVOID AMPUTATION: GLOBAL WOUND CARE PLAN DIAGNOSIS OF DM +/- PERIPHERAL SENSORY NEUROPATHY DFU PREVENTION CARE PLAN TREAT COMORBIDITIES GOOD GLYCAEMIC CONTROL OFFLOAD FOOT ANNUAL PROFESSIONAL FOOT EXAMINATION REGULAR REVIEW AND PATIENT EDUCATION DEVELOPMENT OF DFU DETERMINE CAUSE OF ULCER AGREE TREATMENT WITH PATIENT AND IMPLEMENT WOUND CARE PLAN INITIATE ANTIBIOTIC TREATMENT

44 REVIEW OFFLOADING DEVICE OPTIMISE GLYCAEMIC CONTROL VASCULAR ASSESSMENT PATIENT EDUCATION DEVELOPMENT OF VASCULAR DISEASE EARLY REFERRAL TO VASCULAR SURGEON OPTIMSE DM CONTROL INFECTED ULCER ANTIMICROBIALS OFFLOAD PRESSURE THERAPY DIRECTED AT BIOFILM

45 REASONS FOR POOR TREATMENT OUTCOMES POOR HEALTH LITERACY LOW ACCESS TO QUALITY MEDICAL CARE NON-COMPLIANCE TO MEDICATION LACK OF ACCESS TO DIABETES INFORMATION AND SERVICES WEAK REFERRAL SYSTEMS ABSENCE OF ROUTINE SCREENING FOR DM POVERTY LACK OF CAPACITY FOR MANAGEMENT OF DM IN LOWER LEVELS OF HEALTH CARE BELIEF IN ALTERNATIVE REMEDIES

46 LOCAL AND REGIONAL CHALLENGES LATE PRESENTATION ALTERNATIVE UNORTHODOX CARE THE MIRACLE PHENOMENON POOR PERIPHERAL HEALTH CARE SERVICES DEARTH OF SKILLED MANPOWER LACKED OF DEDICATED FOOT SERVICE DELAYED REFERRALS

47 POOR PATIENT COMPLIANCE POOR FOLLOW UP REFUSAL TO GIVE CONSENT FOR SURGERY LOW LEVELS OF COMMUNITY/ PATIENT AWARENESS AND PRACTICES LACK OF POLITICAL WILL

48 PREVENTION DAILY FOOT INSPECTION GENTLE SOAP AND WATER CLEANSING APPLICATION OF SKIN MOISTURISERS INSPECTIONS OF SHOES FOR SUPPORT AND FIT PROMPT TREATMENT OF MINOR WOUNDS AVOID HOT SOAKS,HEATING PADS,IRRITATING TOPICAL AGENTS STOP CIGARETTE SMOKING CONTROL OF BLOOD SUGAR, BLOOD PRESSURE AND SERUM LIPIDS PROPHYLACTICPODIATRIC SURGERY AVOID USE OF SHARPS TO PARE NAILS WEAR CLEAN SOCKS NEVER WALK BARE FOOT CHECK INSIDE SHOES BEFORE WEARING THEM

49 RECENT ADVANCES BIOENGINEERED SKIN SUBSTITUTES: DERMAGRAF EXTRACELLULAR MATRIX PROTEINS: HYAFF,PROMOGRAN MMP MODULATOR(MATRIX METALLOPROTENASES): DERMAX AUTOLOGOUS PLATELET-RICH PLASMA

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57 CONCLUSION INCREASING PREVALENCE OF DM AND ITS ATTENDANT COMPLCATIONS POOR KNOWLEGDE, ATTITUDE AND PRACTICES LOCAL CHALLENGES RESULT IN HIGH AMPUTATION RATES PARADIGM SHIFT TO PREVENTIVE CARE NEEDED

58 THANK YOU!

59 REFERENCES 1. W. Amogne, A. Reja, A. Amane; Diabetic Foot Disease In Ethiopian Patients: A Hospital Based Study; Ethiopian Journal Health Dev; 2012; 25(1): P. Olabisi, A. Fasanmade, A.Fatai, P. Ekama; The Outcome Of 60-Second Foot Screen Tool Education For Health Care Workers At University College Hospital, Nigeria; Wound Healing Southern Africa; 2012; 5(2): R. Gadepalli, B. Dhawan et al; A Clinico-microbiological Study Of Diabetic Foot Ulcers In An Indian Tertiary Care Hospital; Diabetes Care; August 2006; vol 29;No 8: A.K.C Jain; A New Classification Of Diabetic Foot Complications: A Simple And Effective Teaching Tool; The Journal Of Diabetic Foot Complications; 2012; vol 4; issue 1; No 1: B.U. Aguocha, J.O. Ukpabi, U.U. Onyeonoro,P. Njoku, A.U. Ukegbu; Pattern Of Diabetic Mortality In A Tertiary Health Facility In Southern Nigeria; African Journal Of Diabetes Medicine;May 2013; vol 21; No 1

60 6. N.E. Ngim, W.O. Ndifon, A.M. Udosen, I.A. Ikpeme, E. Isiwele; Lower Limb Amputation In Diabetic Foot Disease: Experience In A Tertiary Hospital In Southern Nigeria; African Journal Of Diabetes Care; May 2012; vol 20; No 1 7. A.E. Edo, E. Eregie, I.U. Ezeani; Diabetic Foot Ulcer Following Rat Bite; African Journal Of Diabetes Medicine; Nov 2010; vol 18; No 2 8. A.O.Ogbera, O. Fasanmade, A.E. ohwovoriole, O. Adediran; An Assessment Of The Disease Burden Of Foot Ulcers In Patients With Diabetes Mellitus Attending A Tertiary Hospital In Lagos Nigeria; Internal Journal of Lower Extremity Wounds; Dec 2006; vol 5;No 4: A.K.C. Jain, S. Joshi; Diabetic Foot Classifications: A review of Literature; Medicine Science;2013; 2(3): J.O. Adeleye; Diabetic Foot Disease: The Perspective Of A Nigerian Tertiary Helth Care Center; Practical Diabetes International; Sep 2000; vol 2; Issue 6:

61 11. A.A. Musa; Diabetic Foot Lesions As Seen In A Nigerian Teaching Hospital: Pattern And A Simple Classification; East African Journal Public Health; March 2012; 9(1): V.L. Rowe; Diabetic Ulcers; Medscape; Sep I. Adigun, J. Olarinoye; Foot Complications In People With Diabetes: Experience With 105 Nigerian Africans; Wounds International; May 2014; vol 5; Issue F. Ogunlesi; challenges Of Caring For Diabetic Foot Ulcers In Resource Poor Settings; The Internet Journal Of Advanced Nursing Practice; 2013; vol 10; No K. Alexiadou. J. Duopis; Management Of Diabetic Foot Ulcers; Diabetes Therapy; April 2012; 3(1); S.Yesil et al; Predictors Of Amputation In Diabetics With Foot Ulcer: Single center Experience In A Large Turkish Cohort; Hormones; 2009;8(4):

62 17. A.A. Otu et al; Profile, Bacteriology And Risk Factors For Foot Ulcers Among Diabetics In A Tertiary Hospital In Calabar Nigeria; Ulcers; 2013; ID A.E. Edo, O.G. Edo, I.U. Ezeani; Risk Factors, Ulcer Grade And Management Outcomes Of Diabetic Foot Ulcers In A Tropical Tertiary Care Hospital; Nigerian Medical Journal; Jan- Feb 2013; vol 54; Issue 1: N.E. Ngim, P. Amah, I. Abang; Tropical Diabetic Hand Syndrome: Report of 2 Cases; The Pan African Medical Journal; 2012;12; Y.Z. Lawal, M. Ogirima et al; Tropical Diabetic Hand Syndrome: Surgical Management And Proposed Classification; Arch Int Surg (Serial Online); 2013; 3: International Best Practice Guidelines: Wound Management In Diabetic Foot Ulcers; Wounds International; 2013

63 22. E. Igbinovia; Diabetic Foot Ulcers: Current Trends In Management; Journal Of Post Graduate Medicine; 2009; vol 11; No 1: L.A. Lavery, D.G. Armstrong, A. Boulton; Screening For Diabetic Peripheral Neuropathy; Neuropathy; 2004; O.O. Desalu, F.K. Salawu, A.K. Jimoh, A.O. Adekoya, O.A. Busari, A.B. Olokoba; Diabetic Foot Care: Self Reported knowledge And Practice Among Patients Attending Three Tertiary Hospitals In Nigeria; Ghana Medical Journal; June 2011;vol 45; No 2: K.O. Ngwogu, E.C. Umez-Emeana, A.C. Ngwogu; The Burden Of Diabetic Foot Ulcers In Aba, Abia State,Nigeria; International Journal Of Basic, Applied And Innovative Research; 2013; 2(4): A.O Ogbera et al; The Foot At Risk In Nigerians With Diabetes Mellitus- The Nigerian Scenario; Int J Endocrinol Metab; 2005; 4:


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