1. Practical Guidelines for the Management of the Diabetic Foot Gerda van Rensburg PODIATRIST Area 556 Johannesburg Hospital

2. Practical Guidelines for the Management of the Diabetic Foot Standardise the assessment and management of the diabetic foot. To increase awareness at all levels of care. Set up a diabetic foot referral pathway

3. Pathophysiology Two or more risk factors present Peripheral neuropathy plays a central role Peripheral vascular disease may result in painful ischemic foot Neuro-ischemic foot symptoms may be absent despite severe peripheral ischemia Infection complicates situation Pathophysiology Two or more risk factors present Peripheral neuropathy plays a central role

4. Pathophysiology Two or more risk factors present Peripheral neuropathy plays a central role Peripheral vascular disease may result in painful ischemic foot Neuro-ischemic foot symptoms may be absent despite severe peripheral ischemia Infection complicates situation Pathophysiology Peripheral vascular disease may result in painful ischemic foot

5. Pathophysiology Two or more risk factors present Peripheral neuropathy plays a central role Peripheral vascular disease may result in painful ischemic foot Neuro-ischemic foot symptoms may be absent despite severe peripheral ischemia Infection complicates situation Pathophysiology Neuro-ischemic foot symptoms may be absent despite severe peripheral ischemia

6. Pathophysiology Two or more risk factors present Peripheral neuropathy plays a central role Peripheral vascular disease may result in painful ischemic foot Neuro-ischemic foot symptoms may be absent despite severe peripheral ischemia Infection complicates situation Pathophysiology Infection complicates situation

7. Five Cornerstones of the Management of the Diabetic Foot Regular inspection and examination of the foot at risk Identification of the foot at risk Education of patient, family and healthcare providers Appropriate footwear Treatment of non-ulcerative pathology

8. Regular Inspection and Examination HistoryPrevious ulcer/amputation Previous foot education Social isolation Poor access to healthcare Barefoot walking

9. Regular Inspection and Examination NeuropathySymptoms: pain, tingling Loss of sensation

10. Testing for Neuropathy

11. Vascular Status Claudication Rest pain Pedal pulses Rubor on dependency

12. Regular inspection and Examination SkinColour, Temperature, Oedema Nail pathologyWrongly cut nails Ingrown nails Infection

13. Regular inspection and Examination Bone / jointDeformities Bony prominence Loss of mobility

14. Risk Areas

15. Regular inspection and Examination Footwear Stockings

16. Identification of the foot at risk Each patient to be assigned to a risk category Presence of one or more risk factors = HIGH RISK Sensory neuropathyIschemia Foot deformityCallus History of ulceration/amputation

17. Education of patient, family and HCP

18. Appropriate footwear

19. Treatment of non ulcerative pathology High risk patient: callus, nail, skin pathology should be treated regularly Treatment by a trained foot care specialist

20. Ulcer treatment Relief of pressure Restoration of skin perfusion Treatment of infection Metabolic control and treatment of co- morbidity Local wound care Instruction of patient and relatives Determining the cause and preventing recurrence

21. Illustration of ulcer due to repetitive stress

22. Pressure Relief

23. Restoration of skin perfusion

24. Treatment of infection Superficial with extensive cellulitis Deep limb- threatening infection

25. Metabolic control and treatment of co-morbidity Blood glucose < 10mmol/l Treat oedema Treat malnutrition

26. Local wound care

27. Instruction of patient and relatives Determining the cause and preventing recurrence