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

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

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

FASTING BLOOD SUGAR <100MG/DL NORMAL 100-125MG/DL IMPAIRED FASTING GLUCOSE ≥126MG/DL PROVISIONAL DIAGNOSIS OF DM 2- HOURS POST PRANDIAL GLUCOSE <140MG/DL NORMAL GLUCOSE TOLERANCE 140-199MG/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%

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 11.7- 19.1% PREVALENCE OF DFU AMONG DIABETICS IN NIGERIA AMPUTATION RATES UP TO 53% MORTALITY RATES UP TO 29% MEAN COST OF TREATMENT N180,581.60K $28,000.00 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

MALE PREPONDERANCE UP TO 85% TYPE 2 DM IN UP TO 88% OF CASES MEAN AGE IS THE 6TH 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

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

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

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

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

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

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

CLINICAL PRESENTATION PRESENT AS INFECTION, ULCER, ABSCESS OR GANGRENE 4% -13.1% NEWLY DIAGNOSED AS DIABETIC AT PRESENTATION 11.7% - 21.1% OF DIABETIC ADMISSIONS IN NIGERIA MEAN DURATION OF DM 7-12 YEARS ONSET OF SYMPTOMS TO PRESENTATION AVERAGELY 6 WEEKS

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

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

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

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

DFU FEATURES ACCORDING TO AETIOLOGY NEUROPATHIC ISCHAEMIC NEUROISCHAEMIC SENSATION SENSORY LOSS PAINFUL DEG OF SENSORY LOSS CALLUS/ NECROSIS OFTEN THICK CALLUS NECROSIS COMMON MINIMALCALLUS PRONE TO NECROSIS WOUND BED PINK, GRANULATING, SURROUNDING CALLUS PALE, SLOUGHY, POOR GRANULATION POOR GRANULATION FOOT TEMP/ PULSES WARM, BOUNDING PULSES COOL, ABSENT PULSES OTHER DRY SKIN, FISSURING DELAYED HEALING HIGH RISK OF INFECTION TYPICAL LOCATION WEIGHT BEARING AREAS OF FOOT TIPS OF TOES, NAIL BEDS, B/W TOES, LATERAL BORDER OF FOOT MARGIN OF FOOT AND TOES PREVALENCE 35% 15% 50%

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

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 0 FOOT AT RISK GRADE 1 SUPERFICIAL ULCER GRADE 2 DEEP ULCER GRADE 3 ULCER WITH BONE INVOLVEMENT GRADE 4 FOREFOOT GANGRENE GRADE 5 FULL FOOT GANGRENE

UNIVERSITY OF TEXAS CLASSIFICATION VALIDATED, GENERALLY PREDICTIVE OF OUTCOME INCREASING USE IN CLINICAL TRIALS AND DIABETIC FOOT CENTERS GRADE 0 GRADE 1 GRADE 2 GRADE 3 STAGE A PRE- 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 B INFECTION STAGE C ISCHAEMIA STAGE D INFECTION AND ISCHAEMIA

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

COLOUR OF FOOT NORMAL 3 DARKER DISCOLOURATION 2 BLACK 1 PERIPHERAL PULSES DORSALIS PEDIS AND POSTERIOR TIBIAL PALPABLE 4 POSTERIOR TIBIAL ONLY 3 DORSALIS PEDIS ONLY 2 NONE 1 SENSATION NORMAL LIGHT TOUCH AND PIN PRICK 3 DIMINISHED HYPOESTHESIA 2 INSENSIBILITY TO INSENSATE 1

ULCER GRADING GANGRENE LIMITED TO 1 OR 2 TOES 5 FULL THICKNESS ULCERATION OF DORSALSKIN 4 ULCER INVOLVEMENT OF >2 TOES OR BALL OF FOOT 3 OPEN PENETRATING ULCER >50% OF SOLE 2 WHOLE FOOT GANGRENE + SUPRAMALLEOLAR 1 NECROTISING CELLULITIS AGE 40 YEARS 3 41- 60 YEARS 2 > 61 YEARS 1 RADIOGRAPH OF FOOT NORMAL 3 COM OR CALCIFIED PERIPHERAL VESSELS 2 COM + CPV 1

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

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

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

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

TREATMENT NON-SURGICAL SURGICAL

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 ENDOCRINOLOGIST INFECTIOUS DISEASE SPECIALIST CARDIOLOGIST PLASTIC SURGEON NEPHROLOGIST PROSTHETIST/ ORTHOTIST PODIATRIST NUTRITIONIST ORTHOPAEDIC SURGEON WOUND CARE SPECIALIST VASCULAR SURGEON

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

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

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

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

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

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

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

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

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

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 SMOKING LIMB ISCHAEMIA OSTEOMYELITIS ULCER SIZE ELEVATED WBC,ESR,CRP REDUCED Hb, ALBUMIN LOCAL OR DIFFUSE GANGRENE

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

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

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

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

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

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

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

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

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

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

THANK YOU!

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