1. DIABETES FOOT MANAGMENT TEAMWORK
By.Dr.J.L.Shah M.D. (Medicine) Physician & Diabetologist
Sonal Hospital &Diabetes Clinic Khand Bazar,Lalgate,Surat.

2. PUT FEET FIRST
PREVENT
AMPUTATIONS

3. BURDEN & MAGNITUDE
60 million feet at risk.
25% of Diabetes Patient Experience foot Problem in their lifetime.
Risk of Amputation 40 times high Compared to Non Diabetics.
75% of all lower limb Amputation are Performed in Diabetics.
Every 30 sec one Diabetic looses
his/her toes / foot / limb in the world.
Prolong Hospitalization & high Cost of Treatment.

4. STAGES IN DIABETIC FOOT
Healthy foot.
High Risk foot.
Ulcerated foot.
Infected foot.
Necrotic foot.
Un salvageable foot

8. MANAGEMENT
Multi disciplinary approach to save maximum number of limbs.
Proper timely & adequate management coupled with foot care education can save % Amputation.
High sensitivity to the senseless foot of patient is needed by the health care provider.

9. COMPONENTS OF MANAGEMENT
Metabolic Control
Mechanical Control
Educational Control
Vascular Control
Microbiological Control
Wound Control

10. METABOLIC CONTROL
In all stages tight Glycemic control is important.
Hyperglycemia is important Risk factor for development of neuropathy & Occlusive Vascular disease.
Hyperglycemia in Ulcerated foot reduces fibroblast proliferation & growth factor impairs protease activity & Hence retard ulcer healing.
Hyperglycemia reduces Chemo taxis & Phagocytosis & Humoral antibodies. Tissueglucose is good media for bacterial Proliferation so, for microbiological control in infected ulcer Glycemic control is essential.
Tight Glycemic control in infected Patient should be achieved by insulin infusion followed by SC MDI Regime.

11. METABOLIC CONTROL
Besides Hyper Glycemic Control of BP, Dyslipidemia & Cessations of Smoking is required.
For BP Control in Patient with Neuroischemic foot  blocker Should be used with Caution
Statins & fibrate are effective & safe in Controlling Dyslipidemia.
All Patient need antiplatelate Therapy & DVT Prophylaxis with LMWH in Patient needing Prolonged bed rest.
Many Patient have associated Renal & Cardiac Failure requiring Proper adjustment in drug dosage.

12. MECHANICAL CONTROL
Hyper Glycemia affects Practically all tissues of the foot. Changes in foot architecture lead to altered biomechanics of foot with development of high planter pressure under Wt.barring points in naturopathic foot.
So, naturopathic ulcers are essentially pressure source & offloading is must for their healing.
Histological Studies have proven the efficacy of off loading within 48 hrs. where ulcers changes its characteristics from nonhealing to heeling.

13. MECHANICAL CONTROL
Neuroischemic ulcers also Respond well to off loading.
In severely infected foot non weight barring is desirable with use of crutches wheelchair or zimer’s frame.
TCC is gold standard for off loading with healing rate as high as 80% but is costly cumbersome & associated with some complication
Removable cast walkers therapeutics shoes, half shoe ,PRAFO are the other modality of off loading in ambulatory patient.
Healing is directly proportional to impulse loading.

14. HEALING OF NEUROPATHIC ULCER USING CUSTOMISED AFO
Study of 10 patient presented in NNDU 2004 at Singapore.
10 patient with 13 weeks neuropathic ulcer (wagnergrade-1) were studied using off loading with Customize AFO.
All Patient healed within 6 week time.

15. EDUCATIONAL CONTROL
Routine foot care for all diabetics.
Prophylactic diabetes foot ware & trauma Prevention education to high risk patient.
Education regarding early sign of infection & Immediate reporting .
Non weight bearing & off loading in Ulcerated and infected foot.
Rehabilitation & Psycho-social support in patient with major Amputation .

16. VASCULAR CONTROL
Vascular assessment with ABPI &
transcutaneous o2 tension as marker, is essential in all diabetic patient.
ABPI < 0.5, o2 tension < 30 mm hg or TBPI <30 mm hg denote severe ischemia.
In severe Neuroischemic foot attempts to improve vascular perfusion by angioplasty or bypass surgery should be done.

17. VASCULAR CONTROL
Aggressive debridement should be avoided when possible in patient with severe ischemia.
Infection should be treated very aggressively as it can have disastrous out come.
Analgesic may be needed to relieve rest pain.
Larva therapy & hyper baric o2 therapy may be useful adjunctive treatment.

18. MICROBIOLOGICAL CONTROL
Infection occur in both neuropathic & neuro ischemic foot frequently.
Symptom & signs of infection are masked by neuropathy.
Patient may present with localized infected ulcer, with surrounding erythema with diffuse spreading erythema ,with massive soft tissue infection with systemic features of toxemia shock.
With severe infection only 50 % patient have systemic features of fever & toxemia.

19. MICROBIOLOGICAL CONTROL
85% of foot ulcers beings as clean wound detection of early infection & adequate microbiological control block road to amputation.
Osteomyelitis may be associated with any of the presentation & all cases with exposed bone, ability to probe to the bone, x-ray /MRF evidences of osteomyelitis ,should be treated as osteomyelitis.
Most infection are polymicrobial in nature & culture from deep tissue swab from deep curetting should be obtained initially & then weekly if needed.
If soft tissue infection is responding well to conservative treatment OM should be treated conservatively.
Most patient respond well to conservative Rx.

20. ANTIBIOTICS FOR TREATING THE INFECTED FOOT
ANTIBIOTIC TREATMENT
MICROORGANISM
ORAL IV
STAPHYLOCOCCUS AUREUS
METHICILLIN-RESISTANT
STAPHYLOCOCCUS AUREUS(MRSA)
STREPTOCOCCUS
FLUCLOXACILLIN 500 MG QDS
SODIUM FUSIDATE 500 MG TDS
CLINDAMYCIN 300 MG TDS
RIFAMPICIN 300 MG TDS
TRIMETHOPRIM 200 MG BD
DOXYCYCLINE 100 MG DAILY
LINEZOLID 600 MG BD
AMOXICILLIN 500 MG TDS
ERYTHRIMYCIN 500 MG QDS
FLUCLOXACILLIN 500 MG QDS
GENTAMICIN 5 MG/KG/DAY
(ACCORDING TO LEVELS)
CLINDAMYCIN MG QDS
VANCOMYCIN 1 G BD
TEICOPLANIN 400MG DAILY
LINEZOLID 600 MG BD
AMOXICILLIN 500 MG TDS
(ACCORDING TO LEVELS

21. ANTIBIOTICS FOR TREATING THE INFECTED FOOT
ANTIBIOTIC TREATMENT
MICROORGANISM
ORAL IV
ENTEROCOCCUS
ANAEROBES
COLIFORMS(E.COLI, PROTEUS,KLEBSIELLA,ENTEROBACTER)
PSEUDOMONAS
AMOXICILLIN 500 MG TDS
METRONIDAZOLE 400 MG TDS
CLINDAMYCIN 300 MG TDS
CIPROFLOXACIN 500 MG BD
CEFADOXIL 1 G BD
RIMETHOPRIP 200 MG BD
AMOXICILLIN 500 MG TDS
VANCOMYCIN 1 G BD
(ACCORDING TO LEVELS)
METRONIDAZOLE 500 MG TDS
CLINDAMYCIN MG QDS
CIPROFLOXACIN 500 MG BD
CEFTAZIDIME 1-2 G TDS
CEFTRIAXONE1-2 G DAILY
GENTAMICIN 5 MG/KG/DAY
PIPERACILLIN/CLAVULANATE 4.5 G TDS
MEROPENEM 500 MG TO 1 G TDS
TICARCILLIN/CLAVULANAT 3.2 G TDS
CEFTAZIDIME 1-2 G TDS.

22. WOUND CONTROL Good wound control can be achieves by :
T : tissue debritment may be surgical, chemical, enzymatic or biological.
I : control of infection & inflamation & oedema.
M: Providing must environment to wound using saline / hydrogel dressing.
E : edge control.

23. WOUND CONTROL
all irritant chemicals & antibiotics damage the granulating tissues and should be avoided.
various dressing materials used for diabetes foot wound include saline soaked gauze , foams ,hydrocolloids , hydrogels ,Alginates, hydrophilicfibre dressing.
Advanced wound healing products includes dermagraft ,apligraf,PDGF,promogran etc.
Supplementary wound healing techniques includes skingraft ,VAC ,maggot therapy, hyperbaric oxygen.

24. CASE STUDY WITH PLERMIN

25. SURGICAL APPROACH TO DIABETES FOOT CARE
Elective & prophylactic surgery for reducing ulcer risk in stage-1&2 patient include correction of hammer& claw toe. well osteotomy, metatarsal resection, cismoidectomy, Akilistendon lengthing, etc. may be considered when conservative treatment failed.
Risk of GA should be dually considered as pt. may have cardiac & renal failure.
SA & LA may be sufficient for elective procedure emergency surgery for major amputation &urgent IND may necessary in some patient.

26. CONCLUSION
T : TIMELY
E : EFFECTIVE
A : ACCURATE
M : MANAGEMENT

27. The End
Thank you