approach to diabetic foot
TRANSCRIPT
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THE DIABETIC FOOT
APPROACH to DIABETIC FOOT
Dr. Faiez Alhmoud Surgery Dpt.
Albashir Hospital(MOH)
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Diabetic Foot (DF)
It will be unwise if we restrict the term (DF) to foot infection, ulcer or gangrene in a diabetic patient
Why? (advanced stage of the disease)
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Diabetic foot definition
Diabetic foot is a disease complex that can develop in the skin, muscles, or bones of the foot as a result of the nerve damage, poor circulation and/or infection that is associated with diabetes.
The Diabetic Foot may be defined as a syndrome in which neuropathy, angiopathy, and infection will lead to tissue breakdown resulting in morbidity and possible amputation ( WHO 1995 )
Any foot pathology that result from diabetes or it’s long – term results (Boulton 2002)
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Epidemiology and facts 15% of the adult population in Jordan are diabetics 15% of those with diabetes will, develop an ulcer 15% of patients develop osteomyelitis & 15%
amputation 80% of foot ulcers are precipitated by external
trauma 20% of diabetics admitted to hospitals because of
foot problems Cellulitis occurs 10 times more frequently in diabetics Osteomyelitis of the foot 15 times more frequently in
diabetics than non-diabetics Diabetic patients are 15x at risk of BKA Nearly half of non-traumatic LLA caused by diabetes. 70% of lower limb amputations begin with a foot
ulcer ~50% of diabetics with LLA require 2nd LLA within 5
years 5 year survival rate ~50% after BKA--Tragic “Rule of
50” The annual direct and indirect costs is high Up to 85% of amputations can be avoided.
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Diabetic foot…..facts
Every 30 seconds a lower limb is lost somewhere in the world as a consequence of diabetes
Diabetic foot infection require attention to local (foot) and systemic (metabolic) issues by multidisciplinary foot care team
Only in the last 20 years progress in the understanding of pathogenesis and management of diabetic foot had been made
However …. there is still gap between what’s known about diabetic foot and what’s really done to them
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Natural history of diabetic foot
It’s unwise to consider that major diabetic foot problem occur all of sudden
There is high risk foot which means There are1- Predisposing factors (Neuro- and angiopathy) العوامل
المهيئة2- Precipitating factors (Trauma and tinea) العوامل المعجلة 3- Perpetuating factors (Pt’s factors & delay healing)
عوامل التكريس
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What’s the high risk foot ?
Long duration and uncontrolled D.M …Plus one or more:
Peripheral neuropathy Peripheral vascular disease Trauma Previous ulcers Diabetic nephropathy or retinopathy Obesity Lack of education Male gender ??!!
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FOOT AT RISK
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Pathophysiology
The critical triad of :1- Neuropathy2- Foot deformity &3- Trauma ……………
will lead to ulcer
The presentation in the majority of pts is an infected ulcer!!
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Neuropathy
Sensory : lack of protective sensation (unrecognized trauma)
Motor : Change in foot anatomy (Pressure points) & altered gait and deformity
Autonomic : Lack of sweat ( dry & cracked skin )
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Neuropathy
The Gift of Pain
“Pain: The gift nobody wants “.
Paul Brand
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Classification and definition of problem
The neuropathic foot – in which
neuropathy predominates but the major
arterial supply to the foot is intact.
The neuro-ischaemic foot – where
neuropathy, and ischaemia resulting from
a reduced arterial supply, contribute to
the clinical presentation.
Infection - is rarely the only factor
but often complicates neuropathy and or
ischaemia, and is responsible for considerable tissue necrosis
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Stages Of Ulcer Development
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Assessment
History Physical examinations Investigations Patient Limb or foot Wound
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Who will take care ?
G. Physicians General Surgeons Diabetologists (Endocrinologist) Orthopaedic surgeon Vascular surgeon Plastic surgeon Podiatrists Specialised nurse
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Assessment………..History
Generally: fever, chills, sweats, vom…
Condition : confused, depressed…. Socially : neglected, lack of home
sup Neuropathy : Numbness, loss of
sens. burning, tingling, numbness &
nocturnal leg pains. Others : duration, diabetic control,
previous ulceration, smoking, HTN....
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Assessment………Clinical Ex.
What to look for ? V.S : tachycardia, hypotension… Signs of volume depletion Cognitive state:delirium,stupor, coma Limb-Foot: 1- Biomechnics: deformities, change pressure points2- Vascular status ( arterial, venous, ABI, ischemia,
gangrene…3- Neuropathy ( light touch, vibration, monofilament
pressure 4- Examining the feet for structural abnormalities such
as nails, calluses, hammer toes, claw toes and flat foot
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Diabetic Foot Examination
D deformity I infection A atrophic nails B breakdown of skin E oedema T temperature I ischemia C callosities S skin colour
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Assessment………Clinical Ex.
Typical neuropathic foot
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Neurologic assessment
Temperature Vibration Sense Pressure Sense Light Touch Proprioception (Romberg’s Sign) Superficial Pain Reflexes
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Nylon monofilament test
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Neuropathy
Charcot foot“Acute or subacute inflammation of all
or part of the foot in people with diabetes complicated by distal symmetrical neuropathy, accompanying fracture or dislocation that cannot be explained by recent trauma, and with or without preceding ulceration of the surrounding skin”
(Jeffcoate 2004)
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Diagnosis of Acute Charcot
Painless
Redness, swelling, and more than 2°C skin temperature difference when compared with the contralateral foot.
Dorsalis pedis pulses are often
bounding.
The patient is afebrile unless a systemic infection is present.
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Ulcer assessment
1. Site, size and shape2. Edges3. Establish its depth and involvement of deep
structures4. Examine it for purulent exudates, necrosis,
sinus tracts, and odor5. Assess the surrounding tissue for signs of
edema, cellulitis, abscess, and fluctuation6. Perform a vascular evaluation. 7. The ability to gently probe through the ulcer
to bone has been shown to be highly predictive of osteomyelitis.
8. Establish the ulcer's etiology9. Exclude systemic infection
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Classification of diabetic foot ulcer
Wagner Grading System Grade 0 skin intact but "foot at risk" Grade 1: Superficial Diabetic Ulcer &
localised Grade 2: Deep ulcer & extension
Involves ligament, tendon, joint capsule or fascia
No abscess or Osteomyelitis Grade 3: Deep ulcer with abscess or
Osteomyelitis Grade 4: Gangrene to portion of forefoot Grade 5: Extensive gangrene of entire foot
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Classification of diabetic foot ulcer
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Neuropathic foot ulcer.
Khanolkar M et al. QJM 2008;101:685-695
© The Author 2008. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email:
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The Charcot foot.
Khanolkar M et al. QJM 2008;101:685-695
© The Author 2008. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email:
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Effects of Diabetic Peripheral Neuropathy
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Vascular assessment
History Changes in skin Pulses Exercise Testing ABPI Duplex Angiography
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Assessment..........Ischemia
Peripheral Vascular DiseaseChronic limb ischaemia
Grade 0 = Mild claudication
Grade 1 = Moderate to severe claudication withouttissue loss or ischaemic rest pain
Critical ischaemia Grade 2 = Ischaemic rest pain
Grade 3 = Tissue loss due to ischaemic ulceration or
gangrene
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Vascular assessment .........
...........Ankle Brachial IndexABI value Indicates <0.9 Abnormal 0.8- 0.9 Mild PAD 0.5- 0.8 Moderate PAD <0.5 Severe PAD <0.25 Very Severe PAD******The ABI has limited use in
evaluating calcified vessels that are not compressible as in diabetics (gives reading above one)
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Ischaemic foot ulcer.
Khanolkar M et al. QJM 2008;101:685-695
© The Author 2008. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email:
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Assessment…….Infection
Infection is diagnosed clinically by
The presence of purulent secretion
OR At least 2 of the cardinal local
manifestations of inflamation Hotness Redness Swelling Function loss or pain
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Clinical assessment of infection
Non-Limb-threatening Infections:
Superficial infection
Lack systemic toxicity
Minimal cellulitis (< 2 cm. Extension from portal of entry)
Ulcer-if present-doesnot penetrate fully thru skin
No bone or joint involvement
No underlying ischemia
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Clinical assessment of infection
Limb-threatening infections: Extensive cellulitis (> 2 cm.)
Lymphangitis
Full-thickness ulcers
Frequent bone & joint infections
Ischemia + gangrene
Fever +
Deep plantar abscesses
Bacteremia + hematogenous spreading infections
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Classification of diabetic foot infection
Minimal inflammation with no pus = 1
2 or more signs or ~2cm erythema around the ulcer or superficial path. and no systemic manifistations = 2
As above plus deeper infection, lymphangitis ,abscess or gangrene =3
As above with systemic or metabolic instability = 4
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Classification of diabetic foot infection
Non-Limb-threatening Infections:
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Classification of diabetic foot infection
Limb-threatening Infection:
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Common Pathogens
MILD infection = MONOMICROBIAL SEVERE infection = POLYMICROBIAL
In acute wounds and cellulitis : S. aur. & B.Hem. Strept. are commonly found (+)
In chronic infected wounds : add entrobacter (-)
Macerated soaked wound : Pseudomonas Long duration & nonhealing : all the above
plus fungi Deep infection & extensive necrosis with
bad odor : all the above plus obligate anaerobes
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Principles of diabetic foot ulcer
managementبدها صبر
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Five cornerstones of management
of the diabetic foot
The situation can be changed & possibly
reduce amputation rates between 50% -85% by:
1- Regular inspection and examination of the foot and patient education
2- Identification of the foot at risk.3- Education of patient, family and healthcare
providers.4- Appropriate footwear.5- Multidisciplinary approach & treatment of
ulcerative and non-ulcer pathology
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Patient education
Decreases the chance of occurrence Foot hygiene Daily inspection Proper footwear Prompt treatment of new lesions
Must take an active role in their care Disease management Routine nail care Ulcer management
Elective surgery to correct structural deformities before ulcerations occur
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A multidisciplinary approach
Providing : - Debridement, - Meticulous wound care, - Adequate vascular supply,- Metabolic control, - Antimicrobial treatment and -Relief of pressure (offloading) are
essential in the treatment of foot ulcer.
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Investigations
Bloodwork for high BS, DKA, hyperosmolar state…..
Gram staining and culture Imaging- Plain X-ray- MRI ?- Doppler – Angiogram- US? For deep abscess- Doppler and ABI
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Approach to foot wound in diabetics
General Principles1- Avoid antibiotics in uninfected foot2- Determine the need for hospitalizationSevere infection or critical ischemia
3- Stabilize the patient and correct:- Fluids and electrolytes - Hyperglycemia, hyperosmolarity ,acidosis- Treat other exacerbating factors4- Choose antibiotic regimen:Limited data support the use of topical antibioticsMild-moderate infection, give narrow spectrum antibiotics –no
anaerobSevere infection, give broad-spectrum with anaerobic
coverage
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Principles of Foot ulcer management
1.Infection Control2.Offloading3.Vascular assessment4.Wound care
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Infection Control
Foot infections are the most common cause of admission to hospital for patients with diabetes
Infection is a precursor to amputation in many cases
Need to be treated aggressively Sampling by sterile swabs misses important
pathogens True bacteriological yield is obtained from
deep tissue samples IF INFECTION IS PRESENT, DO NOT WAIT
FOR SWAB RESULTS
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Approach to foot wound in diabetics
……Principles of wound care1- Determine the need for surgeryRanges from debridement to revascularizationDetermine life- or limb-threatening condition ( NF, GG,
Ischemia…. )
2- Formulate wound care plan- Daily inspection- Dressing and debridement as needed- Removal of pressure…..
3- Twice- weekly follow up for outpatients4- WBC, ESR, C-RP, culture … are of limited
value
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Debridement
Sharp
Larval
Enzymatic (Lytic)
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Approach to diabetic foot ulcer
According to ulcer stage0 At-risk foot, no ulceration : Patient
education, accommodative footwear, regular clinical examination
1 Superficial ulceration, not infected :Offloading with total contact cast (TCC), walking brace, or special footwear
2 Deep ulceration exposing tendons or joints : Surgical debridement, wound care, offloading, culture-specific antibiotics
3 Extensive ulceration or abscess : Debridement or partial amputation, offloading, culture-specific antibiotics
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Approach to ischemic diabetic foot
Ischemia Classification A Not ischemic : no treatmentB Ischemia without gangrene:
Noninvasive vascular testing, vascular consultation if symptomatic
C Partial (forefoot) gangrene :Vascular consultation and debridement
D Complete foot gangrene : Major extremity amputation, vascular consultation
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Approach to diabetic foot infection
Antibiotics Empirical antibiotics Benzylpenicillin or ampicillin – Streptococcus sp. Oxacillin, nafcillin or 1 st generation cephalosporin (eg.
cefazolin) – Staphylococcus sp. Quinolone + aminoglycoside (gentamycin) – Pseudomonas
sp. Methicillin-resistant Staphylococcus aureus – vancomycin
or cotri-moxazole Clostridial species are sensitive to a combination of
penicillin G and clindamycin Duration of antibiotic treatment * 1-2 weeks course for mild to moderate infections * more than 2 weeks for more serious infections * 6 - 8weeks for osteomyelitis * If all infected bone is removed,a shorter course (1-2 weeks)
of antibiotics, as for soft tissue infection, may be adequate
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Offlaoding
Remove pressure from the affected site is essential
How ?- Footwear- Specialised offloading devices
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Offlaoding FootwearGood shoes are integral to good foot
health
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Offloading
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Vascular assessment
Surgical revascularisation
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Follow up
OsteomyelitisConsider potential osteomyelitis in any 1- Deep or extensive chronic ulcer and over bony
prominence2- Unhealed ulcer after 6 weeks of Abx. And offloading
ttt.3- Ulcer in which bone is visible or easily felt4- Sausage toe
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Osteomyelitis
Initial screening tool is the plain X-ray : Easily obtained, relatively inexpensive and
provides anatomical information Demineralization, periosteal reaction, bony
destruction: (the classic triad) Appear after 30 – 50% of bone is destroyed
and can take as much as 2 weeks to appear
Found in other conditions such as fracture or deformity
Sensitivity and specificity approximately 54% and 80%
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Osteomyelitis
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Follow up……Osteomyelitis
DiagnosisSerial X-rays with 2-4 weeks interval- If typical, treat as ostemyelitis- If not but clinically suspected MRI or Bone scan or Radionuclide or Scintigraphic imaging Triple Phase Bone Scan (TPBS) Gallium Scan Indium-111 Leukocyte Scan- Probe to Bone- Empirical antibiotics for 6-8 weeks and repeat Ro or- Bone biopsyMRI is the most accurate imaging modalityThree-phase bone scintigraphy is highly sensitive
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Outcome
Good outcome to appropriate therapy
In 80–90% of mild-moderate infection 50-80% of severe or OM infection
Poor outcome associated withSigns of systemic infectionInadequate limb ischemiaOMNecrosis or gangreneProximal site of infectionInexperienced surgeon
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Prevention
Early detection of neuropathy Educate patient about- Optimizing glycemic control- Using appropriate footwear- Avoid foot trauma- Perform daily self examination- Smoking cessation
Refer patient with critical ischemia
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Key Message Of all late complications of diabetes, foot
problems are the most easily detectable and easily preventable.
Relatively simple interventions can reduce amputations by 50 - 80%. (Bakker et al 1994).
Strategies aimed at preventing foot ulcers are cost effective and cost saving.
“The pathway to amputation Is littered with bandages and dressings
which have deceived both the doctor and patient into thinking that by dressing an ulcer they were curing it”
Diabetics should treat their Feet like their Face
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Key Message
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Mission:… Happy Feet
QUSTIONS ?