ANATOMY & PATHOPHYSIOLOGY OF DISBETIC FOOT INFECTION
DR ARUN BALPRESIDENT
DIABETICV FOOT SOCIETY OF INDIA
LONGITUDINAL ARCHES
MEDIAL: HIGHER MORE MOBILE RESILIENT
LATERAL:LOW LIMITED MOBILITY BUILT TO BEAR WT.
HEMOSTASIS 1 hour
WOUNDING
PlateletsFibrin
INFLAMMATION days 1 through 7Proteoglycans
NeutrophilsMacrophages]
LymphocytesPROLIFERATION days 2 through 20
Normal wound healing
Fibroblasts[produce growth factors]
CollagenEpithelial Cells
Endothelial Cells
REMODELING 1 week to 6 months
Collagen Fibril Cross linking
Scar Maturation
Time from injury
WOUND BED PREPARATION
DYNAMIC & RAPIDLY EVOLVING CONCEPTREDUCES THE WOUND HEALING TIMEREDUCES HE COST OF THE TREATMENTDEFINATION:GLOBAL MANAGEMENTTO ACCELERATE ENDOGENOUS HEALING AND TO FACILITATE OTHER THERAPEUTIC MEASURESIT IS THIRD STAGE OF WOUND CARE REVOLUTION
EVOLUTION OF TIME FRAMEWORK
T = TISSUE MANAGEMENTI = INFECTION/INFLAMMATION
CONTROL M = MOISTURE CONTROLE = EDGE/EPIDERMAL
CONTROL
TISSUE MANAGEMENTDEBRIDEMENT
REMOVAL OF NECROTIC, DEVITALIZED, CONTAMINATED TISSUESHARP AND/OR SURGICAL DEBRIDEMENTNECROTIC TISSUE MASKES THE INFECTIONCREATES PHYSICAL BARRIER TO HEALINGINHIBITS CONSTITUENTS OF EXTRACELLULAR MATRIXPREVNETS GRANULATION TISSUE FORMATION
SELECTION OF TYPE OF DEBRIDEMENT
SIZE,POSITION,TYPE OF THE WOUNDMOISTURE LEVELPAIN MANAGEMENTTIME AVAILABLEFACILITIES AVAILABLELEVEL OF HEALTHCARE TRAINING
SURGICAL OR SHARP DEBRIDEMENT
FASTEST WAY TO REMOVE DEBRIS AND NECROTIC TISSUEMINIMAL DAMAGE TO THE SURROUNDING TISSUERELEASES CYTOKINES THAT HELPS WOUND REPAIRNEEDS TRAININGNEEDS INFRASTRUCTURE
ENZYMATIC DEBRIDEMENT
MOST SELECTIVEEXOGENOUS PROTEPLYTIC ENZYMES ARE USED TO RMOVE NECROTIC TISSUEWORK WITH ENDOGENOUS ENZYMES TO DEGRADE THE NECROTIC TISSUEMAY CAUSE MINOR TRASIENT PAIN AND DISCOMFORT
Papain-Ures CollagenaseDebridement +++ +++Speed ++ +Selectivity
- +++
Pain
++ -
Mt.Debridement
- ++
Reduce Bact.Burden
++
+++
Reduce Exudate ++ ++More Gran.Tissue ++ Epithelization - ++
ENZYME DEBRIDEMENT
AUTOLYTIC DEBRIDEMENT
NATURAL DEBRIDEMENTPHAGOCYTIC CELLS AND PROTEOLYTIC EZYMES LIQUIFY AND SEPARATE NECROTIC TISSUEMOIST ENVIRONMENT NECESSARY FOR AUTOLYTIC DEBRIDEMENTCAN RESULT IN TO SIGNIFICANT WOUND EXUDATEDOES NOT DAMAGE HEALTHY TISSUEREQUIRES MINIMAL TECHNOLOGY AND TRAININGMINIMAL PAIN
BIOLOGICAL DEBRIDEMENT
USE OF LARVAE /MAGGOTSGREEN BOTTLE FLY LARVAEUSEFUL IN PATIENTS WITH THICK SLOGHLIMITED AVAILABILITYNOT ACCEPTED BY MANY PATIENTSERADICATES INFECTION AND SMELL
MECHANICASL DEBRIDEMENT
NON SELECTIVE METHODWOUND IRRIGATION,WHIRPOOL THERAPY,WET TO DRY DRESSINGSIGNIFICANT DISCOMFORT AND PAINWOUND IRRIGATION IS UNSUITABLE FOR GRANULATING WOUNDS
MAINTENANCE DEBRIDEMENT
AN EXTENDED PHASE OF DEBRIDEMENTREQUIRED DUE TO CO MORBIDITIESSIGLE EPISODE OF DEBRIDEMENT MAY NOT BE SUFFECIENTOFFERS DISTINCT ADVANTAGE IN WOUND MANAGEMENTENZYMATIC AND AUTOLYTIC DEBRIDEMENT IS VERY USEFUL
Vacuum-Assisted Wound Closure
Topical negative pressure therapy which can be used to achieve closure of diabetic foot woundsThe pump applies subatmospheric pressure through a tube and foam sponge applied to the ulcer over a dressing and sealed in place with a plastic filmThe dressing is replaced every two to three daysSmall portable pumps are now available
Vacuum-Assisted Wound Closure
Negative pressure improves the dermal blood supply, and stimulates granulation which can form over bone and tendon. It reduces bacterial colonisation and diminishes oedema and interstitial fluidCourse of treatment is usually 7-10 daysThe effect may wear off after 3 days but if the pump is removed and then replaced after 1 day this restores the effectExcessive pain may prohibit the use of this technique (even in neuropathic feet)
Larva therapy (maggots)
The larvae of the green bottle fly Lucilia sericata are used to debride ulcers, especially in the neuroischaemic footThis results in relatively rapid atraumatic physical removal of necrotic materialLarvae also produce secretions that have antimicrobial activity against Gram-positive cocci including MRSARandomized clinical trials are awaitedExpensive (unless you grow your own)