dr harikrishna - management of diabetic foot

7/31/2019 Dr Harikrishna - Management of Diabetic Foot

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MANAGEMENT OFDIABETIC FOOT

DR. HARIKRISHNA .R .

MD(UKM) OSH(NIOSH) OHD(DOSH) CMIA(MAL)Post Grad in Wound Healing & Tissue Repair (Cardiff, UK)

Cert in Hyperbaric Medicine (USA)

ESWT (Austria, Germany) , FMSWCP

DIABETIC FOOTCARE UNIT ,

KUALA LUMPUR HOSPITAL


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Nerveslet you feel sensations suchas pain, vibration, pressure, heat &

cold.

Blood vesselscarrynutrients and oxygen to your feet

to nourish them and help them

heal them heal from injuries.

Bonesgive your foot shape andhelp distribute the pressure from your

weight.

Jointsare the connectionbetween your bones. They help

absorb pressure and enable the

parts of your foot to move. Your

arch is a group of joints thatprovides stability for your entire

foot.

Bone

Blood Vessel

Nerve

Fat

SkinTHE FOOT


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Leonardo daVinci describedthe foot as

A masterpiece

of engineering

and a work ofart


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What is the definition

of a wound ?A wound is an injury to the

integument or to the underlying

structures that may or may notresult in a loss of skin integrity.

Physiological function of thetissue is impaired .


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Wounds are the visible resultof individual cell death ordamage and can be classified

by site,size,depth and causation- DAVID 1986


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ULCER

Definition:

An interruption of continuity of anepithelial surface with an inflamedbase.


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DIABETIC FOOT

ULCERS25%pt.s develop foot ulcers in their life

time

40-80% of ulcers eventually get infected25-50% of infections require minor foot

amputation

And 10-40% require major amputation85% amputations are preceded by foot

ulcerations


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Altered skin integrity

Wound healing failure

Infection or gangrene

Amputation

Peripheral Vascular

DiseaseAltered Response

to Infection

Diabetes Mellitus

Triopathy of

Neuropathy


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Risk Factors for Foot Ulcers

Duration of diabetes

Previous history of ulcer or amputation

Peripheral neuropathy & angiopathy

Structural deformity

Poor glycaemic control Impaired functional ability

Smoking


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Common Sites for DiabeticFoot Ulcers

Dorsum toes claw toes

Plantar aspect Metatarsal head

Inter-digital space

Heel


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TYPES OF FOOT LESIONS

Neuropathic Foot 90 %

Extrinsic 70 %

Intrinsic 30 %

Neuroischaemic Foot 10 %

The scenario would change withlongevity & longstanding DM


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NEUROPATHIC ULCERS - CAUSES

Extrinsic factorsIll fitting footwear

Falls / accidents

Objects inside shoes

Thermal trauma

Injury due to sharp objectsHome surgery


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ILL FITTINGFOOTWEAR


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THERMAL TRAUMA


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INJURY DUE TO SHARP OBJECTS


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HOME SURGERY


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NEUROPATHIC ULCERS-CAUSES

Intrinsic factorsLimited joint mobility

Bony prominences

Foot deformities

Plantar callus

Neuroarthropathy (Charcot Foot)Scar tissue

Fissures (Cracks)


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WOUNDASSESSMENT

Wound edges

Assess forundermining &

condition of

margin

Size

Measure

and/or trace

wound area.

Measure

depth

Surrounding Skin

Assess for: color,moisture, suppleness

Wound bed

Assess for:

necrotic and

granulation

tissue,

fibrin slough,

epithelium,exudate,odor


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CLINICAL APPEARANCE

SiteSize

Edges & walls - 4 types

inflammed indurated

covered with slough

healthy in colorTypes of exudate

State of the surrounding tissue


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VISITRAK


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3 STAGES OF ULCER

Spreading / extending / active

Stagnant / chronic

Healing


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DRY HEALING


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MOIST HEALING

a moist environment as created beneath a

semi permeable membrane allows optimalconditions for the re-epithelization of

surface wounds

(Winter, 1971)


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CLASSIFICATIONS

Wagners Classification

University of Texas Diabetic Woundclassification

Kings College Classification


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WAGNERS CLASSIFICATION OFDIABETIC FOOT ULCERS

Grade 1

Superficial ulcers through full skin

thickness but without subcutaneoustissue involvement


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Grade 2

Deep ulcers penetrating superficialadipose tissue to tendon, capsule/ bone

without deep infection (involvement of thesubcutaneous tissue)


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Grade 3

Deep penetrating ulcers

- complicated

- need surgical debridement

with I/V antibiotic

- patient need to be admitted

to hospital(osteitis , abscess , osteomyelitis)


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Grade 4

Areas of Gangrene associated with

ulceration- common site - toes, forefoot/ heel

- surgical excision of dead tissue


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Grade 5

Extensive gangrene of the foot -

major amputation / disarticulationrequired


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A Comparison of Two Diabetic Foot UlcerClassification Systems

The Wagner and the University of Texas wound classificationsystems

Samson O. Oyibo, MRCP, Edward B. Jude, MD, IbrahimTarawneh, MD, Hienvu C. Nguyen, DPM, Lawrence B. Harkless,DPM and Andrew J.M. Boulton, MD

From the Department of Medicine and Diabetes (S.O.O., E.B.J., I.T.,A.J.M.B.), Manchester Royal Infirmary, Manchester, U.K.; and theDepartment of Orthopedics (H.C.N., L.B.H.), University of TexasHealth Science Center, San Antonio, Texas.

Address correspondence and reprint requests to Dr. Samson Oyibo,Department of Medicine, Manchester Royal Infirmary, Oxford Road,Manchester, M13 9WL, U.K. E-mail: [email protected].

OBJECTIVE In this study, the following two ulcer classification

systems were applied to new foot ulcers to compare them aspredictorsof outcome: the Wagner (grade) and the University ofTexas (UT) (gradeand stage) wound classification systems.
mailto:[email protected]:[email protected]


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RESEARCH DESIGN AND METHODSUlcer size, appearance, clinicalevidenceof infection, ischemia, and neuropathy at presentation were

recorded, and patients were followed up until healing or for6 months.

RESULTSOf 194 patients with new foot ulcers, 67.0% were neuropathic,

26.3% were neuroischemic, 1.0% were ischemic, and 5.7% had no identified

underlying factors. Median (interquartile range [IQR]) ulcersize atpresentation was 1.5 cm2 (0.6-4.0). Lower-limb amputationswere performedfor 15% of ulcers, whereas 65% healed [median(IQR) healing time 5 (3-10)weeks] and 16% were not healed atstudy termination; 4% of patients died.Wagner grade (P


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University of Texas Diabetic WoundClassification

Classification System

Stages

Stage A: No infection or ischemiaStage B: Infection present

Stage C: Ischemia present

Stage D: Infection and ischemiapresent


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Grading

Grade 0: Epithelialized wound

Grade 1: Superficial wound

Grade 2: Wound penetrates totendon or capsule

Grade 3: Wound penetrates to bone

or joint
http://www.fpnotebook.com/SUR10.htmhttp://www.fpnotebook.com/SUR10.htm


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KINGS SIMPLE STAGING

Stage 1Normal Foot

Not presenting any risk factors,

neuropathy, ischaemia, deformity, callus orswelling

Stage 2 High Risk Foot

Patients feet present with 1 or more of the

risk factors Stage 3 Ulcerated Foot

The foot has a skin breakdown, no matterhow minor, that lasts for a week or more


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Treatment & Management

Strategy TIGHT Glycaemic Control Investigations

FBC/ESR/C-REACTIVE PROTEIN X RAY

C&S Cleansing Dressing

Wound hydration Moisture retentive dressings ( moist wound healing)

Exudate management Bacterial burden

Mechanical Therapy padding , Off Loading Surgery I&D, debridement, amputation

Advice

TEAMWORK


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Wound Bed Preparation

Debridement Bacterial Balance

Exudate Management

Dr. Gary Sibbald, et al

Preparing the wound bed for healing debridement, bacterialbalance & moisture balanceOstomy/ wound management 2000, 46(1)


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WOUND BED PREPARATION

IDENTIFY& REMOVE

BARRIERS TO WOUND

HEALING

Wound bed preparation is the management of the wound to

accelerate endogenous healing or to facilitate the effectiveness of

other therapeutic measuresParis International Advisory board in June 2002

PROMOTEWOUND

HEALING


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ENVIRONMENTAL DRESSING

Expensive

Can be left in situ for several days

Reducing cost of both materials and time

Many types:

-Semipermeable polymeric films eg. Opsite

-Hydrocolloids eg. Duoderm CGF

-Hydrogels eg. Intrasite Gel & DuodermHydroactive Gel

-Alginates eg. Kaltostat & Sorbsan-Polyurethane foams eg. Lyofoam

- Hydrofibre eg Aquacel

-Charcoal dressings eg Carboflex

-Silver dressings eg Acticoat , Silverlon , Silversorb

MANAGEMENT OF


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MANAGEMENT OFDIABETIC FOOT ULCERS

ENVIRONMENTAL DRESSING

G O


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MANAGEMENT OFDIABETIC FOOT ULCERS

DEBRIDEMENT :- the removal of foreign matter or devitalised ,

injured and infected tissue from a woundWHITESIDE M.C.R.& MOOREHEAD R.J. (1998)

- to remove devitalised tissue when appropriatefor the patients condition and when consistent

with the patients goals

EPUAP REVIEW (1999)

- Surgical debridement is the gold standard ofcare , once ischaemia is excluded. Wagner 1984 ,

Knowles 1997 , Laing 1994 , Steed 1996 , Levin 1996

METHODS OF


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METHODS OFDEBRIDEMENT

SURGICAL

MECHANICAL

AUTOLYTIC

ENZYMATIC

BIOLOGICAL


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CENTRAL

PLANTAR SPACE

ABSCESS

CENTRAL PLANTAR SURGERY TOTAL


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CENTRAL PLANTAR

SPACE ABSCESSSURGERYTOTAL

DEROOFING

FOOT EXPLORATION


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CHARCOT`S FOOT

EARLIEST

RADIOLOGICALSIGN


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METHODS OF OFF LOADING


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METHODS OF OFF LOADING

BED REST

CRUTCH/WALKER WALK

TOTAL CONTACT CAST

MODIFIED FOOT WEAR

ROCKER OUTSOLE

OUTSOLE WEDGE/FLARE

INSOLE STRESS RELIEF(WING)PADMETATARSAL BARS


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Total Contact Cast

Optimizes protection for diabeticulcerations

Reduces pressure at the site of the ulcer

while allowing ambulationMinimally padded and carefully molded to

the shape of the foot and the leg and hasthe heel for walking

Reduces oedema Effective for ulceration of the sole

Not indicated for the use in deep infections


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TOTAL

CONTACTCAST

AT RISK FOOT


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AT RISK FOOT Ischaemia

Numbness Structural Deformities

Callus and / or Corn

Absence of Pedal Pulses A capillary refill time in excess of 3 secs

Limb pain and / or parasthesia

Intermittent Claudication History of Foot Ulcer

Loss of sensation of light touch,sharp andblunt touch

ADVANCES IN MANAGEMENT OF


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ADVANCES IN MANAGEMENT OFDIABETIC FOOT

HYPERBARIC OXYGEN

GRANULOCYTE COLONY STIMULATING

FACTOR & GROWTH FACTORSPAMIDRONATE TO HASTEN STAGE OF

REFORMATION IN ACUTE CHARCOT

FOOTPEDOGRAPH TO DETECT HIGH

PRESSURE AREAS IN FOOT

MAGGOT THERAPY

O OC O C


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MONOCHROMATIC INFRARED THERAPY (MIRE)

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3.7.2009


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17092009


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17092009

Prep Before 1st MDT

Sloughy halluxbefore MDT

3.7.09

After 48 hoursst Post MDT


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1st Post MDT20.7.2009

20072009


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20072009 Post First MDT

20072009

Post First MDTAft l i


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After clearingmaggots

20072009

3rd MDT 27.7.09

Outcome of 3rd MDT on 29.7.09


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Hallux after 3rd MDT on 29.7.09

Hallux after 3rd MDT


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Medial and dorsal view after 3rd MDT29.7.09


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19.8.2009

5.10.2009


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22.12.2009


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19.2.2010


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20.5.2010


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19.7.2010


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NADI 2010 LUCILIA THE SAGA


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Preparation process Maggot therapy


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Shake containerPour water to release maggots

Use stick to stir

Approx. 200 + maggots

Loosening with water



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Maggot dispense on gauze before dressing


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NADI 2010 LUCILIA THE SAGA Shortcut to MVI_2145.lnk

R 6/11/09


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R-6/11/09


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C C


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Clinical Case 1

28/7/013/9/01

25/2/02 5/9/02

Cli i l C 2


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Clinical Case 2

Cli i l C 3


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Clinical Case 3

Cli i l C 4


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Clinical Case 4

Clinical Case 5


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Clinical Case 5

Clinical Case 6


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August 2008 HKL

CME MDT The Malaysian Scenario

THANK YOU


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THANK YOU

dr harikrishna - management of diabetic foot

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