FOOT PROBLEMS IN DIABETIC FOOT PROBLEMS IN DIABETIC PATIENTSPATIENTS

Diagnosis and managementDiagnosis and management

Objectives:Objectives:

Clarify the amplitude of the problem of Clarify the amplitude of the problem of diabetic footdiabetic foot

Recognize the different patho-physiologic Recognize the different patho-physiologic mechanisms leading to diabetic foot problemsmechanisms leading to diabetic foot problems

Clarify the overall management of different Clarify the overall management of different problems related to the diabetic footproblems related to the diabetic foot

Amplitude of the problem:Amplitude of the problem: Diabetes mellitus is a rather very common systemic Diabetes mellitus is a rather very common systemic

diseasedisease 12-15 million people are diabetics in the US. 12-15 million people are diabetics in the US. 20% of these patients will be hospitalized at least once 20% of these patients will be hospitalized at least once

in their life time with foot problemsin their life time with foot problems Diabetic patients account for more than two thirds of Diabetic patients account for more than two thirds of

patients undergoing non-traumatic limb amputation patients undergoing non-traumatic limb amputation annuallyannually

This will cost a BILLION dollars every yearThis will cost a BILLION dollars every year

Grunfeld et alGrunfeld et al

Patho-physiologyPatho-physiology

NEOUROPATHYNEOUROPATHY

ISCHAEMIAISCHAEMIA

INFECTIONINFECTION

Neuropathy:Neuropathy:

One of the triad of the pathological conditions One of the triad of the pathological conditions characteristic of this disease (neuropathy, characteristic of this disease (neuropathy, nephropathy and retinopathy)nephropathy and retinopathy)

Pathogenesis:Pathogenesis:

Changes in the vasa nervosaChanges in the vasa nervosa

Metabolic disorders with release of nerve Metabolic disorders with release of nerve toxic substancetoxic substance

Neuropathy affects:Neuropathy affects:

Motor Nerves resulting in:Motor Nerves resulting in:

wasting of small muscles of the foot and wasting of small muscles of the foot and foot foot deformities (claw foot)deformities (claw foot)

Autonomic nerves resulting in:Autonomic nerves resulting in:

Dryness of the skin and loss of sweat and Dryness of the skin and loss of sweat and oil secretion which leads to excessive callus oil secretion which leads to excessive callus formation and skin cracksformation and skin cracks

Loss of neurogenic component of Loss of neurogenic component of inflammatory response which leads to plunting inflammatory response which leads to plunting of inflammatory response and less severe signs of inflammatory response and less severe signs of a severe infectionsof a severe infections

Sensory nerves:Sensory nerves:

sensory loss of superficial and deep sensory loss of superficial and deep sensation is the most important part of sensory sensation is the most important part of sensory affectionaffection

Patients are unaware of trauma to the Patients are unaware of trauma to the foot and usually result in pressure sores over foot and usually result in pressure sores over weight bearing points of the footweight bearing points of the foot

Neuropathic arthropathy:Neuropathic arthropathy:

Joints can be affected by neuropathy Joints can be affected by neuropathy resulting in the so called resulting in the so called Charcot footCharcot foot

It is relatively painless progressive It is relatively painless progressive degenerative arthropathy of single or multiple degenerative arthropathy of single or multiple jointsjoints

caused by loss of proprioceptive and pain caused by loss of proprioceptive and pain sensationsensation

leads to foot deformity and abnormal leads to foot deformity and abnormal pressure pointspressure points

Infection:Infection:

Patho-physiology:Patho-physiology:

peripheral neuropathy:peripheral neuropathy:

Sensory and autonomic neouropathy provides Sensory and autonomic neouropathy provides site of entry of organisms and blunt site of entry of organisms and blunt neurogenic immune responseneurogenic immune response

Metabolic state:Metabolic state:

Hyperglycaemia an manifest protienurea causes Hyperglycaemia an manifest protienurea causes a state of immuno-suppression a state of immuno-suppression

Infection causes Infection causes increased metabolic and increased metabolic and oxygen demands of oxygen demands of tissues and inability to tissues and inability to meet with this demand meet with this demand will increase tissue will increase tissue damage and necrosis damage and necrosis

Microbiology:Microbiology:

Usually in limb threatening diabetic foot Usually in limb threatening diabetic foot infections there is polymicrobial bacterial infections there is polymicrobial bacterial infection with gram positive, gram negative, infection with gram positive, gram negative, and anaerobic bacterial infection .and anaerobic bacterial infection .

sometimes with very severe life sometimes with very severe life threatening infections fungus infection is also threatening infections fungus infection is also presentpresent

Ischemia:Ischemia:Diabetes mellitus is an independent risk factor for Diabetes mellitus is an independent risk factor for

atherosclerosis (coronary, cerebral and peripheral)atherosclerosis (coronary, cerebral and peripheral)

Usually atherosclerosis affects crural vessel Usually atherosclerosis affects crural vessel (anterior tibial, posterior tibial and peroneal) with sparing (anterior tibial, posterior tibial and peroneal) with sparing of aortoiliac and femoral segmentsof aortoiliac and femoral segments

Ankle vessels runoff are usually patent (posterior Ankle vessels runoff are usually patent (posterior tibial and dorsalis pedis) ,but they may lead to a diseased tibial and dorsalis pedis) ,but they may lead to a diseased foot arches (distal vessel disease)foot arches (distal vessel disease)

Medial calcification affects all vessels but the Medial calcification affects all vessels but the vessels remain patent in spite heavy calcificationvessels remain patent in spite heavy calcification

DIAGNOSISDIAGNOSIS Clinical examination:Clinical examination:

Careful history taking and thorough Careful history taking and thorough general examination is essentialgeneral examination is essential

Careful Careful inspectioninspection and and palpationpalpation of the of the foot lesion (look and feel in all aspects of the foot lesion (look and feel in all aspects of the foot and between toes). Probing any foot ulcer foot and between toes). Probing any foot ulcer or sinus to detect bone affectionor sinus to detect bone affection

Palpation of peripheral pulses is essential Palpation of peripheral pulses is essential to exclude ischaemia to exclude ischaemia

Imaging studies:Imaging studies:

Plain X ray:Plain X ray: it is the basic study in all patients with diabetic it is the basic study in all patients with diabetic foot it can show: osteomylitis, bone fractures, joint foot it can show: osteomylitis, bone fractures, joint dislocations, foreign bodies, gas due to gas forming dislocations, foreign bodies, gas due to gas forming infections, soft tissue inflammatory hypertrophyinfections, soft tissue inflammatory hypertrophy

MRI scanMRI scan: very sensitive in detecting the extent of soft tissue : very sensitive in detecting the extent of soft tissue infection and bone and joint involvementinfection and bone and joint involvement

Bone scan and radio-active labeled leukocyte scan are of low Bone scan and radio-active labeled leukocyte scan are of low clinical importanceclinical importance

Pedobarography:Pedobarography: computerized method to detect points of computerized method to detect points of high pressure in patients with neuropathic ulcershigh pressure in patients with neuropathic ulcers

Vascular studies:Vascular studies:Ankle brachial pressure indexAnkle brachial pressure index (ABPI): is (ABPI): is

usually of no value in diabetic patients because of usually of no value in diabetic patients because of calcified pedal vesselscalcified pedal vessels toe pressure is usually used in diabetics (toe pressure of 30 mm gH indicates good vascularity)

Duplex scan: can be done to evaluate blood vessels in non limb threatening infections and in follow up

Angiography: It is done when planning for vascular reconstruction in case of ischemic diabetic infections

MRA:MRA: Is used in case of severe renal Is used in case of severe renal impairment and severe dye hypersensitivity which is impairment and severe dye hypersensitivity which is not uncommon in diabeticsnot uncommon in diabetics

TreatmentTreatment Treatment of neuropathic ulcers:Treatment of neuropathic ulcers:Avoid pressure over the ulcerAvoid pressure over the ulcer

Non weight bearing using crutches, wheel chairs Non weight bearing using crutches, wheel chairs and sometimes applying slabs and casts. Wearing a and sometimes applying slabs and casts. Wearing a specially designed shoes specially prepared by foot specially designed shoes specially prepared by foot care personscare persons

Topical applications on the ulcersTopical applications on the ulcerstrimming of the surrounding callus. Antibiotic trimming of the surrounding callus. Antibiotic ointments and gels. Applying saline soaked gauze ointments and gels. Applying saline soaked gauze padspads

Proper treatment of infection and ischaemia if presentProper treatment of infection and ischaemia if present

Treatment of infection:Treatment of infection:Severe limb threatening diabetic foot infection Severe limb threatening diabetic foot infection

should be treated as an emergency. Some of should be treated as an emergency. Some of theses infection will require major limb theses infection will require major limb amputation or may turn to a life threatening amputation or may turn to a life threatening infections if not treated properlyinfections if not treated properly

Treatment consists of: Treatment consists of: Surgical drainage and debridementSurgical drainage and debridement Antibiotic therapyAntibiotic therapy Care of general condition and blood sugar Care of general condition and blood sugar controlcontrol

Antibiotic therapy:Antibiotic therapy:

In limb threatening diabetic foot infections In limb threatening diabetic foot infections the patient should be hospitalized and IV the patient should be hospitalized and IV antibiotics administered to reach an efficient antibiotics administered to reach an efficient plasma concentrationplasma concentration

It should cover gram positive and negative It should cover gram positive and negative bacteria and anaerobes as wellbacteria and anaerobes as well

It should be started as empiric treatment and It should be started as empiric treatment and soon be changed according to culture and soon be changed according to culture and sensitivitysensitivity

Surgical drainage:Surgical drainage:

It is the corner It is the corner stone in treatment of stone in treatment of diabetic foot infection. diabetic foot infection. It should be done as It should be done as soon as possible. It soon as possible. It should aim at draining should aim at draining all pus pockets and all pus pockets and debriding all infected debriding all infected tissues including bone tissues including bone and joints and joints

Some hints:Some hints:

1.1. Skin incision should be longitudinal and further Skin incision should be longitudinal and further than infected subcutaneous tissue which is than infected subcutaneous tissue which is further opened further than the deeper infected further opened further than the deeper infected planes so no pockets will remainplanes so no pockets will remain

2.2. Cartilage and cortical bone do not heal well and Cartilage and cortical bone do not heal well and should be removedshould be removed

3.3. Tendons are avascular and should be removed Tendons are avascular and should be removed as hi as possibleas hi as possible

4.4. Never attempt to close a diabetic foot infection Never attempt to close a diabetic foot infection wound the role is wound the role is OPENOPEN drainage drainage

5.5. When planning your When planning your incisions and incisions and amputations be aware amputations be aware that the sole of the that the sole of the foot will be covered foot will be covered by sole skin and any by sole skin and any remaining ulcer will remaining ulcer will not be in a pressure not be in a pressure point ( long posterior point ( long posterior flaps )flaps )

6.6. The best dressing is dressings which The best dressing is dressings which maintain a humid environment. Avoid maintain a humid environment. Avoid irritant applications which are in common irritant applications which are in common use like hydrogen peroxideuse like hydrogen peroxide

7.7. Remaining row clean areas can be covered Remaining row clean areas can be covered later by flabs or split thickness skin graftslater by flabs or split thickness skin grafts

Diabetic foot infection with ischaemia:Diabetic foot infection with ischaemia:

Ischaemia with diabetic foot infection is Ischaemia with diabetic foot infection is diagnosed when there is inability to feel the diagnosed when there is inability to feel the pedal pulsespedal pulses

It’s a dangerous condition which is usually It’s a dangerous condition which is usually a limb threatening and sometimes turn up to be a a limb threatening and sometimes turn up to be a life threatening life threatening

The patient should be referred to a vascular The patient should be referred to a vascular surgeon consultation as soon as possiblesurgeon consultation as soon as possible

Urgent vascular reconstruction may be Urgent vascular reconstruction may be needed for limb salvage needed for limb salvage

Any questions…….?Any questions…….?

Tank youTank you