the diabetic foot dr.edwin stephen. the diabetic foot collection of foot problems which are not...
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The Diabetic FootThe Diabetic FootThe Diabetic FootThe Diabetic Foot
Dr.Edwin StephenDr.Edwin Stephen
The Diabetic FootThe Diabetic Foot
Collection of Collection of foot problems foot problems which are which are not unique to, not unique to, but occur more but occur more commonly in commonly in diabetic patientsdiabetic patients
FactsFacts
Commonest cause of hospitalization in Commonest cause of hospitalization in DMDM
US 2/3US 2/3rdrd of non traumatic of non traumatic amputationsamputations
FactsFacts
Indian figures not knownIndian figures not known2004 Surgery Dept Stats 2004 Surgery Dept Stats 14% admissions – diabetic foot infections 14% admissions – diabetic foot infections
( S2 )( S2 )Surgery amputationsSurgery amputations
DM DM 87%87%majormajor 4040minorminor 6363
OthersOthers 13%13%major major 0909minorminor 1414
Aetiology of the Diabetic FootAetiology of the Diabetic Foot
NeuropathyNeuropathy
Reduced response to infectionReduced response to infection
IschaemiaIschaemia
NeuropathyNeuropathy
Up to 50% of type 2 diabetic patients Up to 50% of type 2 diabetic patients havehave
significant neuropathy and at-risk feetsignificant neuropathy and at-risk feet
International Consensus on the Management and the International Consensus on the Management and the Prevention of the Diabetic Foot (2003)Prevention of the Diabetic Foot (2003)
Assessment of Assessment of NeuropathyNeuropathy
Neuropathic Foot ChangesNeuropathic Foot Changes
Clawing/Retraction of Clawing/Retraction of minor digitsminor digits
Atrophy of plantar fatty Atrophy of plantar fatty padpad
Restricted ROM of jointsRestricted ROM of joints
Muscle wastingMuscle wasting
Warm feet Warm feet
Changes to joint Changes to joint alignmentalignment
Skin anhydrosisSkin anhydrosis
Charcot ArthropathyCharcot Arthropathy
High Index of High Index of suspicionsuspicion
DiabeticDiabetic
Hot / red / swellingHot / red / swelling
Trauma - minor / Trauma - minor / majormajor
Pain + / -Pain + / -
Architectural Architectural DisruptionDisruption
Ulcer + / -Ulcer + / -
Management of Diabetic Management of Diabetic NeuropathyNeuropathy
Look for it!Look for it! Tight glycaemic controlTight glycaemic control PainfulPainful
medicationmedication referral to neurologistreferral to neurologist
Intensive podiatry/orthotic inputIntensive podiatry/orthotic input Pressure Off-LoadingPressure Off-Loading
Pressure Off-LoadingPressure Off-Loading
Total Contact CastDiabetic Air
Walker
Aetiology of the Diabetic FootAetiology of the Diabetic Foot
NeuropathyNeuropathy
Reduced response to infectionReduced response to infection
IschaemiaIschaemia
Diabetic Foot InfectionDiabetic Foot Infection
Polymicrobial - gram (+) cocci, gram (-) Polymicrobial - gram (+) cocci, gram (-) bacilli and anaerobesbacilli and anaerobes
Redness and swelling may not be Redness and swelling may not be presentpresent
Suspect if deterioration in glycaemic Suspect if deterioration in glycaemic controlcontrol
Unusual foot pain with no fracture etcUnusual foot pain with no fracture etc
Diabetic Foot SepsisDiabetic Foot Sepsis
Surgical principlesSurgical principles
Drain pus urgently / immediatelyDrain pus urgently / immediately
Xray foot Xray foot
Assess perfusionAssess perfusion
Debride necrotic tissueDebride necrotic tissue
Revascularise early if requiredRevascularise early if required
MRI useful to assess soft tissuesMRI useful to assess soft tissues
Diabetic Foot SepsisDiabetic Foot Sepsis
Severe ischaemia Severe ischaemia is present in 5 to is present in 5 to 15% of admitted 15% of admitted cases of foot cases of foot sepsissepsis
If ischemia present it must If ischemia present it must be corrected be corrected
OROR
measures to treat measures to treat infection/neuropathy infection/neuropathy
will failwill fail
Aetiology of the Diabetic FootAetiology of the Diabetic Foot
NeuropathyNeuropathy
Reduced response to infectionReduced response to infection
IschaemiaIschaemia
The concept of small vessel disease The concept of small vessel disease is erroneous and has no place in is erroneous and has no place in management of diabetic footmanagement of diabetic foot
Distribution similar to Distribution similar to atherosclerosisatherosclerosis
Foot arteries almost always sparedFoot arteries almost always spared
Diabetic Vascular DiseaseDiabetic Vascular Disease
Large vessel diseaseLarge vessel diseasecommoncommon
early age of onsetearly age of onset
rapid progressionrapid progression
Microvascular diseaseMicrovascular diseasepresence in limbs controversialpresence in limbs controversial
retinal and renal lesions commonretinal and renal lesions common
Assessment of Foot PerfusionAssessment of Foot Perfusion
SubjectiveSubjectivepalpation of pulsespalpation of pulses
ObjectiveObjectiveDoppler pressures (ankle/brachial index)Doppler pressures (ankle/brachial index)
toe pressurestoe pressures
NB:ABI unreliable in diabetes/renal failure/ NB:ABI unreliable in diabetes/renal failure/ rheumatoid arthritis/leg swellingrheumatoid arthritis/leg swelling
Doppler StudiesDoppler Studies
Low readingsLow readings (ABI <0.5) (ABI <0.5)confirm severe ischaemiaconfirm severe ischaemia
High readingsHigh readings (ABI >0.5) (ABI >0.5)difficult to interpret if no pulses palpabledifficult to interpret if no pulses palpable
Toe PressuresToe Pressures
Toe PressuresToe Pressures
Better predictors of wound healingBetter predictors of wound healing
DiabeticsDiabetics toe pressuretoe pressure <40mmHg <40mmHg skin perfusion pressureskin perfusion pressure healing very healing very
unlikelyunlikely
40 to 60mmHg 40 to 60mmHg healing likelyhealing likely
Management - MedicalManagement - Medical
↓ ↓ Progression of diseaseProgression of disease
Stop smokingStop smoking
Rx predisposing factorsRx predisposing factors
Foot careFoot care
Management - MedicalManagement - Medical ↓ ↓ progression of diseaseprogression of disease
↑ ↑ blood flowblood flowExercisesExercises
DrugsDrugs
-Antiplatelet :Aspirin / ticlopidine / -Antiplatelet :Aspirin / ticlopidine / clopidogrelclopidogrel
-Dipyridamole ( Persantin )-Dipyridamole ( Persantin )
-Pentoxiphylline ( Trental )-Pentoxiphylline ( Trental )
-Cilostazol ( Pletoz )-Cilostazol ( Pletoz )
Management - medicalManagement - medical↓ ↓ progression of diseaseprogression of disease
↑ ↑ blood flowblood flow
Relief of painRelief of pain-NSAIDS:-NSAIDS: check renal functionscheck renal functions
-Opiates:-Opiates: cause constipationcause constipation
-Epidural analgesia-Epidural analgesia
-Antibiotic-Antibiotic
-Drainage abscess-Drainage abscess
Management - Management - interventionintervention
Endovascular Endovascular Balloon angioplasty +/- StentBalloon angioplasty +/- Stent
SurgerySurgery BypassBypass
Anatomical Anatomical
Aorto-bifemoralAorto-bifemoral
Ileo-femoralIleo-femoral
Femoro-popliteal Femoro-popliteal
Extra-anatomicalExtra-anatomical
Axillo-bifemoralAxillo-bifemoral
Femoro-femoralFemoro-femoral
CaseCase
52 yrs male52 yrs maleSmoking ++Smoking ++DM X 5 yrsDM X 5 yrs
Rest pain & blackening of right foot x Rest pain & blackening of right foot x 3 months3 months
B\L lower limb pulses absentB\L lower limb pulses absentABI R - 0 , L – 0.2ABI R - 0 , L – 0.2
ManagementManagement
Underwent emergency Aorto-bifem Underwent emergency Aorto-bifem bypass and right trans-tarsal bypass and right trans-tarsal amputationamputation
Outcome Outcome
Post Op ABI left 1.1Post Op ABI left 1.1
Right stump healed wellRight stump healed well
CaseCase
55 yrs male 55 yrs male
DM x 6 yrs DM x 6 yrs
Smoking many yearsSmoking many years
Rest pain / nonhealing wound R foot x Rest pain / nonhealing wound R foot x 4 m4 m
Right lower limb pulses absentRight lower limb pulses absent
ABI R – 0.24 L – 1.03ABI R – 0.24 L – 1.03
ManagementManagement
Underwent left fem to right bypass Underwent left fem to right bypass usingusing
8mm ringed PTFE graft8mm ringed PTFE graft
Outcome Outcome
Post-operative recovery uneventfulPost-operative recovery uneventful
ABI R 1.07 L – 0.96ABI R 1.07 L – 0.96
Wounds healed wellWounds healed well
CaseCase
60 yrs male60 yrs male
DM x 12yrsDM x 12yrs
HT x 9 yrsHT x 9 yrs
Heavy smoker Heavy smoker
3 months H/O ulceration toes L foot & 3 months H/O ulceration toes L foot & rest painrest pain
ABI ABI RR 0.5 0.5 LL 0.32 0.32
ManagementManagement
Underwent left Femoro-popliteal Underwent left Femoro-popliteal bypass using reversed LSVbypass using reversed LSV
Outcome Outcome
Post op course uneventfulPost op course uneventful
Post-op ABI R – 0.54 L – 0.73Post-op ABI R – 0.54 L – 0.73
Wound healed within a monthWound healed within a month
CaseCase
64 yrs male 64 yrs male
DM x 16 yrsDM x 16 yrs
HT x 2yrsHT x 2yrs
Heavy smoker Heavy smoker
Painful nonhealing ulcer left footPainful nonhealing ulcer left foot
ABI ABI RR 0.7 0.7 LL 0.43 0.43
ManagementManagement
Underwent balloon angioplasty and Underwent balloon angioplasty and stenting of left common iliac arterystenting of left common iliac artery
ManagementManagement
Followed byFollowed by
Left Femoro-popliteal bypass using Left Femoro-popliteal bypass using reversed GSVreversed GSV
Patient did wellPatient did well
CaseCase
69 yrs male69 yrs male DM + 12 yrsDM + 12 yrsHT+ / Smoking +HT+ / Smoking +Rest pain left forefootRest pain left forefootLeft popleteal and pedal pulses absentLeft popleteal and pedal pulses absentABI ABI
R – 0.93R – 0.93L – 0.21L – 0.21
ManagementManagement
Underwent fem-anterior tibial bypass Underwent fem-anterior tibial bypass using reversed GSVusing reversed GSV
Required forefoot amputation Required forefoot amputation
assess perfusion, degree of neuropathy, mechanical abnormalities
pus/wet gangrene in foot present
dry gangrene/ ulceration ±cellulitis/
osteomyelitis
draindebride
Management Algorithm for Management Algorithm for the the
Diabetic Foot LesionDiabetic Foot Lesion
assess perfusion, degree of neuropathy, mechanical
abnormalities
ischaemic footABI <0.5 and/or
toe pressure <40mmHg
probably adequate perfusion
ABI >0.5 andtoe pressure 40-60mmHg
good perfusion, pulses present, ABI >0.8 and
toe pressure >60mmHg
vascular imaging no vascular interventionpodiatry/orthotic care
± local procedure
no vascular interventionpodiatry/orthotic care
± local procedure
revascularisation if possible- angioplasty
- bypassfailure success failure success
NB: less likely outcome
Management Algorithm for Management Algorithm for the the
Diabetic Foot LesionDiabetic Foot Lesion
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