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Diabetic Foot

Diabetic Foot. Diabetic Foot. Any foot pathology that results directly from diabetes or its long term complications ( Boulton 2002)

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Diabetic Foot

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  1. Diabetic Foot

  2. Diabetic Foot • Any foot pathology that results directly from diabetes or its long term complications ( Boulton 2002) • The foot of a diabetic patient that has the potential risk of pathologic consequences including infection, ulceration and or destruction of deep tissues associated with neurologic abnormalities, various degrees of peripheral vascular disease and/or metabolic complications of diabetes in the lower limb

  3. Diabetic Foot • Diabetic foot ulcer • Diabetic foot infections • Charcot Joints

  4. Epidemiology • DM is the largest cause of neuropathy • 50% patients don’t know that they have diabetes • Foot ulcerations is most common cause of hospital admissions for Diabetics • Expensive to treat, may lead to amputation and need for chronic institutionalized care

  5. Pathophysiology • Combination of factors • Neuropathy • Peripheral arterial disease • Abnormal foot biomechanics • Delayed wound healing

  6. Diabetic Neuropathy • Microvascular complication • Occlusion of vasa nervosum • Can be • Sensory / motor/ autonomic • Mono / poly / radiculopathy • Most commonly distal symmetric sensory neuropathy

  7. Neuropathy • Sensory Neuropathy • Loss of touch and temperature • Minor trauma goes unnotices • Disorders of proprioception • Abnormal weight bearing • Callus formation, ulceration • Motor and sensory neuropathy • Abnormal foot biomechanics • Structural changes

  8. Neuropathy • Autonomic neuropathy • Anhidrosis in lower limbs • Drying of feet • Fissure formation

  9. Altered biomechanics • Abnormal weight bearing • Fixed foot deformities • Hammer toe • Claw toe • Prominent metatarsal heads • Charcot’s joints

  10. Hammer Toes Claw Toes

  11. Hallux Valgus

  12. Other factors • Impaired wound healing • Does not allow resolution of fissures and minor injuries • Increased chances of infection

  13. Peripheral arterial disease • 30 times more prevalent in diabetics • Diabetics get arteriosclerosis obliterans or “lead pipe arteries” • Calcification of the media • Often increased blood flow with lack of elastic properties of the arterioles • Not considered to be a primary cause of foot ulcers

  14. Causal Pathways for Foot Ulcers % Causal Pathways Neuropathy: 78% Minor trauma: 79% Deformity: 63% Behavioral ? Neuropathy  Deformity  Minor Trauma - Mechanical (shoes) - Thermal - Chemical Poor self-foot care ULCER

  15. Risk Factors for Diabetic Foot • Male Sex • DM > 10 years duration • Peripheral neuropathy • Abnormal foot structure • Peripheral arterial disease • Smoking • H/O previous ulceration / amputation • Poor glycemic control

  16. Evaluation of a patient with diabetic foot

  17. Examination • Neurological examination • Vibration perception • Light pressure • Light touch • Two point discrimination • Pain • Temperature perception • Deep tendon reflexes • Clonus • Babinski test • Romberg test • Vascular Examination • Palpation of pulses • Skin/limb colour changes • Presence of edema • Temperature gradient • Skin changes • Atrothy • Abnormal wrinkling • Absence of hair • Onychodystrophy • Venous filling time

  18. Examination • Dermatological • Skin appearance • Calluses • Fissures • Nail appearance • Hair growth • Ulceration/infection/ gangrene • Interdigital lesions • Tineapedis • Markers of diabetes • Musculoskeletal • Biomechanical abnormalities • Structural deformities • Prior amputation • Restricted joint mobility • Tendo Achilles contractures • Gait evaluation • Muscle group strength testing • Plantar pressure assessment

  19. Investigations • Blood investigation • FBS, PPBS • HbA1C • Complete blood counts • ESR • RFT • Urinalysis • Wound / blood culture

  20. Imaging • Plain X-rays • Osteomyelitis • Fractures • Dislocations • Osteolysis • Structural foot abnormalities • Arterial calcification • Tissue gas

  21. X rays

  22. Vascular evaluation • Non invasive evaluation • Doppler segmental pressure and waveform analysis • Ankle brachial pressure index • Toe blood pressure • Transcutaneous CO2 • Laser doppler velocimetry

  23. Interpretation of ABI InterpretationABI Normal 0.90-1.30 Mild obstruction 0.70-0.89 Moderate obstruction 0.40-0.69 Severe obstruction <0.40 Poorly compressible >1.30 2° to medial calcification *Poor ulcer healing with ABI < 0.50 **Further vascular evaluation needed

  24. Vascular evaluation • Invasive evaluation • Arteriography • MR angiography • CT angiography

  25. Classification of Diabetic Foot ulcers

  26. Wagner’s Classification 0 – Intact skin (impending ulcer) 1 – superficial 2 – deep to tendon or ligament 3 - deep abscess, osteomyelitis 4 – gangrene of toes or forefoot 5 – gangrene of entire foot

  27. Wanger’s stage 0

  28. Wanger’s Stage 0

  29. ClassificationType 1, type 2

  30. ClassificationType 3

  31. Type 4

  32. Treatment • Prevention • Identification of high risk patients • Patient education • Careful selection of foot wear • Daily inspection of feet • Daily foot hygiene • Keep foot clean, moist • Avoidance of self treatment of foot abnormalities and high risk behavior ( walking barefoot) • Prompt consultation with health care provider • Orthotic shoes and devices • Callus management • Nail care

  33. Identifying at risk patient • History: • Prior amputation or foot ulcer • Peripheral artery disease (PAD) • Exam: • Insensate • Foot deformities • Absent pulses • Prolonged venous filling time • Reduced ABI • Pre-ulcerative cutaneouspathology

  34. Risk stratification for ulcer risk

  35. Treatment • Attention to other risk factors • Smoking • Hypertension • Dyslipidemia • Glycemic control

  36. Treatment • Plantar surface of the foot is the most common site • Ulcer may be • Primarily neuropathic • a/w surrounding cellulitis/ ostemyelitis • Cellulitis without ulceration may occur

  37. Treatment • Offloading • Debridement • Wound dressing • Antibiotics • Revascularisation • Amputation

  38. Treatment • Wagner 0-2 • Total contact cast • Distributes pressure and allows patients to continue ambulation • Principles of application • Changes, Padding, removal • Antibiotics if infected

  39. Treatment • Wagner 0-2 • Surgical if deformity present that will reulcerate • Correct deformity • exostectomy

  40. Treatment • Wagner 3 • Excision of infected bone • Wound allowed to granulate • Grafting (skin or bone) not generally effective

  41. Treatment • Wagner 4-5 • Amputation • ? level

  42. Indications for Amputation • Uncontrollable infection or sepsis • Inability to obtain a plantar grade, dry foot that can tolerate weight bearing • Non-ambulatory patient • Decision not always straightforward

  43. Treatment • After ulcer healed • Orthopedic shoes with accommodative (custom made insert) • Education to prevent recurrence

  44. Wound Care products • Dressings • Gauze pads • Transparent films • Hydrogels • Foam • Hydrocolloid • Alginate • Collagen dressing • Antimicrobial dressings

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