Ce diaporama a bien été signalé.
Nous utilisons votre profil LinkedIn et vos données d’activité pour vous proposer des publicités personnalisées et pertinentes. Vous pouvez changer vos préférences de publicités à tout moment.
APPROACH to DIABETIC FOOT 
Dr. Faiez Alhmoud 
Surgery Dpt. 
Albashir Hospital 
(MOH)
Diabetic Foot (DF) 
 It will be unwise if we restrict the 
term (DF) to foot infection, ulcer or 
gangrene in a diabetic ...
Diabetic foot definition 
 Diabetic foot is a disease complex that can develop in 
the skin, muscles, or bones of the foo...
Epidemiology and facts 
 15% of the adult population in Jordan are diabetics 
 15% of those with diabetes will, develop ...
Diabetic foot…..facts 
 Every 30 seconds a lower limb is lost somewhere 
in the world as a consequence of diabetes 
 Dia...
Natural history of diabetic 
foot 
 It’s unwise to consider that major 
diabetic foot problem occur all of 
sudden 
 The...
What’s the high risk foot ? 
Long duration and uncontrolled D.M …Plus 
one or more: 
 Peripheral neuropathy 
 Peripheral...
FOOT AT RISK
Pathophysiology 
 The critical triad of : 
1- Neuropathy 
2- Foot deformity & 
3- Trauma …………… 
will lead to ulcer 
The p...
Neuropathy 
 Sensory : lack of protective 
sensation (unrecognized trauma) 
 Motor : Change in foot anatomy 
(Pressure p...
Neuropathy 
The Gift of Pain 
“Pain: The gift nobody wants “. 
Paul Brand
Classification and definition 
of problem 
 The neuropathic foot – in which 
neuropathy predominates but the major 
arter...
Stages Of Ulcer Development
Assessment 
 History 
 Physical examinations 
 Investigations 
 
 
 Patient 
 Limb or foot 
 Wound
Who will take care ? 
 G. Physicians 
 General Surgeons 
 Diabetologists (Endocrinologist) 
 Orthopaedic surgeon 
 Va...
Assessment………..History 
 Generally: fever, chills, sweats, vom… 
 Condition : confused, depressed…. 
 Socially : neglec...
Assessment………Clinical Ex. 
What to look for ? 
 V.S : tachycardia, hypotension… 
 Signs of volume depletion 
 Cognitive...
Diabetic Foot Examination 
 D deformity 
 I infection 
 A atrophic nails 
 B breakdown of skin 
 E oedema 
 T temper...
Assessment………Clinical Ex. 
Typical neuropathic foot
Neurologic assessment 
 Temperature 
 Vibration Sense 
 Pressure Sense 
 Light Touch 
 Proprioception (Romberg’s Sign...
Nylon monofilament test
Neuropathy 
 Charcot foot 
“Acute or subacute inflammation of all or part 
of the foot in people with diabetes 
complicat...
Diagnosis of Acute Charcot 
 Painless 
 Redness, swelling, and more than 2°C skin 
temperature difference when compared ...
Ulcer assessment 
1. Site, size and shape 
2. Edges 
3. Establish its depth and involvement of deep 
structures 
4. Examin...
Classification of diabetic foot 
ulcer 
Wagner Grading System 
 Grade 0 skin intact but "foot at risk" 
 Grade 1: Superf...
Classification of diabetic foot 
ulcer
Neuropathic foot ulcer. 
Khanolkar M et al. QJM 2008;101:685-695 
© The Author 2008. Published by Oxford University Press ...
The Charcot foot. 
Khanolkar M et al. QJM 2008;101:685-695 
© The Author 2008. Published by Oxford University Press on beh...
Effects of Diabetic Peripheral 
Neuropathy
Vascular assessment 
 History 
 Changes in skin 
 Pulses 
 Exercise Testing 
 ABPI 
 Duplex 
 Angiography
Assessment..........Ischemia 
Peripheral Vascular Disease 
Chronic limb ischaemia 
Grade 0 = Mild claudication 
Grade 1 = ...
Vascular assessment ......... 
...........Ankle Brachial Index 
ABI value Indicates 
 <0.9 Abnormal 
 0.8- 0.9 Mild PAD ...
Ischaemic foot ulcer. 
Khanolkar M et al. QJM 2008;101:685-695 
© The Author 2008. Published by Oxford University Press on...
Assessment…….Infection 
Infection is diagnosed clinically by 
 The presence of purulent secretion 
OR 
 At least 2 of th...
Clinical assessment of 
infection 
Non-Limb-threatening Infections: 
 Superficial infection 
 Lack systemic toxicity 
 ...
Clinical assessment of 
infection 
Limb-threatening infections: 
 Extensive cellulitis (> 2 cm.) 
 Lymphangitis 
 Full-...
Classification of diabetic foot 
infection 
 Minimal inflammation with no pus = 1 
 2 or more signs or ~2cm erythema 
ar...
Classification of diabetic foot 
infection 
Non-Limb-threatening 
Infections:
Classification of diabetic foot 
infection 
Limb-threatening Infection:
Common Pathogens 
 MILD infection = MONOMICROBIAL 
 SEVERE infection = POLYMICROBIAL 
 In acute wounds and cellulitis :...
Principles of diabetic 
foot ulcer management 
بدها صبر
Five cornerstones of management 
of the diabetic foot 
The situation can be changed & possibly 
reduce amputation rates be...
Patient education 
Decreases the chance of occurrence 
 Foot hygiene 
 Daily inspection 
 Proper footwear 
 Prompt tre...
A multidisciplinary approach 
 Providing : 
- Debridement, 
- Meticulous wound care, 
- Adequate vascular supply, 
- Meta...
Investigations 
 Bloodwork for high BS, DKA, hyperosmolar 
state….. 
 Gram staining and culture 
 Imaging 
- Plain X-ra...
Approach to foot wound in 
diabetics 
 General Principles 
1- Avoid antibiotics in uninfected foot 
2- Determine the need...
Principles of Foot ulcer 
management 
1.Infection Control 
2.Offloading 
3.Vascular assessment 
4.Wound care
Infection Control 
 Foot infections are the most common cause of 
admission to hospital for patients with diabetes 
 Inf...
Approach to foot wound in 
diabetics 
 ……Principles of wound care 
1- Determine the need for surgery 
Ranges from debride...
Debridement 
 Sharp 
 Larval 
 Enzymatic 
(Lytic)
Approach to diabetic foot ulcer 
According to ulcer stage 
0 At-risk foot, no ulceration : Patient education, 
accommodati...
Approach to ischemic diabetic foot 
Ischemia Classification 
A Not ischemic : no treatment 
B Ischemia without gangrene: N...
Approach to diabetic foot infection 
Antibiotics Empirical antibiotics 
 Benzylpenicillin or ampicillin – Streptococcus s...
Offlaoding 
Remove pressure from the affected site is 
essential 
 How ? 
- Footwear 
- Specialised 
offloading 
devices
Offlaoding 
 Footwear 
Good shoes are integral to good foot health
Offloading
Vascular assessment 
Surgical revascularisation
Follow up 
 Osteomyelitis 
Consider potential osteomyelitis in any 
1- Deep or extensive chronic ulcer and over bony prom...
Osteomyelitis 
Initial screening tool is the plain X-ray : 
 Easily obtained, relatively inexpensive and 
provides anatom...
Osteomyelitis
Follow up……Osteomyelitis 
Diagnosis 
Serial X-rays with 2-4 weeks interval 
- If typical, treat as ostemyelitis 
- If not ...
Outcome 
 Good outcome to appropriate therapy 
In 80–90% of mild-moderate infection 
50-80% of severe or OM infection 
 ...
Prevention 
 Early detection of neuropathy 
 Educate patient about 
- Optimizing glycemic control 
- Using appropriate f...
Key Message 
 Of all late complications of diabetes, foot problems 
are the most easily detectable and easily 
preventabl...
Key Message
Mission:… Happy Feet 
QUSTIONS ?
Prochain SlideShare
Chargement dans…5
×

Approach to diabetic foot

30 642 vues

Publié le

Publié dans : Santé & Médecine
  • Nine Signs Wealth is Coming Your Way...  http://scamcb.com/manifmagic/pdf
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici
  • This Deadly Molecule Causes Diabetes (not belly fat)... ➤➤ http://ishbv.com/bloodsug/pdf
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici
  • Eat This POTENT Vegetable To Melt Diabetic Fat. IMPORTANT: Be careful, only eat it twice a day or you will lose diabetic belly fat too fast...  http://ishbv.com/bloodsug/pdf
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici
  • DOWNLOAD FULL BOOKS, INTO AVAILABLE FORMAT ......................................................................................................................... ......................................................................................................................... 1.DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. PDF EBOOK here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. EPUB Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... 1.DOWNLOAD FULL. doc Ebook here { https://tinyurl.com/y6a5rkg5 } ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .............. Browse by Genre Available eBooks ......................................................................................................................... Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult,
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici
  • Don't fear hair loss - fight it! Try Profollica� natural two-step hair loss system for visible results you'll see and love! ♥♥♥ http://t.cn/AiHip2fH
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici

Approach to diabetic foot

  1. 1. APPROACH to DIABETIC FOOT Dr. Faiez Alhmoud Surgery Dpt. Albashir Hospital (MOH)
  2. 2. Diabetic Foot (DF)  It will be unwise if we restrict the term (DF) to foot infection, ulcer or gangrene in a diabetic patient  Why?    (advanced stage of the disease)
  3. 3. Diabetic foot definition  Diabetic foot is a disease complex that can develop in the skin, muscles, or bones of the foot as a result of the nerve damage, poor circulation and/or infection that is associated with diabetes.  The Diabetic Foot may be defined as a syndrome in which neuropathy, angiopathy, and infection will lead to tissue breakdown resulting in morbidity and possible amputation ( WHO 1995 )  Any foot pathology that result from diabetes or it’s long – term results (Boulton 2002)
  4. 4. Epidemiology and facts  15% of the adult population in Jordan are diabetics  15% of those with diabetes will, develop an ulcer  15% of patients develop osteomyelitis & 15% amputation  80% of foot ulcers are precipitated by external trauma  20% of diabetics admitted to hospitals because of foot problems  Cellulitis occurs 10 times more frequently in diabetics  Osteomyelitis of the foot 15 times more frequently in diabetics than non-diabetics  Diabetic patients are 15x at risk of BKA  Nearly half of non-traumatic LLA caused by diabetes.  70% of lower limb amputations begin with a foot ulcer  ~50% of diabetics with LLA require 2nd LLA within 5 years  5 year survival rate ~50% after BKA--Tragic “Rule of 50”  The annual direct and indirect costs is high  Up to 85% of amputations can be avoided.
  5. 5. Diabetic foot…..facts  Every 30 seconds a lower limb is lost somewhere in the world as a consequence of diabetes  Diabetic foot infection require attention to local (foot) and systemic (metabolic) issues by multidisciplinary foot care team  Only in the last 20 years progress in the understanding of pathogenesis and management of diabetic foot had been made  However …. there is still gap between what’s known about diabetic foot and what’s really done to them
  6. 6. Natural history of diabetic foot  It’s unwise to consider that major diabetic foot problem occur all of sudden  There is high risk foot which means  There are 1- Predisposing factors (Neuro- and angiopathy) العوامل المهيئة 2- Precipitating factors (Trauma and tinea) العوامل المعجلة 3- Perpetuating factors (Pt’s factors & delay healing) عوامل التكريس
  7. 7. What’s the high risk foot ? Long duration and uncontrolled D.M …Plus one or more:  Peripheral neuropathy  Peripheral vascular disease  Trauma  Previous ulcers  Diabetic nephropathy or retinopathy  Obesity  Lack of education  Male gender ??!!
  8. 8. FOOT AT RISK
  9. 9. Pathophysiology  The critical triad of : 1- Neuropathy 2- Foot deformity & 3- Trauma …………… will lead to ulcer The presentation in the majority of pts is an infected ulcer!!
  10. 10. Neuropathy  Sensory : lack of protective sensation (unrecognized trauma)  Motor : Change in foot anatomy (Pressure points) & altered gait and deformity  Autonomic : Lack of sweat ( dry & cracked skin )
  11. 11. Neuropathy The Gift of Pain “Pain: The gift nobody wants “. Paul Brand
  12. 12. Classification and definition of problem  The neuropathic foot – in which neuropathy predominates but the major arterial supply to the foot is intact.  The neuro-ischaemic foot – where neuropathy, and ischaemia resulting from a reduced arterial supply, contribute to the clinical presentation.  Infection - is rarely the only factor but often complicates neuropathy and or ischaemia, and is responsible for considerable tissue necrosis
  13. 13. Stages Of Ulcer Development
  14. 14. Assessment  History  Physical examinations  Investigations    Patient  Limb or foot  Wound
  15. 15. Who will take care ?  G. Physicians  General Surgeons  Diabetologists (Endocrinologist)  Orthopaedic surgeon  Vascular surgeon  Plastic surgeon  Podiatrists  Specialised nurse
  16. 16. Assessment………..History  Generally: fever, chills, sweats, vom…  Condition : confused, depressed….  Socially : neglected, lack of home sup  Neuropathy : Numbness, loss of sens. burning, tingling, numbness & nocturnal leg pains.  Others : duration, diabetic control, previous ulceration, smoking, HTN....
  17. 17. Assessment………Clinical Ex. What to look for ?  V.S : tachycardia, hypotension…  Signs of volume depletion  Cognitive state:delirium,stupor, coma  Limb-Foot: 1- Biomechnics: deformities, change pressure points 2- Vascular status ( arterial, venous, ABI, ischemia, gangrene… 3- Neuropathy ( light touch, vibration, monofilament pressure 4- Examining the feet for structural abnormalities such as nails, calluses, hammer toes, claw toes and flat foot
  18. 18. Diabetic Foot Examination  D deformity  I infection  A atrophic nails  B breakdown of skin  E oedema  T temperature  I ischemia  C callosities  S skin colour
  19. 19. Assessment………Clinical Ex. Typical neuropathic foot
  20. 20. Neurologic assessment  Temperature  Vibration Sense  Pressure Sense  Light Touch  Proprioception (Romberg’s Sign)  Superficial Pain  Reflexes
  21. 21. Nylon monofilament test
  22. 22. Neuropathy  Charcot foot “Acute or subacute inflammation of all or part of the foot in people with diabetes complicated by distal symmetrical neuropathy, accompanying fracture or dislocation that cannot be explained by recent trauma, and with or without preceding ulceration of the surrounding skin” (Jeffcoate 2004)
  23. 23. Diagnosis of Acute Charcot  Painless  Redness, swelling, and more than 2°C skin temperature difference when compared with the contralateral foot.  Dorsalis pedis pulses are often bounding.  The patient is afebrile unless a systemic infection is present.
  24. 24. Ulcer assessment 1. Site, size and shape 2. Edges 3. Establish its depth and involvement of deep structures 4. Examine it for purulent exudates, necrosis, sinus tracts, and odor 5. Assess the surrounding tissue for signs of edema, cellulitis, abscess, and fluctuation 6. Perform a vascular evaluation. 7. The ability to gently probe through the ulcer to bone has been shown to be highly predictive of osteomyelitis. 8. Establish the ulcer's etiology 9. Exclude systemic infection
  25. 25. Classification of diabetic foot ulcer Wagner Grading System  Grade 0 skin intact but "foot at risk"  Grade 1: Superficial Diabetic Ulcer & localised  Grade 2: Deep ulcer & extension  Involves ligament, tendon, joint capsule or fascia  No abscess or Osteomyelitis  Grade 3: Deep ulcer with abscess or Osteomyelitis  Grade 4: Gangrene to portion of forefoot  Grade 5: Extensive gangrene of entire foot
  26. 26. Classification of diabetic foot ulcer
  27. 27. Neuropathic foot ulcer. Khanolkar M et al. QJM 2008;101:685-695 © The Author 2008. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
  28. 28. The Charcot foot. Khanolkar M et al. QJM 2008;101:685-695 © The Author 2008. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
  29. 29. Effects of Diabetic Peripheral Neuropathy
  30. 30. Vascular assessment  History  Changes in skin  Pulses  Exercise Testing  ABPI  Duplex  Angiography
  31. 31. Assessment..........Ischemia Peripheral Vascular Disease Chronic limb ischaemia Grade 0 = Mild claudication Grade 1 = Moderate to severe claudication without tissue loss or ischaemic rest pain Critical ischaemia Grade 2 = Ischaemic rest pain Grade 3 = Tissue loss due to ischaemic ulceration or gangrene
  32. 32. Vascular assessment ......... ...........Ankle Brachial Index ABI value Indicates  <0.9 Abnormal  0.8- 0.9 Mild PAD  0.5- 0.8 Moderate PAD  <0.5 Severe PAD  <0.25 Very Severe PAD ******The ABI has limited use in evaluating calcified vessels that are not compressible as in diabetics (gives reading above one)
  33. 33. Ischaemic foot ulcer. Khanolkar M et al. QJM 2008;101:685-695 © The Author 2008. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
  34. 34. Assessment…….Infection Infection is diagnosed clinically by  The presence of purulent secretion OR  At least 2 of the cardinal local manifestations of inflamation  Hotness  Redness  Swelling  Function loss or pain
  35. 35. Clinical assessment of infection Non-Limb-threatening Infections:  Superficial infection  Lack systemic toxicity  Minimal cellulitis (< 2 cm. Extension from portal of entry)  Ulcer-if present-doesnot penetrate fully thru skin  No bone or joint involvement  No underlying ischemia
  36. 36. Clinical assessment of infection Limb-threatening infections:  Extensive cellulitis (> 2 cm.)  Lymphangitis  Full-thickness ulcers  Frequent bone & joint infections  Ischemia + gangrene  Fever +  Deep plantar abscesses  Bacteremia + hematogenous spreading infections
  37. 37. Classification of diabetic foot infection  Minimal inflammation with no pus = 1  2 or more signs or ~2cm erythema around the ulcer or superficial path. and no systemic manifistations = 2  As above plus deeper infection, lymphangitis ,abscess or gangrene =3  As above with systemic or metabolic instability = 4
  38. 38. Classification of diabetic foot infection Non-Limb-threatening Infections:
  39. 39. Classification of diabetic foot infection Limb-threatening Infection:
  40. 40. Common Pathogens  MILD infection = MONOMICROBIAL  SEVERE infection = POLYMICROBIAL  In acute wounds and cellulitis : S. aur. & B.Hem. Strept. are commonly found (+)  In chronic infected wounds : add entrobacter (-)  Macerated soaked wound : Pseudomonas  Long duration & nonhealing : all the above plus fungi  Deep infection & extensive necrosis with bad odor : all the above plus obligate anaerobes
  41. 41. Principles of diabetic foot ulcer management بدها صبر
  42. 42. Five cornerstones of management of the diabetic foot The situation can be changed & possibly reduce amputation rates between 50% - 85% by: 1- Regular inspection and examination of the foot and patient education 2- Identification of the foot at risk. 3- Education of patient, family and healthcare providers. 4- Appropriate footwear. 5- Multidisciplinary approach & treatment of ulcerative and non-ulcer pathology
  43. 43. Patient education Decreases the chance of occurrence  Foot hygiene  Daily inspection  Proper footwear  Prompt treatment of new lesions Must take an active role in their care  Disease management  Routine nail care  Ulcer management Elective surgery to correct structural deformities before ulcerations occur
  44. 44. A multidisciplinary approach  Providing : - Debridement, - Meticulous wound care, - Adequate vascular supply, - Metabolic control, - Antimicrobial treatment and -Relief of pressure (offloading) are essential in the treatment of foot ulcer.
  45. 45. Investigations  Bloodwork for high BS, DKA, hyperosmolar state…..  Gram staining and culture  Imaging - Plain X-ray - MRI ? - Doppler – Angiogram - US? For deep abscess - Doppler and ABI
  46. 46. Approach to foot wound in diabetics  General Principles 1- Avoid antibiotics in uninfected foot 2- Determine the need for hospitalization Severe infection or critical ischemia 3- Stabilize the patient and correct: - Fluids and electrolytes - Hyperglycemia, hyperosmolarity ,acidosis - Treat other exacerbating factors 4- Choose antibiotic regimen: Limited data support the use of topical antibiotics Mild-moderate infection, give narrow spectrum antibiotics –no anaerob Severe infection, give broad-spectrum with anaerobic coverage
  47. 47. Principles of Foot ulcer management 1.Infection Control 2.Offloading 3.Vascular assessment 4.Wound care
  48. 48. Infection Control  Foot infections are the most common cause of admission to hospital for patients with diabetes  Infection is a precursor to amputation in many cases  Need to be treated aggressively  Sampling by sterile swabs misses important pathogens  True bacteriological yield is obtained from deep tissue samples  IF INFECTION IS PRESENT, DO NOT WAIT FOR SWAB RESULTS
  49. 49. Approach to foot wound in diabetics  ……Principles of wound care 1- Determine the need for surgery Ranges from debridement to revascularization Determine life- or limb-threatening condition ( NF, GG, Ischemia…. ) 2- Formulate wound care plan - Daily inspection - Dressing and debridement as needed - Removal of pressure….. 3- Twice- weekly follow up for outpatients 4- WBC, ESR, C-RP, culture … are of limited value
  50. 50. Debridement  Sharp  Larval  Enzymatic (Lytic)
  51. 51. Approach to diabetic foot ulcer According to ulcer stage 0 At-risk foot, no ulceration : Patient education, accommodative footwear, regular clinical examination 1 Superficial ulceration, not infected :Offloading with total contact cast (TCC), walking brace, or special footwear 2 Deep ulceration exposing tendons or joints : Surgical debridement, wound care, offloading, culture-specific antibiotics 3 Extensive ulceration or abscess : Debridement or partial amputation, offloading, culture-specific antibiotics
  52. 52. Approach to ischemic diabetic foot Ischemia Classification A Not ischemic : no treatment B Ischemia without gangrene: Noninvasive vascular testing, vascular consultation if symptomatic C Partial (forefoot) gangrene :Vascular consultation and debridement D Complete foot gangrene : Major extremity amputation, vascular consultation
  53. 53. Approach to diabetic foot infection Antibiotics Empirical antibiotics  Benzylpenicillin or ampicillin – Streptococcus sp.  Oxacillin, nafcillin or 1 st generation cephalosporin (eg. cefazolin) – Staphylococcus sp.  Quinolone + aminoglycoside (gentamycin) – Pseudomonas sp.  Methicillin-resistant Staphylococcus aureus – vancomycin or cotri-moxazole  Clostridial species are sensitive to a combination of penicillin G and clindamycin Duration of antibiotic treatment * 1-2 weeks course for mild to moderate infections * more than 2 weeks for more serious infections * 6 - 8weeks for osteomyelitis * If all infected bone is removed,a shorter course (1-2 weeks) of antibiotics, as for soft tissue infection, may be adequate
  54. 54. Offlaoding Remove pressure from the affected site is essential  How ? - Footwear - Specialised offloading devices
  55. 55. Offlaoding  Footwear Good shoes are integral to good foot health
  56. 56. Offloading
  57. 57. Vascular assessment Surgical revascularisation
  58. 58. Follow up  Osteomyelitis Consider potential osteomyelitis in any 1- Deep or extensive chronic ulcer and over bony prominence 2- Unhealed ulcer after 6 weeks of Abx. And offloading ttt. 3- Ulcer in which bone is visible or easily felt 4- Sausage toe
  59. 59. Osteomyelitis Initial screening tool is the plain X-ray :  Easily obtained, relatively inexpensive and provides anatomical information  Demineralization, periosteal reaction, bony destruction: (the classic triad)  Appear after 30 – 50% of bone is destroyed and can take as much as 2 weeks to appear  Found in other conditions such as fracture or deformity  Sensitivity and specificity approximately 54% and 80%
  60. 60. Osteomyelitis
  61. 61. Follow up……Osteomyelitis Diagnosis Serial X-rays with 2-4 weeks interval - If typical, treat as ostemyelitis - If not but clinically suspected MRI or Bone scan or Radionuclide or Scintigraphic imaging  Triple Phase Bone Scan (TPBS)  Gallium Scan  Indium-111 Leukocyte Scan - Probe to Bone - Empirical antibiotics for 6-8 weeks and repeat Ro or - Bone biopsy MRI is the most accurate imaging modality Three-phase bone scintigraphy is highly sensitive
  62. 62. Outcome  Good outcome to appropriate therapy In 80–90% of mild-moderate infection 50-80% of severe or OM infection  Poor outcome associated with Signs of systemic infection Inadequate limb ischemia OM Necrosis or gangrene Proximal site of infection Inexperienced surgeon
  63. 63. Prevention  Early detection of neuropathy  Educate patient about - Optimizing glycemic control - Using appropriate footwear - Avoid foot trauma - Perform daily self examination - Smoking cessation  Refer patient with critical ischemia
  64. 64. Key Message  Of all late complications of diabetes, foot problems are the most easily detectable and easily preventable.  Relatively simple interventions can reduce amputations by 50 - 80%. (Bakker et al 1994).  Strategies aimed at preventing foot ulcers are cost effective and cost saving.  “The pathway to amputation Is littered with bandages and dressings which have deceived both the doctor and patient into thinking that by dressing an ulcer they were curing it”  Diabetics should treat their Feet like their Face
  65. 65. Key Message
  66. 66. Mission:… Happy Feet QUSTIONS ?

×