Diabetic foot Dr Jitesh Jain
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Management of diabetic foot. latest trends
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Diabetic foot Dr Jitesh Jain
- 1. DIABETIC FOOT Jitesh Jain MS, FNB(Sports medicine) Consultant orthopedic and arthroscopic surgeon Mahavir Jaipuriya Rajasthan Hopital Jaipur.
- 2. Definition (WHO) • In diabetic patients infection, ulceration or destruction of deep tissues of lower limb associated with neurological abnormalities & various degrees of peripheral vascular diseases
- 3. Disease burden • Epidemiological studies have estimated prevalence of foot ulcers in diabetic patients ranging from 4% to 27%. • One fifth of total hospital admissions and 20%-30% of total expenditure spent on diabetes care is estimated due to foot ulcers and leg problems .
- 4. Disease burden • Lower limb amputations are 15 times higher in diabetic patients compared to non diabetic patients
- 5. DFU is analogous to cancer • 5 year survival rate after appearance of a DFU is around 50%-60% • 40% of DFU patients develop a new ulcer after healing of one foot ulcer within one year.
- 6. ETIOPATHOGENEIS: MULTIFACTORIAL Causative factors Contributing factors Peripheral neuropathy Peripheral vascular disease Structural foot deformity leading to high foot plantar pressure Uncontrolled hyperglycemia Trauma to foot
- 7. Etiopathogenesis: multifactorial Sensory neuropathy Motor neuropathy Autonomic neuropathy sensation of pain, pressure and proprioception are decreased or lost. This results in loss of protective sensation and increases vulnerability to injuries to foot leads to muscle imbalance in the leg and foot muscles with resultant plantar surface pressure alteration and typical foot deformities i.e. hammer toe and hallux rigidus contributes by causing dry skin, fissures and crusting Hyperglycemia Endothelial dysfunction and vasoconstriction in peripheral blood vessels cause hypercoagulability
- 8. Risk factors for DFUs History of prior ulceration Poor control of blood sugar Long duration of diabetes mellitus Chronic renal disease
- 9. Risk factors for DFUs Peripheral neuropathy Foot deformity and decreased mobility of the foot Foot callosity Improperly fitted shoes Old age Visual impairment
- 10. Classification of diabetic foot ulcer
- 11. Wagner stage 1 • Superficial diabetic ulcer- no exposed bone/tendons
- 12. Wagner stage 2 • Exposed tendons/ligament/ deep fascia/ joint capsule/bone • No osteomyelitis/abscess
- 13. Wagner stage 3 • Osteomyelitis/abscess • Bone exposed/involved- X ray changes are seen
- 14. Wagner stage 4 • Localized/ partial foot gangrene
- 15. Wagner stage 5 Whole foot gangrene
- 16. PEDIS classification • More relevant to the prognosis of the ulcer. Higher the grade of PEDIS (2 or >2) poorer is the prognosis.
- 17. Stages of DFU development
- 19. Examination of DFU Size, depth, edge, floor, base,location and numbers. Presence of sinus tract. Any exudate from the ulcer. Erythema, swelling, discoloration and component of cellulitis
- 20. Determining the etiopathogenesis • Neuropathy assessment: Touch To assess the neuropathy a 10 g monofilament test is currently recommended. With both eyes closed, the monofilament is touched at 90° to the skin and pressed till it buckles to 1 cm, patient is asked to say yes when a touch is felt. Vibration:128 Hz tuning fork
- 21. Screen the patient for peripheral vascular disease. • History of rest pain and intermittent claudication • pedal pulses and popliteal pulses. • Ankle-brachial index Values between 0.91 to1.3 is considered Normal and below 0.40 is suggestive of critical ischemia
- 22. Culture from a DFU • When infection is suspected (erythema, purulent discharge) culture is best taken from the purulent drainage or from the ulcer base.
- 23. Risk assessment in Diabetic foot: • Low risk foot: only callus is present • Medium risk foot: structural deformity/ peripheral neuropathy/peripheral arterial disease • High risk foot: previous ulceration or amputation along with any of two: structural deformity/ peripheral neuropathy/peripheral arterial disease
- 24. Management: multidisciplinary approach • vascular surgeon, orthopedician, podiatrist, orthotist, endocrinologist, educator, specialist nurse and dietician
- 25. Tips for foot care that should be involved in patient education: • Foot inspection • Never walk bare feet. • Trim nails • Don’t try to remove callus at home • Care of dry skin. • Doctor’s Visit
- 26. Blood sugar control: most important • Every 1% increase in HbA1C level increases the relative risk of peripheral vascular disease by more than 25% . • Goal -keep the HbA1C below 7.0% to 7.5% (150 to 170 mg/d).
- 27. Surgical management • Sharp surgical debridement • Regular weekly serial debridement should be done if new necrotic tissues form
- 28. Surgical management • In severe ischemia aggressive debridement should be avoided and revascularization procedure should be performed before serial debridement if necessary.
- 29. Case 1: sharp serial debridement
- 31. Wound ready for skin grafting
- 34. Case 2 sharp surgical debridement
- 37. Wound ready for skin grafting
- 39. Other kinds of debridement • Enzymatic debridement - papain, streptokinase and streptodornase, are used to remove necrotic tissues. • Autolytic debridement - moist dressings such as hydrocolloids, hydrogels • Biologial debridement
- 40. Advance dressings for DFU • Hydrogel and hydrocolloid dressings- have a great absorbency and provide moistened environment. • Alginate and silver impregnated dressings have antibacterial properties and commonly used for infected wound.
- 41. Newer therapies for diabetic foot: • Hyperbaric oxygen therapy (HBOT), • Vacuum dressing (negative pressure wound therapy, NPWT) • Electric stimulation (ES) and • Bioengineered skin (BES).
- 42. HBOT and ES: effective adjuvant to surgical debridement • HBOT therapy has been reported to decrease tissue hypoxia and enhanced tissue perfusion decreases sensitivity to inflammatory cytokines and promotes collagen production and angiogenesis thus improving healing rates. • ES improves blood flow, up-regulates cellular responses and decreases infection.
- 43. HBOT: How its given? – One treatment session takes approximately 120 min. Patients are placed in a pressure chamber. • First, the chamber is pressurised with compressed air for 15 min. Patients are exposed to 2.4 absolute atmosphere (ATA) pressure while breathing 100% oxygen. • Each therapy session consists of three oxygenation periods. These periods last 25 min each and are separated by 5-min air breaks. After that, the chamber is decompressed for 15 min and the therapy is finished.
- 44. HBOT chamber
- 45. Wagner type 5 DFU after serial debridement and HBOT therapy
- 46. NPWT: Effective in chronic non healing ulcers • By continuously removing wound exudate it reduces bacterial load and promotes cellular proliferation, up-regulates cellular function and enhances angiogenesis.
- 47. NPWT • A sterile water tight seal is created over the wound with polyurethane or polyvinyl alcohol and adhesive tape. • A negative pressure of 80-125 mmHg is used in pulsed fashion or continuously and suctioned fluid is collected in a container at bed side.
- 49. NPWT After debridement 2 VAC cycles of 6 days each
- 50. Bioengineered skin in DFUs
- 51. Bioengineered skin: RCTs have proved efficacy of BES • This method aims at changing the cellular environment to more favorable milieu by replacing the diseased extracellular matrix with a new ground substance matrix with cellular components. • Derma graft and Apligraf, are commercially available skin equivalents for use in chronic non healing DFU. • Oasis is an acellular biomaterial derived from porcine small intestine submucosa. It contains many dermal components including collagen, hyaluronic acid, proteoglycans, fibronectin, and growth factors such as fibroblast growth factor-2, transforming growth factor β1, and VEGF.
- 52. Offloading and pressure modulation mainstays of management of neuropathic foot ulcers Technique description advantage disadvantage Total contact cast (TCC) POP cast is molded to the shape of the foot with minimal padding. A heel is given for walking. This cast so designed that it allows for equal distribution of the pressure on the sole while offloading the ulcer area. 1. Most studied and effective for neuropathic ulcer. 2. Faster healing rate compared to other techniques 3. Gold standard for neuropathic ulcers. 1. It needs weekly change and expert cast technician 2. It can’t be applied in case of infection as it does not allow for inspection of the ulcer 3. If not properly applied, rigid cast can cause irritation or even ulceration to insensate neuropathic foot 4. It need to be covered during shower 5. poor compliance
- 54. Steps of TCC application • Stockinette is applied to eliminate wrinkles • Verticle felt strips are placed down the medial and lateral sides of leg and malleoli • Cast padding is applied over them • Felt pad for plantar surface is applied • Self adhesive foam is placed over toes and trimmed. Cat is applied over all layers. • Plantar plywood platform is incorporated in the cast • Cast shoe is applied.
- 56. Removable cast walker (RCW) Removable cast walker (RCW) It is a shoe shaped cast- like device that is easily removable. 1. It allows for self- inspection and topical application of dressing on the ulcer. 2. More compliant for the patient as it can be removed during sleep and shower. 3. It can be used for infected ulcer 1. Healing rate is slower than TCC
- 58. Instant TCC Instant TCC It is a combinatio n of TCC and RCW. In this method RCW is worn and elastotape or adhesive bandages are wrapped around it for tight fitting. 1.Healing rates are comparable to TCC 2. It can be removed by the patient as and when required. 1. A few studies have shown healing rates comparable to TCC but more RCTs are required to establish it as gold standard for neuropathic ulcer.
- 59. Instant TCC
- 60. Foot wears for diabetic patients
- 61. Charcot arthropathy Neuropathic (charcot) osteoarthropathy is a non infective destructive , lesion of a bone and joint resulting from a fracture or dislocation in a patient who has peripheral neuropathy
- 63. Pathophysiology
- 64. Classification
- 66. Classification
- 67. Classification
- 68. classification
- 69. Clinical presentations Warmth and erythema may be present
- 70. Management : nonoperative • In stage I and stage II- well-padded total- contact cast and protected weight bearing • In stage III, continued bracing may be necessary to accommodate deformity and to prevent ulceration over bony prominences.
- 71. Management: operative • Exostectomy • If deformity correction is required, arthrodesis of the involved joints may be performed
Notes de l'éditeur
- Burden of diabetes has increased in the world considerably in recent decades and so as the morbidity and mortality from diabetic foot ulcers
- Diabetes related lower limb complications are a large and growing contributor to the disability burden worldwide. We can prevent such extreme disability by combined efforts of skilled clinical team and patient education.
- Many studies have shown a temporal relationship between simultaneous occurrence of onset of dialysis and foot ulceration in diabetics (16-18). Probably inflammation associated with DFU diminishes the renal function.
- The presence of peripheral neuropathy seems to contribute to the development of ulceration and those with pre-ulceration, callosities and deformity seem to be at increased risk.
- Diabetic ulcers are most common in the forefoot beneath one of the metatarsal heads (Fig. 82-2) or the interphalangeal joint of the hallux
- A classification of diabetic ulcers by Brodsky does not include gangrene. In this scheme, grade 0 is intact skin, but represents a preulcerative lesion, with erythema, callus formation, and possible intradermal sheer hemorrhage over a bony prominence. Grade I is a superficial but full-thickness skin ulcer down but not through the subcutaneous tissue. Grade II ulceration is down to the tendon and joint capsule, but neither the joint nor the bone is visible. Grade III ulceration implies exposed bone or joint and osteomyelitis or pyarthrosis
- Most common location of DFU
- A graduated tuning fork (128 Hz) is used to screen the vibration perception threshold.
- Ankle-brachial index is the ratio of the highest systolic blood pressure at the ankle to the systolic blood pressure at the arm, and is measured using a Doppler device
- In diabetics polymicrobial infection predominates and both aerobic and anaerobic cultures should be asked for
- Timely management, systemic disease Patients should be taught their responsibility for their own health. Health care givers should teach the patient about importance of controlling blood sugar and regular monitoring of blood glucose level. Written information should be given by educator nurse regarding modifiable cardiovascular risk factor such as diet, BMI, alcohol, smoking and exercise
- Inspect your foot daily and wash them with water at room temperature. Especial attention should be given to area between the toes. Never walk bare feet. Always wear socks and shoes. Trim nails timely and don’t try to remove callus at home with knife or chemical agent. For dry skin use oil or creams but it should not be applied in between toes. Visit your health care giver at earliest whenever you notice a cut, scratch, and changes in the colour or texture of the foot or sore/ulcer.
- Hyperglycemia is the main cause of the development of DFU. It delays wound healing by hampering phagocytosis and chemotaxis thus compromising cellular immunity. Early control of blood sugar delays the development of neuropathy in diabetic patients but it has not been shown by any study that glycemic control can reverse the established neuropathy
- Sharp surgical debridement is the gold standard for the management of diabetic foot ulcers. Surgical debridement involves removal of all necrotic tissues, debris and infected tissues and disruption of surface bio films with scalpel, scissors and curettes.
- Enzymatic debridement is useful for ischemic ulcer where aggressive sharp surgical debridement is very painful
- It is mainly used as an adjuvant therapy to debridement and antibiotics
- Studies have shown a faster healing rate, faster time for wound closure and less time for healthy granulation tissue in non-healing ulcers with use of NPWT.
- The pathogenesis of neuropathic diabetic foot ulcers involves mechanical trauma due to focal pressure and repetitive moderate stress. Offloading the affected foot has been used as a useful management strategy as it allows for the pressure to be spread over a wider area away from the affected part. A variety of offloading techniques are in use including surgical offloading.