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Diabetic Foot: DR - Rishi Kumar Gupta

The document discusses diabetic foot, which refers to the foot of a diabetic patient that has potential risk of infection, ulceration or tissue destruction due to neurological issues, vascular disease or metabolic complications of diabetes. Diabetic foot poses a major burden in India, with high rates of hospitalization, morbidity, and amputation. Proper management requires a holistic approach including metabolic control, wound care, infection treatment, vascular assessment, offloading, and patient education to prevent relapse and complications. Timely treatment is important to avoid adverse outcomes like amputation.

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Sinu Acharya
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189 views39 pages

Diabetic Foot: DR - Rishi Kumar Gupta

The document discusses diabetic foot, which refers to the foot of a diabetic patient that has potential risk of infection, ulceration or tissue destruction due to neurological issues, vascular disease or metabolic complications of diabetes. Diabetic foot poses a major burden in India, with high rates of hospitalization, morbidity, and amputation. Proper management requires a holistic approach including metabolic control, wound care, infection treatment, vascular assessment, offloading, and patient education to prevent relapse and complications. Timely treatment is important to avoid adverse outcomes like amputation.

Uploaded by

Sinu Acharya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Diabetic Foot

Dr.Rishi Kumar Gupta


• World Health Organization is,
“The foot of a diabetic patient that has the
potential risk of pathologic consequences,
DEFINITION 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”
• India is set to become the diabetes capital of
the world with a projected 109 million
individuals with diabetes by 2035.
BURDEN OF • India ranks second (after China) with more than
66.8 million diabetics in the age group of 20-70.
DISEASE • The prevalence of Diabetes in India is 8.6% and,
as of 2013, more than 1 million Indians die each
year due to diabetes related causes.
• Diabetic Foot (DF) is one of the most common
complications for admissions imposing
tremendous medical and financial burden on
our healthcare system.
• The lifetime risk of a person with diabetes
BURDEN having a foot ulcer could be as high as 25% and
is the commonest reason for hospitalization of
CONT. diabetic patients (about 30%) and absorbs
about 20% of the total health-care costs, more
than all other diabetic complications.
• Foot ulcers among outpatient and inpatient
diabetics attending hospitals in rural India was
found to be 10.4%.
• Approximately, 85% of non-traumatic lower limb
amputations are seen in patients with prior history
of diabetic foot ulcer.
• Each year, more than 1 million people with diabetes
MORBIDITY lose at least a part of their leg due to diabetic foot.
• It shows that every 20 seconds a limb is lost in the
AND world somewhere.
MORTALITY • More than half of all foot ulcers become infected,
requiring hospitalization, while 20% of infections
result in amputation.
• After a major amputation, 50% of people will have
the other limb amputated within two years’ time.
• For treating a simple and complex diabetic foot
ulcer in low Income countries like India can be
equivalent to 5.7 years of average annual
income.

• The management of diabetic foot requires a


holistic and rigorous approach without which
there will be high levels of relapse, morbidity
and even mortality.

• It estimated that 90% of diabetic patients in


India do not see a specialist in their lifetime.
SCOURGE OF
DIABETIC FOOT

• Diabetic foot is quiet dreaded disability due


to:
• Long stretches of hospitalization
• Mounting expenses
• Ever dangling high degree of
amputation
Classification & Staging
• A standard classification of diabetic foot is useful to:
• assess the etiology
• find prognosis
• facilitate appropriate treatment
• monitor progress
• serve as a form of communication

• No universally accepted classification.


• The diabetic foot is classified on the basis of etiology into:

• Neuropathic foot (neuropathy is dominant)


a. with infection
b. without infection

• Neuroischemic foot (vascular disease is dominant)


a. with infection
b. without infection
WAGNER’S
CLASSIFICATION

• It is the most widely


discussed classification.
• It grades the foot
depending on severity.
PATHOGENESIS
• Vasculopathy In diabetes, there
is macro and microangiopathy
Decreased local
• Macroangiopathy blood flow
• Atherosclerosis of large arteries
• Microangiopathy
• Increased thickness of basement
membrane & endothelial Poor antibiotic Poor wound
proliferation penetration healing
• Capillary Damage
•
CLINICAL FEATURES
Pain in the foot.
Ulceration.
Absence of sensation.
Absence of pulsations in the foot
Loss of joint movements.
Abscess formation.
Change in temperature and colour when gangrene sets in.
Patient may succumb to ketoacidosis or septicaemia

CLINICAL FEATURES
MANAGEMENT
3.
1. Mechanical 2. Metabolic
Microbiological
FIVE control control
control
ASPECTS OF
PATIENT
TREATMENT 4. Vascular
5. Education
management
INVESTIGATIONS
• Blood sugar, urine ketone bodies.
• Blood urea and serum creatinine.
• X-ray of part to look for osteomyelitis.
• Pus for culture and sensitivity.
• Doppler study of lower limb to assess arterial patency.
• Angiogram to look for proximal blockage.
• Ultrasound of abdomen to see the status of abdominal aorta.
• Glycosylated haemoglobin estimation.
TREATMENT
• Antibiotics—decided by pus C/S.
• Regular dressing.
• Drugs: Vasodilators, pentoxiphylline, dipyridamole, low dose aspirin.
• Diabetes is controlled by insulin only.
• Diet control, control of obesity.
• Surgical debridement of wound.
• Amputations of the gangrenous area.
• Level of amputation has to be decided by skin changes and temperature
changes or Doppler study.
• Care of feet in diabetic:
• Any injury has to be avoided.
• MCR footwears must be used (Microcellular rubber).
• Feet has to be kept clean and dry, especially the toes and clefts.
• Hyperkeratosis has to be avoided
• Management of the ulcer falls into three parts:
• removal of callus
• eradication of infection
• reduction of weight bearing forces, often requiring bed rest with the foot
elevated.
DEBRIDEMENT
RATIONALE TO REMOVE CALLUS
• Removes callus, thus lowering plantar pressures.
• Enables the true dimensions of the ulcer to be seen.
• Stimulates ulcer healing.
• Removes any physical barrier to growth of new epithelium across the ulcer from
the margin.
• Prevents callus from sealing off an ulcer, which would prevent drainage and
promote infection.
• Enables drainage of exudate and removal of dead tissue (this renders infection
less likely by reducing bacterial load and removing material which is a suitable
growth medium for bacteria)
• Enables a deep swab or deep tissue to be taken for microscopy and culture
• Encourages healing by converting a chronic ulcer into an acute ulcer.
The debridement procedure:
• Remove all callus surrounding the ulcer with a sterile scalpel
• When debriding the ulcer bed, work from the middle outwards: this
carries debris and bacteria away from the ulcer bed
• Cut away all slough and non-viable tissue. It is helpful to grip the
material that is to be cut away with a pair of forceps and to apply
gentle traction so that the material to be cut is under tension. It is
difficult to remove macerated callus or slough evenly and precisely,
unless tension is applied.
RADIOGRAPH

• To assess the possibility of osteomyelitis.


• A deep penetrating ulcer is present, when
lesions fail to heal.
• Continue to recur.
• Gas in soft tissue signifies deep tissue
infection and the need for urgent surgical
débridement.
STANDARD TREATMENT OF DIABETIC FOOT
ACCORDING TO WAGNER CLASSIFICATION
GRADE TREATMENT

Foot at Risk Prevention

Grade-I Localized, superficial ulcer Antibiotics & glycemic control

Grade-II Deep Ulcer to bone, ligament, or Debridement, Antibiotics and


joint glycemic control

Grade-III Deep abscess, osteomyelitis Debridement, some form of


amputation

Grade-IV Gangrene of toes, forefoot Wide debridement and amputation

Grade-V Gangrene of entire foot Below knee amputation


• Deep indolent ulcer requires off loading, with a total contact plaster
cast.
• It should conform to the contours of the foot, thereby reducing shear
forces on the plantar surface.
• Any foot lesion which has not healed in one month requires further
investigation and a different approach
• Total contact casts are the gold
standard for offloading diabetic
neuropathic wound

• Boghossian, Jano & Miller, John &


Armstrong, David. (2017). Offloading the
diabetic foot: toward healing wounds and
extending ulcer-free days in remission.
Chronic Wound Care Management and
Research. Volume 4. 83-88.
10.2147/CWCMR.S114775.
INDICATIONS FOR CONSERVATIVE SURGICAL
APPROACH OR PRIMARY AMPUTATION

Weledji EP, Fokam P. Treatment of the diabetic foot - to amputate or not?. BMC Surg.
2014;14:83. Published 2014 Oct 24. doi:10.1186/1471-2482-14-83
URGENT TREATMENT
• Danger signs: urgent treatment needed
• Redness and swelling of a foot

• Cellulitis, discolouration, and crepitus (gas in soft tissues)

• A pink, painful, pulseless foot even without gangrene indicates critical


ischaemia
Remember: Cornerstone of ulcer is Prevention
1. Identification of the at-risk
foot
2. Regular inspection and
examination of the at-risk foot
3. Education of patient, family
and healthcare providers
4. Routine wearing of
appropriate footwear
5. Treatment of pre-ulcerative
signs
RECENT ADVANCES

• Recently developed
BIOMATERIALS that elicit healing
through cell-material interactions
and/or the sustained delivery of
drugs.
• These tunable therapeutic
systems increase angiogenesis,
collagen deposition, cell
proliferation, and growth factors
concentrations, while decreasing
inflammation and enzymatic
degradation of the extracellular
matrix.
• A nanometer (nm) is a scale that equal to one billionth of a meter 10-9m.
• The size of nano biomaterial is usually controlled at 1 to 100 nm level,
which is very important to biological properties and functions.
• The smaller the particle, the larger surface area-to-volume ratio it is. That
can increase the particle dissolution rate.
• The large surface areas of nano particles can load more surface functional
ligands. So the nano particles have good solubility and bioavailability, (Du
and Liu, 2014; Liu and Wong, 2013; Liu, 2012) (Fig 1).
• The sizes and surface characteristics of nano particles can be controlled.
• Eg:
a) Nano-Ag provides a larger surface area for attaching native ECM is collagen
as a scaffold.
b) Nanofibrous scaffolds coupled with stem cells
c) Anionic polymers and magnetic nanoparticles loaded with usnic acid
(Fe3O4@UA).
TAKE HOME MESSAGE
• Any foot problems can be prevented, and all diabetic patients should
be aware of the potential problem of foot damage.
• Every patient should be issued with information containing
straightforward safety instructions.
• A good podiatrist must be available for diabetic patients.
Thank You

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