Diabetic foot
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1) 5-15% of diabetics develop foot ulcers, and 70% of healed ulcers recur within 5 years. 85% of non-traumatic lower limb amputations occur due to diabetic foot ulcers. 2) The main causes of diabetic foot ulcers are neuropathy, arterial disease, and an abnormal wound healing response. Neuropathy causes loss of sensation while arterial disease increases risk of atherosclerosis. 3) Management of diabetic feet focuses on prevention through patient education, regular examination and protective footwear. Treatment involves aggressive wound care, antibiotics, and sometimes surgery or amputation in severe cases.
Diabetic foot
- 1. 1 THE DIABETIC FOOTTHE DIABETIC FOOT Channa RatnatungaChanna Ratnatunga Department of SurgeryDepartment of Surgery University of PeradeniyaUniversity of Peradeniya
- 2. 2 5-15% of Diabetics develop foot5-15% of Diabetics develop foot ulcersulcers 70% of healed Diabetic ulcer are70% of healed Diabetic ulcer are likely to recur within 5 yearslikely to recur within 5 years 85% of non traumatic lower limb85% of non traumatic lower limb amputations follow diabetic footamputations follow diabetic foot ulcersulcers DIABETIC FOOTDIABETIC FOOT PREVALANCE AND PROGNOSISPREVALANCE AND PROGNOSIS
- 3. 3 Why do Diabetics sustain traumaWhy do Diabetics sustain trauma to feet?to feet? Extrinsic -Extrinsic - Poor visionPoor vision Falls due to joint immobilityFalls due to joint immobility CVAsCVAs Oedema due to CardiacOedema due to Cardiac causescauses Intrinsic -Intrinsic -
- 4. 4 Intrinsic Causes of DiabeticIntrinsic Causes of Diabetic Foot UlcerationFoot Ulceration NeuropathyNeuropathy Arterial DiseaseArterial Disease Abnormal tissue responseAbnormal tissue response to trauma and sepsisto trauma and sepsis
- 5. 5 NeuropathyNeuropathy SensorySensory – loss of pressure,– loss of pressure, pain, temperature and jointpain, temperature and joint sense. i.e. removes warningsense. i.e. removes warning signalssignals MotorMotor – weakness and– weakness and atrophy of intrinsic musclesatrophy of intrinsic muscles of foot, hence altered footof foot, hence altered foot structure and leading tostructure and leading to deformity and altereddeformity and altered biomechanicsbiomechanics AutonomicAutonomic – AV shunting– AV shunting affects maintenance of skinaffects maintenance of skin integrity and vascular tone.integrity and vascular tone. i.e. warm, dry, fissured footi.e. warm, dry, fissured foot
- 6. 6 Pes Cavus Ulceration at the tip
- 7. 7 Charcot footCharcot foot Long duration Diabetic neuropathy Hyperaemic response Osteopenia Local fractures Inflammatory response Proprioception – Deformity 0.2% of Diabetics
- 8. 8 Arterial DiseaseArterial Disease MacrovascularMacrovascular –– AtherosclerosisAtherosclerosis (Tibial) 4 to 20 times(Tibial) 4 to 20 times greater risk than ingreater risk than in non-diabeticsnon-diabetics MicrovascularMicrovascular -- MicroangiopathyMicroangiopathy
- 9. 9 Arterial DiseaseArterial Disease Macrovascular DiseaseMacrovascular Disease Atherosclerosis -Atherosclerosis - Male/ Female ratio equalMale/ Female ratio equal Advanced diseaseAdvanced disease Spontaneous ulcerationSpontaneous ulceration (Critical ischaemia common(Critical ischaemia common PregangrenePregangrene due to multi-segment disease)due to multi-segment disease) Neuropathy – no rest painNeuropathy – no rest pain GangreneGangrene Systemic diseaseSystemic disease Coronaries, CerebralsCoronaries, Cerebrals CalcificationCalcification Unreliable AB indexUnreliable AB index Collateral diseaseCollateral disease Poor reservePoor reserve AngiographyAngiography often foot vesselsoften foot vessels preservedpreserved
- 10. 10
- 11. 11 Arterial DiseaseArterial Disease Microvascular DiseaseMicrovascular Disease Early onset of micro-vascularEarly onset of micro-vascular dysfunctiondysfunction Affects arterioles an capillaries ofAffects arterioles an capillaries of several organsseveral organs Basement membrane thickeningBasement membrane thickening may impair oxygen diffusionmay impair oxygen diffusion Reduced tissue response to sepsisReduced tissue response to sepsis
- 12. 12 Diabetic Microangiopathy Foot ulceration is not due to microangiopathy
- 14. 14 In a Diabetic footIn a Diabetic foot Wound healing is affected by..Wound healing is affected by.. 1.1. Growth factors deficiencyGrowth factors deficiency Impaired fibroblast responseImpaired fibroblast response Abnormalities of Extracellular matrixAbnormalities of Extracellular matrix 2.2. Alterations in..Alterations in.. Neuroinflammatory responseNeuroinflammatory response Hyperaemic responseHyperaemic response Thermoregulatory responseThermoregulatory response
- 15. 15 Diabetic footDiabetic foot Infections IInfections I Cell mediated immunity depressedCell mediated immunity depressed Phagocytic function of multinuclearPhagocytic function of multinuclear leukocytes affectedleukocytes affected Leucocyte migration at microcirculatoryLeucocyte migration at microcirculatory level is affectedlevel is affected Hyperglycaemia associated withHyperglycaemia associated with mycotic infections could contributemycotic infections could contribute
- 16. 16 Painless collection of pusPainless collection of pus Tracking of pus along tendon sheathsTracking of pus along tendon sheaths Staphylococcus aureusStaphylococcus aureus is commonis common Foot compartmentsFoot compartments Diabetic footDiabetic foot Infections IIInfections II Deep interosseous space Medial plantar space Central plantar space Lateral plantar space
- 17. 17 CLINICAL ASSESSMENT OFCLINICAL ASSESSMENT OF A DIABETIC FOOT IA DIABETIC FOOT I Glycaemic controlGlycaemic control SmokingSmoking Renal diseaseRenal disease Poor social circumstancePoor social circumstance
- 18. 18 CLINICAL ASSESSMENT OF ACLINICAL ASSESSMENT OF A DIABETIC FOOT IIDIABETIC FOOT II Extent of NeuropathyExtent of Neuropathy Vibration sense – using tuning forkVibration sense – using tuning fork Discriminating touch – 10g monofilamentDiscriminating touch – 10g monofilament NylonNylon Ankle jerksAnkle jerks
- 19. 19 CLINICAL ASSESSMENT OF ACLINICAL ASSESSMENT OF A DIABETIC FOOT IIIDIABETIC FOOT III Extent of IschaemiaExtent of Ischaemia Pulse examination – Aortoiliac andPulse examination – Aortoiliac and FemPop bruitsFemPop bruits Skin color, TemperatureSkin color, Temperature ABPIABPI X ray medial calcinosisX ray medial calcinosis
- 20. 20 CLINICAL ASSESSMENT OF ACLINICAL ASSESSMENT OF A DIABETIC FOOT IVDIABETIC FOOT IV Extent of Neuroischaemia and sepsisExtent of Neuroischaemia and sepsis WargnerWargner 1-5 a Global Severity Score1-5 a Global Severity Score 1:1: Superficial ulceration limited to dermisSuperficial ulceration limited to dermis 2:2: Ulceration down to fascia or bone withoutUlceration down to fascia or bone without abscess orabscess or osteomyelitisosteomyelitis 3:3: Deep ulcers with abscess or osteomyelitisDeep ulcers with abscess or osteomyelitis 4:4: Localised gangrene confined to the toes orLocalised gangrene confined to the toes or forefootforefoot 5:5: Gangrene requiring immediate major (aboveGangrene requiring immediate major (above ankle) amputationankle) amputation
- 21. 21 Extent of InfectionExtent of Infection Is Due to..Is Due to.. Walking on pusWalking on pus Tracking of pus along tendonsTracking of pus along tendons Foot compartmentsFoot compartments SepticaemiaSepticaemia
- 22. 22 MANAGEMENTMANAGEMENT OF DIABETIC FEETOF DIABETIC FEET PreventionPrevention Patient and Physician EducationPatient and Physician Education
- 23. 23 DIABETIC FOOTDIABETIC FOOT Ten CommandmentsTen Commandments For patientFor patient Don’t walk barefootDon’t walk barefoot Inspect the feet dailyInspect the feet daily No hot fomentationNo hot fomentation Correct footwearCorrect footwear Don’t weight bear (unsupported) on the affected footDon’t weight bear (unsupported) on the affected foot Do not sit cross-leggedDo not sit cross-legged Don’t remove footwear during travelingDon’t remove footwear during traveling Cut nails regularly (trim square)Cut nails regularly (trim square) No home surgeryNo home surgery Clean the feet twice a dayClean the feet twice a day
- 24. 24 DIABETIC FOOTDIABETIC FOOT Six principles of prevention ofSix principles of prevention of foot ulcersfoot ulcers For PhysicianFor Physician PPodiatric careodiatric care PPulse examinationulse examination PProtective shoesrotective shoes PPressure reductionressure reduction PProphylactic surgeryrophylactic surgery PPreventive educationreventive education
- 25. 25 Protective footwearProtective footwear Accommodation and cushioningAccommodation and cushioning Wide toe boxWide toe box Extra depthExtra depth Total contact insolesTotal contact insoles Rocker soleRocker sole WedgingWedging
- 26. 26 ShoesShoes Heel to toe length, Arch length, WidthHeel to toe length, Arch length, Width Measure both feetMeasure both feet Fit while weight bearingFit while weight bearing Check for the positioning of the first MPCheck for the positioning of the first MP jointjoint Allow half a inch between end of theAllow half a inch between end of the longest toe and the end of shoelongest toe and the end of shoe Sniff fit around the heelSniff fit around the heel
- 27. 27 Therapeutic footwearTherapeutic footwear Bed rest, crutches, wheel chair, kneeBed rest, crutches, wheel chair, knee caliperscalipers Total contact cast, Scotchcast bootsTotal contact cast, Scotchcast boots Half shoes, Half sandalsHalf shoes, Half sandals OrthosesOrthoses
- 28. 28 ManagementManagement Wound careWound care Deep swabbing,Deep swabbing, Pus culture & ABSTPus culture & ABST Hb, TransfusionsHb, Transfusions Hyperbaric OHyperbaric O22 X raysX rays MRIMRI Leukocyte tagged scansLeukocyte tagged scans
- 29. 29 ManagementManagement Other measuresOther measures Weight reductionWeight reduction Aggressive debridement and drainage ofAggressive debridement and drainage of tissue spacetissue space IV antibioticsIV antibiotics PenicillinPenicillin Co-amoxyclavCo-amoxyclav MetronidazoleMetronidazole ClindamycinClindamycin Cultured skin dermisCultured skin dermis Leukocyte colony stimulating factorsLeukocyte colony stimulating factors
- 30. 30 ManagementManagement Other proceduresOther procedures Rest injured areaRest injured area Prophylactic surgery to correct BiomechanicalProphylactic surgery to correct Biomechanical damagedamage RevascularizationRevascularization AngioplastyAngioplasty Distal venous bypassDistal venous bypass Prevention of recurrent ulcerationPrevention of recurrent ulceration AmputationAmputation