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1 Evaluation and Treatment of Diabetic Foot Ulcerations John M. Giurini, D.P.M. Associate Professor in Surgery Harvard Medical School Disclosure Statement I have no financial interests to disclose in regards to this lecture. Causes of ulcerations Peripheral sensory neuropathy Ischemia Sensorimotor neuropathy Mixed neuroischemia 1

2 History is Made! HISTORY Who? Who has been treating? What? What has been done? What has not been done? When? When did it develop? Where? How? How did it start? PHYSICAL EXAM Neurological Sensory neuropathy Motor neuropathy Autonomic neuropathy Vascular Pulses Dermatological Texture, turgor & temperature 2

3 PHYSICAL EXAM Musculoskeletal Foot structure Deformities Mobility Ulceration Location Depth Appearance 3

4 Dermatological Skin condition Turgor,tone Edema Pitting vs. non-pitting Erythema Cellulitis Temperature Ischemia Charcot 4

5 VASCULAR Pulses Palpable vs. nonpalpable Noninvasive studies PVR s ABI s TcPO 2 Arteriography DSA MRA 5

6 Neuroischemic Neuroischemic 6

7 Neuroischemic Neuroischemic Neuroischemic 7

8 Neuroischemic 8

9 Musculoskeletal Deformities Bunions, hammertoes Plantarflexed metatarsals Prior surgery/amputations Mobility Limited joint mobility Veves, et.al. Boulton, et.al. Charcot Foot Rockerbottom foot Musculoskeletal Foot Structure Pes cavovarus Rigid vs. flexible Pes planovalgus Rigid vs. flexible 9

10 10

11 Ulcer Evaluation Location Forefoot, Midfoot, Rearfoot Weightbearing vs. nonweightbearing Depth Superficial vs. Deep Structures involved Classification Drainage Serous Serosanguinous Purulent Ulcer Evaluation Microbiology Odor Color Drainage Prior Antibiotic treatment Special Studies X-rays Bone scans CT scans MRI UT Diabetic Wound Classification System A B C Pre or postulcerative lesion (epithelialized) Superficial, not involving tendon, capsule or bone Penetrates to tendon or capsule Penetrates to Bone INFECTION INFECTION INFECTION INFECTION ISCHEMIA ISCHEMIA ISCHEMIA ISCHEMIA D INFECTION and ISCHEMIA INFECTION and ISCHEMIA INFECTION and ISCHEMIA INFECTION and ISCHEMIA 11

12 Peak Pressures Under the Diabetic Foot *: p <0.05 * * 19 * Heel MTH Great Toe Controls Diabetes Neuropathy Veves

13 13

14 Debridement of Ulceration 14

15 Probe vs. Scan vs. MRI Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW. Probing to bone in infected pedal ulcers. JAMA, 1995:273(9): Pham HT. Presentation at ACFAS Scientific Meeting, Orlando, Fla., February,

16 Methods 211 patients admitted with lower extremity infection All pedal ulcers probes with sterile blunt metal probe. All bone specimens sent for path & micro Patient Data 177 insulin requiring diabetes 27 non-insulin requiring diabetes 7 non-diabetics All patients with peripheral sensory neuropathy Results Soft tissue debridement & IV antibiotics: 56 Bone resection & IV antibiotics:

17 Ulcer Location Digits Met heads Midfoot Rearfoot Results Bone probed: 95 Bone not probed: 60 Results Bone probed (95) 88 Osteo 7 No osteo Bone not probed (60) 57 No osteo 3 Osteo 17

18 Results Ischemic: Nonpalpable pedal pulses Rubor, pallor Skin turgor & temperature Hair growth In-situ saphenous vein Pop-pedal bypass preferred 18

19 Toe or ray amp TMA BKA Metatarsal head resections/osteotomy PMHR Charcot joint reconstruction 19

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