AIM OF MASTERCLASS. Overview of the diabetic foot disease. Modern approach to management

Transcription

1 AIM OF MASTERCLASS Overview of the diabetic foot disease Modern approach to management

2 DIABETIC FOOT DISEASE THROUGHOUT THE WORLD, THERE IS AN AMPUTATION EVERY 20 SECONDS MOST OF THESE AMPUTATIONS ARE PREVENTABLE!!!!!!

3 DIABETIC FOOT DISEASE What is the cause of these amputations? Natural history can be rapidly progressive quickly leading to necrosis This speed of progress coupled with any delay in diagnosis can result in overwhelming tissue destruction

4 WHY SUCH A SITUATION? Three great pathologies Primary Neuropathy Ischaemia Secondary Infection

5 Diabetic neuropathy Approx. 60 to 70 per cent of people with diabetes have some form of nerve damage.

6 PERIPHERAL NERVOUS SYSTEM Peripheral nervous system is an early warning system To detect external insults to the body and internal malfunctions within It is programmed to direct appropriate protective responses To maintain the homeostatic integrity of the body.

7 Impact of Neuropathy The signs and symptoms of external physical insults and also internal malfunction are minimal Homeostasis is lost Diagnosis of disease is delayed Thus the window of opportunity for intervention is missed The end stage of tissue death is quickly reached.

8 DIAGNOSIS Monofilaments Vibration threshold

9 Monofilaments

10 Monofilament

11 NEUROTHESIOMETER

12 IMPACT OF NEUROPATHY Inability to respond appropriately to stresses/ insults Physical trauma Bacterial invasion

13 NEUROPATHIC FOOT ULCER

14 Pathogenesis of neuropathic ulcer Courtesy L. Delbridge, G. Ctercteko,

15 CALLUS IN NEUROPATHIC FOOT

16 NEUROPATHIC ULCER

17 CHARCOT FOOT

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21 High index of Clinical Suspicion A Red Hot Swollen Foot should be considered as a Charcot foot until proved otherwise!

22 RESPONSE TO BACTERIAL INVASION No rubor No calor No dolor Diabetic foot infections do not always present with the classical signs of local infection as indicated by inflammation

23 RESPONSE TO BACTERIAL INVASION Diabetic foot infections do not always present with the classical signs of systemic infection Impaired innate immune response No leucocytosis and fever

24 DIGITAL NECROSIS

25 Septic arteritis + medial calcification + intimal hyperplasia

26 IMPACT OF NEUROPATHY Trauma Infection Gangrene No awareness No tenderness or fever No pain Heart attack Hypoglycaemia No chest discomfort No warnings

27 Classical Medicine Neuropathy Neuropathic Medicine Symptoms and Signs No Symptoms and Signs Minimal Symptoms and Signs Investigations No Investigations Imaging/ Lab.Tests Diagnosis No Diagnosis Diagnosis Treatment No Treatment Treatment Healing Tissue Death Healing

28 NEUROPATHIC MEDICINE Meticulous assessment to recognise subtle symptoms and signs. Prompt use of imaging to provide picture of what is going on inside the body (in the presence of neuropathy, this information is absent ) Attention to serum inflammatory markers.

29 ISCHAEMIA Macrovascular complications Ischaemic heart disease Cerebrovascular disease Peripheral vascular disease

30 DISTRIBUTION OF DISEASE EJVS Diehm et al. 2005

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37 ASSESSMENT OF ISCHAEMIA

38 Transcutaneous oxygen Critical ischaemia < 30mmHg

39 TOE PRESSURE CRITICAL ISCHAEMIA < 30MMHG

40 Neuroischaemic Foot

41 NEUROISCHAEMIC FOOT ULCER High risk Ulcer

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44 Early neuroischaemic lesion

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46 SIMPLE CLASSIFICATION Neuropathic foot Ischaemic foot

47 STRATIFICATION OF DIABETIC FOOT Neuropathic Foot Neuropathic ulcerated foot Charcot foot Ischaemic Foot Neuroischaemic foot Critically ischaemic foot Acutely ischaemic foot Renal ischaemic foot

48 SIMPLE STAGING SYSTEM 1 Normal 2 High risk 3 Ulcerated 4 Infected 5 Necrotic

49 Stage Neuropathic Charcot Neuroischaemic Critical ischaemic Acute ischaemic Renal ischaemic

50 DIABETIC FOOT TEAM Podiatrist Nurse Orthotist Physiotherapist Surgeon Radiologist Diabetologist

51 MULTIDISCIPLINARY CARE Wound Vascular Microbiological Mechanical Metabolic Educational

52 TYPES OF ULCERATION Neuropathic Ulceration Neuroischaemic Ulceration

53 NEUROPATHIC ULCER Painless Apex of toe Prominent Plantar Metatarsal heads Heavy callus build up around the periphery Important to probe ulcer

54 NEUROPATHIC FOOT ULCERS Mechanical Control Redistribute plantar pressures

55 NEUROPATHIC ULCER

56 NEUROPATHIC ULCER

57 POST DEBRIDEMENT

58 REDISTRIBUTIVE PADDING

59 AIRCAST WALKER Prefabricated walking cast Bivalved cast with Velcro strapping lined with 4 air cells which can be inflated with a hand pump through 4 valves to ensure a close fit Flat plastazote insole which can be replaced with a cradled insole Won t accommodate deformity Removable!!!

60 AIRCAST BOOT

61 TOTAL CONTACT CAST Gold standard treatment for the ulcerated neuropathic foot Very efficient method of redistributing plantar pressure Acute charcot osteoarthropathy Training required Kings Casting Course contact: Maureen Bates ( )

62 TOTAL CONTACT CAST

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64 BIVALVED CAST

65 NEUROISCHAEMIC ULCER Margins of the foot Apices of toes Subungual Ulcers Shallow Ulcers Little callus build up

66 NEUROISCHAEMIC ULCER

67 NEUROISCHAEMIC ULCER

68 POST DEBRIDEMENT

69 NEUROISCHAEMIC ULCER

70 CRITICALLY ISCHAEMIC FOOT

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73 TREATING PERIPHERAL CIRCULATION

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75 Ulcer at 12 weeks

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78 SCOTCH CAST BOOT Simple, removable boot made of stockinette, felt, softban and cast tape. Ideal for neuroischaemic ulcers as padded on borders/margins of the foot.

79 SCOTCH CAST BOOT

80 Scotchcast boot Bespoke Shoe

81 DARCO

82 ACUTE CHARCOT OSTEOARTHROPATHY CHARCOT Bone & joint destruction that occurs in the neuropathic foot 3 phases: Acute charcot Bony destruction/deformity Stabilization

83 ACUTE CHARCOT Red Hot Swollen Sometimes painful (30% patients) History of minor trauma Post surgical debridment

84 INVESTIGATIONS X Ray normal Bone Scan hot spots, early evidence of bone destruction MRI

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87 CASE STUDY MALE, AGE 70, TYPE 2, DURATION OF DIABETES - 5 YEARS; SWELLING OF LEFT FOOT Hot swollen left foot Normal X -ray Hot bone scan

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90 CASE STUDY TREATMENT: TOTAL CONTACT CAST (8 MONTHS) Mid-tarsal bone sclerosis Preserved arch

91 ACUTE CHARCOT Total Contact Cast (TCC) Crutches Reduce Activity

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93 CASE STUDY 1 Type 1- diagnosed 1983 Female Age 49 Smoker Hep C Right foot Charcot Chronic lateral malleoli ulceration since 1990 Offered an amputation at another hospital Referred to King s 1995

94 PROBLEM LIST Peripheral neuropthy Retinopathy CKD stage 3 Chronic hep C

95 Casting Patient active Had a young daughter Foot became more unstable Severely inverted and infected 2012 Occluded Superficial femoral artery Superficial femoral artery endarterectomy and femoral to popliteal artery bypass

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102 Orthopaedic hind-foot and mid-foot corrective osteotomy and fusion. Achilles tendon release Ischaemic leg post op Graft blocked Emergency angiogram and anterior tibial to dorsalis pedis bypass

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104 Challenge Poor quality tissue Poorly perfused Involve deep structures Probing to bone and metal work Oedema

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113 THE ULTIMATE CHALLENGE

114 INTRODUCTION There is a high rate of major amputation up to 30% of dialysis patients. 1 The annual rate of major and minor amputation is up to 13.8%. 2 Major amputation accounts for more than 58% of the total amputations. 2 1 Morbach et al, Eggers et al, 1999

115 DIABETIC RENAL FOOT

116 Female Age 61 years Type 1 diabetic Chronic Renal Failure CASE STUDY Peritoneal dialysis 4½ years duration, retinopathy, peripheral neuropathy & peripheral vascular disease Presented with infected left foot wound following amputation of lesser toes 5 weeks previous

117 FOOT AT PRESENTATION

118 INTERVENTION IV antibiotics Vancomycin (MRSA positive swab) 2 downstream angioplasties of Popliteal & ATA stenosis Surgical debridement of devitalised tissue & bone VAC therapy commenced 24 hrs post-op

119 24 HRS POST DEBRIDEMENT

120 1 WEEK VAC THERAPY

121 2 WEEKS VAC THERAPY

122 4 WEEKS VAC THERAPY

123 7 WEEKS VAC THERAPY (THERAPY STOPPED AT THIS STAGE)

124 7 WEEKS AFTER VAC STOPPED

125 16 WEEKS HEALED

126 SUMMARY Rapid treatment of sepsis Rapid revascularisation Angioplasty Intense follow up Aware of their co-morbidities

127 DIABETIC FOOT TEAM Podiatrist Nurse Orthotist Physiotherapist Surgeon Radiologist Diabetologist

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130 DIABETIC FOOT CLINIC Co-ordinate primary and secondary care Wound care/orthotics/plasters Emergency referrals Education / Research Charcot foot clinics Vascular diabetic clinics Orthopaedic diabetic clinics Post operative reviews and follow ups Debridement/ minor surgery Outpatient antibiotic service

131 Time Mon Tue Wed Thu Fri 08:00 08:30 Ward Round for Admissions Ward Round for Admissions Ward Round for Admissions Ward Round for Admissions Ward Round for Admissions 09:00 SOS Clinic SOS Clinic SOS Clinic SOS Clinic SOS Clinic 09:30 10:00 10:30 11:00 Joint Diabetic Foot/ Orthopaedic/Plastic Clinic & Ward Round Joint Diabetic Foot/ Vascular Clinic & Ward Round Charcot Clinic Ulcer Clinic Joint Diabetic Foot/ Vascular Clinic 11:30 12:00 12:30 13:00 Vascular Radiology MDT 13:30 14:00 14:30 15:00 15:30 Ulcer Clinic (WARD ROUND) Ulcer Clinic (MDT on Ward) Charcot Clinic Ulcer Clinic (WARD ROUND) Ulcer Clinic 16:00 16:30 17:00 17:30

132 Percentage of total patients Major Amputations /90 90/91 91/92 92/93 93/94 94/95 95/96 96/97 97/98 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 Year

133 GOOD NEWS UP UNTIL RECENTLY, THE DIABETIC FOOT HAS DEFEATED EVERY HEALTH CARE SYSTEM IN THE WORLD ADVANCES IN OUR UNDERSTANDING HAVE LEAD TO IMPROVEMENTS IN CARE ULCERS ARE NOW HEALED AND AMPUTATIONS PREVENTED

134 THE END

135 HANDS

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137 PRESSURE RELIEVING ANKLE FOOT ORTHOSES (PRAFO)

138 NEUROPATHY Loss of nociceptive C fibres Loss of axon reflex Peptide mediators released from cutaneous C fibres are potent pro-inflammatory agents Failure of vasodilatation

139 PREVALON BOOT

140 Stage Neuropathic Charcot Neuroischaemic Critical ischaemic Acute ischaemic Renal ischaemic

141 Stage Neuropathic Charcot Neuroischaemic Critical ischaemic Acute ischaemic Renal ischaemic

142 THREE GREAT PATHOLOGIES Primary Neuropathy Ischaemia Secondary Infection

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146 Percentage REDUCTION IN MAJOR AMPUTATIONS

147 Diabetes Care :

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149 Neuropathic High risk Ulcer Infection Necrosis

150 Charcot Foot Mechanical forces Infection

151 LEUCOCYTOSIS Leucocytosis is a poor indicator of acute osteomyelitis of the foot in diabetic mellitus 54% of patients with acute osteomyelitis had normal white blood cell count Armstrong DG, 1996