ULCERS 1/12/ million diabetics in the US (2012) Reamputation Rate 26.7% at 1 year 48.3% at 3 years 60.7% at 5 years

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1 Jay Christensen D.P.M Advanced Foot and Ankle of Wisconsin 2-4% of the population at any given time will have ulcers % of the total population Average age of patients 70 years increased as more people are living longer Women are twice likely to be affected than men. ULCERS 29.1 million diabetics in the US (2012) Reamputation Rate 26.7% at 1 year 48.3% at 3 years 60.7% at 5 years Annual mortality of diabetics with ulceration 11% Annual mortality of patient with amputation 22% An ulcer is defined as an area of discontinuation of the surface epithelium. A leg ulcer is a discontinuity of the squamous epithelium of the skin usually around the ankle or on the foot Grade 1 into the Subcutaneous Fat Grade 2 to the Fasicia or Tendon Grade 3 Bone exposed Site according to cause Size and depth Shape Multiple? Base, edges, surrounding skin Nutritional status and underlying medical conditions will prolong wound healing. Problem How big is the wound? Smaller than 2.0 cm and only the fat layer exposed Simple wound care Large with tendon or bone exposed More involved wound care Common types Venous Arterial Diabetic 1

2 A chronic leg ulcer is consider when an open wound is present for more than 4-6 weeks duration. Results when the repair mechanism is caught in one or more stages of healing: Inflammation Proliferation Reepithelialisation Remodelling Infection commonly polymicrobial Venous Arterial Mixed arterial and venous Neuropathic Diabetes Connective tissue disorders- vasculitis Infective tuberculosis. Malignancy Trauma Stasis Superficial or deep veins Combination Obstructive Varicosities from venous hypertension Increased pressure at ankle Swelling of the tissues widening endothelial gap junctions Sequestration of the RBCs, WBCs, Proteins Leukocyte migration theory White cells migrate into the interstitial tissue break down of the WBCs lead to the cytokines and proteases release. Loss of tissue integrity Different sizes for various ankle diameters Main stay of the edema management For prevention and during treatment Improves healing rate compared to no compression therapy considerably Multi layer better than single layer Indicate the presence of severe occlusive disease Atherosclerosis Inflammatory Vascular disease Loss of nutrients and oxygen lead to tissue break down with ischemic pain Arterial ulcers are common in the toes and lateral ankle 2

3 Very painful Dry wounds The skin will eventually demarcate over multiple weeks Will need some Vascular intervention or work up Keep dry until surgical intervention Will need some amputation as the skin and tissue will not heal if too advanced Hyperglycemia leads to increased glucose content in the tissues which binds to proteins leading to cellular damage Increase sorbitol and fructose in cells leads to accumulation of water in the cells Neutrophil dysfunction and phagocytosis Shoe trauma and blistering Thermal injury Charcot foot deformity Osteoarthritis deformity Neuropathy Neuropathy allows patients to walk relatively painless with large open wounds Much more at risk of infection Don t hesitate to culture if not healing 3

4 ankle pressure ABI = brachial pressure For screening of the ischemic disease For compression therapy For monitoring purposes CRP, ESR, Renal & Liver functions Wound swab and qualitative cultures Duplex studies of the venous system Connective disease profile X-ray of the underlying bones, possible MRI Angiography Biopsy of the ulcers, could be a basal cell carcinoma Protect from bacterial invasion Maintain optimum moisture If it is WET, make it DRY If it is DRY, make it WET Absorb inflammatory fluid from wound site Protect granulation tissue Reduce pressure if plantar Debridement Mechanical / surgical / biological / enzymatic Off loading foot wear Antibiotics if necessary Appropriate wound care with dressing changes Is home care nursing necessary? 4

5 Minimal role for Hydrogen peroxide Alcohol Neosporin Alginates Sea weed preparation absorb exudates Betadine/ Iodosorb dessicant and moisture control with antibacterial Santyl debridement Antibiotic ointments Nutrition-proteins, zinc, vitamin c Pain management Change of dressings Removal of dead tissue Reduction of exudate fluid Decrease the bacterial load Bacteria will colonize the wound, if significant worsening or stagnation, culture the wound Not necessarily infected if healing well Wound most likely polymicrobial Continuously watch for SOI Fever, chills, nausea, vomiting, increased blood sugar or pain Questions? 5