LI MB SALVAGE MANAGEMENT October 11, 2018 DISCLOSURE STATEMENT My opinions do not represent the VA s opinions in regards to product preference No specific proprietary data from the VA has been included within this presentation. 3 BASIC OF ELEMENTS OF LIMB SALVAGE MANAGEMENT Manage the pathologies to stabilize the affected limb Implement integument protection techniques to reduce recidivism Optimize continued medical management 1
MANAGING THE PATHOLOGIES TO STABILIZE THE AFFECTED LIMB 6 PRIMARY PATHOLOGIES Cellulitis Osteomyelitis Perfusion Glycemic Control Inadequate Offloading or Compression Poor Nutrition 2
RADIOLOGY Osteomyelitis may be acute resulting in delayed wound closure. (resection may be necessary) Abscess or tissue necrosis may require I&D and debridement (otherwise not visible) Inadequate Offloading most often demonstrated by hyperkeratotic tissue presence. Lesion markers should be used to evaluate. 3
SEROLOGY Hypernatremia may indicate dehydration impeding wound healing and cell viability Glucose/HgA1c provides an insight into how hyperglycemia disrupts metabolic pathways of proteins and other cellular components, will interfere with wound healing Iron reveals critical abnormalities in oxygen utilization and collagen synthesis Pre-albumin/Albumin are used to evaluate potential nutritional deficiencies CRP is an inflammatory marker IMMUNOLOGY Elevated WBC s is indicative of infection. Lack of elevation can indicate inhibition of the immune system via uncontrolled diabetes, colonized and or critically colonized wound in the absence of overt infection. Neutrophil elevation may indicate an increase in MMP presence and or infection Monocyte elevation may provide insight into potential inflammatory phase resolution and proliferative phase entry 4
VASCULAR ABI s are generally unreliable in diabetics. PVR in combination with TBI s and PASV provide a more accurate depiction of the direction of flow, the amplitude (velocity) and the pressure closer to the ulceration increasing the predictive healing potential. SPP assesses the angiosomes supplying the ulcerated tissue, illustrating a much more illuminated picture of perfusion and subsequent diffusion. TcPO2 measures the diffusion of oxygen through the skin, providing the clinician with valuable assessment of the capillary bed NVIU evaluates for thrombus, obstruction, reflux, structural abnormalities and the presence of flow 5
MICROBIOLOGY Use iodine (wait 30s) or aqueous iodophor (wait 1 min) apply in widening concentric circles. Remove iodine prep with sterile saline in same manner Use sterile gauze or scalpel to manually or surgically debride ulcer surface and discard Collect tissue from the clean deep base of the ulcer Chlorhexidine Gluconate is an acceptable substitute. BIOMECHANICS Knowledge of the all of the normal ROM s of every joint in the foot and ankle provides valuable insight into the science of dispersion and effective immobilization. Many DFU develop as a result of repetitive micro-trauma left unaddressed due to peripheral neuropathy. X-rays also provide a visual depiction of anomalies which become symptomatic without intervention. (surgical/conservative) 6
IMPLEMENTING INTEGUMENT PROTECTION TECHNIQUES OFF-LOADING TECHNIQUES Non-Weight bearing External Fixator with Footplate Total Contact Cast Instant Total Contact Cast Cam Walker Multipodos Boots Forefoot/Heel Relief Shoe Modified Orthoses Metatarsal bars/pads/u-dispersion pads Diabetic Shoes (Plastazote inserts) PURPOSE OF OFF-LOADING Decrease Peak Pressure Decrease Shearing Decrease Capillary Ischemia Decrease Cutaneous Heat (Boney Prominences) Decrease Pain 7
MECHANISM OF FORMATION Local Pressure Exceed Normal Capillary Pressure Reduced Oxygenation Degree Duration Impairment of Microcirculation to the affected tissue Reduced Diffusion/Perfusion to the affected tissue Tissue Death PRESSURE CALCULATION Average foot weighs 5 lbs. 30 mmhg is critical value of ischemia Average Retro-Calcaneal ulcer is 1 square inch Force(W) x Area = Pressure 5 lbs x 1 square inch = 5 PSI > 30 mmhg is needed to maintain the capillary lumen 70 mmhg is needed to collapse the capillary lumen 1 PSI = 52 mmhg 259 mmhg / 70 mmhg = 3.7 5 PSI = 259mmHG Tissue Death within hours INTEGUMENT INTEGRITY MANAGEMENT OPTIONS Lubricants Support stockings/wraps ICD s Powders Hyperkeratotic tissue and nail debridement Motion control devices (braces/afos) 8
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