Diabetic Foot Ulcer Treatment and Prevention Alexander Reyzelman DPM, FACFAS Associate Professor California School of Podiatric Medicine at Samuel Merritt University Diabetic Foot Ulcers One of the most common complications of diabetes Annual incidence 1% to 4% 1-2 Lifetime risk 15% to 25% 3-4 ~15% of diabetic foot ulcers result in lower extremity amputation 3,5 ~85% of lower limb amputations in patients with diabetes are proceeded by ulceration 6-7 Peripheral neuropathy is a major contributing factor in diabetic foot ulcers 1-7 Other factors: foot deformity, callus, trauma, and peripheral vascular disease 1. Reiber and Ledoux. In The Evidence Base for Diabetes Care. Williams et al, eds. Hoboken, NJ: John Wiley & Sons 2002:641. 2. Boulton et al. NEJM. 2004;351:48. 3. Sanders. J Am Podiatry Med Assoc. 1994;84:322. 4. Boulton et al. Lancet.2005;366:1719. 5. Ramsey et al. Diabetes Care 1999;22:382. 6. Pecoraro et al. Diabetes Care. 1990;13:513. 7. Apelqvist and Larsson. Diabetes Metab Res Rev. 2000:16:S75. 5-Year Mortality Rates In order to treat wounds, we must understand the factors associated with the etiology of those wounds Armstrong et al. Int Wound J. 2007;Dec;4(4):286. CA = Carcinoma. PAD = Peripheral artery disease. 1
Wagner Classification Stage 0- pre-ulcerative lesion Stage I- superficial with exposed sub Q Stage II- down to tendon, ligament or bone, not infected Stage III- infected Stage IV- localized gangrene of forefoot Stage V - extensive gangrene A B C D UT Diabetic Wound Classification System 0 1 2 3 Pre or postulcerative lesion (epithelialized) Superficial, not involving tendon, capsule or bone Penetrates to tendon or capsule Penetrates to Bone INFECTION INFECTION INFECTION INFECTION STANDARD TREATMENT FOR DIABETIC FOOT ULCERS Standard treatment modalities 1 Sharp debridement of nonviable tissue Treatment of infection Saline-moistened dressings Off-loading to decrease pressure on extremity Arterial revascularization if indicated A wound that remains unhealed after 4 weeks is cause for concern, as it is associated with unfavorable outcomes, including amputation Debridement 1) Debridement reduces the bio-burden 2) potentially prevents an infection 3) allows for better visualization and inspection of the wound. Steed and coworkers reported in their multi-center study that the patients that underwent debridement showed an improved healing response compared to the patients who did not undergo debridement. 1. Consensus Development Conference on Diabetic Foot Wound Care. ADA. Diabetes Care. 1999;22:1354-1360. 2
Infection Continue until healthy bleeding soft tissue and/or bone are encountered Callus tissue surrounding the ulcer must be removed Regular debridement, typically weekly, can expedite the rate of wound healing and increase the probability of wound closure Secondary Signs of Infection Chronic exudate Delayed healing Friable granulation tissue Discolored granulation tissue Malodor pocketing Risk Factors for Foot Infections in Individuals with Diabetes Lavery, et al Diabetes Care, Vol 29, Number 6, June 2006 Statistically significant risk factors for foot infection Wound depth to bone Wound duration >30 days Recurrent foot wound Traumatic wound etiology Peripheral vascular disease The risk of developing an infection was 2,193 times greater in subjects who develop a foot wound than in those without a wound Is there too much pressure on the wound/ulcer Pressure 3
PLANTAR PRESSURES AND ULCERATION TCC Multiple reports in literature discussing reduction of peak plantar pressure on the forefoot and midfoot. Gold-Standard Unaffected Limb S/P Partial First Ray and Charcot Affected Limb Photograph and scans courtesy of John S. Steinberg, DPM, University of Texas Health Science Center at San Antonio, San Antonio, Tex. Aircast Removable Walker Boots DH Walker CROW Bledsoe DH Walker 4
Healing of Neuropathic Ulcers: Results of a Meta-analysis Advanced Wound Management GOOD WOUND CARE x 4 weeks 50% Healed? YES NO These data provide clinicians with a realistic assessment of their chances of healing neuropathic ulcers Even with good, standard wound care, healing neuropathic ulcers in patients with diabetes continues to be a challenge Continue with treatment Change to Advanced Wound Healing Margolis et al. Diabetes Care. 1999;22:692. Types of Products Protective Footwear: Permanent Shoes Negative Pressure Collagen Growth Factor Acellular Dermal Matrix Bioengineered Skin Dermagraft Apligraf 5
Thank You Tissue Engineering Growing living human dermal substitutes Dermal fibroblasts are seeded onto a bioabsorbable scaffold After 2 weeks, a living dermal substitute has formed which can support the migration, proliferation and stratification of an epidermis Product Description What is Apligraf? Supplied as a living, bi-layered skin substitute* Indications: Venous Leg Ulcers Diabetic Foot Ulcers Well-tolerated in over 12,000 patient applications *The persistence of Apligraf cells on the wound and the safety of this device in venous ulcer patients beyond 1 year and in diabetic foot ulcer patients beyond 6 months have not been evaluate 6
Dermagraft DERMAGRAFT from the Package Histological cross-section of DERMAGRAFT 7