Front line management of the Diabetic Foot n o ti e b a i D + s te k o Sm = g in p Am a t u Sam Fratesi MD
Smoking + diabetes = amputation
Almost 2 million Canadians have diabetes In amputated diabetics 50% ulcer develop contralateral limb <2 years 50% contralateral amputation within 5 years 3 year mortality after 1st amputation..50%
15% of diabetics will develop a foot ulcer in their lifetime amputation in the diabetic is 15-20 times higher than the non-diabetic every year 1 in every 250 diabetics will undergo amputation
Multifactorial etiology of diabetic foot ulcer neuropathy Arterial insufficiency impaired cell immunity Non-compliance diabetic foot ulcer infection trauma
Diabetic ulcers Etiology of skin breakdown A N G I O P A T H Y N E U R O P A T H Y INFECTION
85% of leg amputations in the diabetic preceded by a foot ulcer Major cause of a diabetic related hospital admission is a foot related problem
60 % of diabetics with foot ulceration have neuropathy without clinically significant arterial disease 20% have ulcers primarily due to arterial disease 20 % have ulcers secondary to a combination of both neuropathy and arterial disease
Diabetic neuropathy Pathophysiology autonomic Skin abnormality,immune deficiency poor circulation sensory Continuous/repetitive trauma motor Foot deformity/abnormal pressure points
METARSAL HEAD PROMINENCE AND ULCERATION ulceration is over the plantar surface of the metatarsal heads.
HAMMER-TOE DEFORMITY Claw-toe deformity with loss of function of intrinsic muscles of foot
CHARCOT'S FOOT Progressive neuropathy + Repetitive trauma + osteoporosis
ISCHEMIC FOOT ULCER
Diabetic ulcer risk Peripheral neuropathy Foot deformity Limited joint movement Elevated plantar pressure Prior ulcer/amputation Peripheral vascular disease Susceptibility to infection
Structural deformity
Autonomic neuropathy
Sensory neuropathy
Insensate foot
Motor neuropathy
Combined motor/sensory neuropathy
Tissue loss in the diabetic foot High foot pressure Callus/trauma ulceration Diabetic foot amputation Failure to heal infection
Factors that may affect healing in the diabetic patient: Metabolic control Infection Ischemia Continuing trauma Patient education and compliance Concurrent medical problems/medication Wound environment Multidisciplinary foot care program
Atherosclerosis of the lower limb in the diabetic: Diabetes>20 years > 50% lose peripheral pulse Diabetics have small vessel disease plus more trifurcation disease than non-diabetics Distal revascularization has saved many diabetic limbs Smoking + diabetes = amputation
Wagner s classification of foot ulcers Grade 0..the at risk foot Grade 1.superficial ulcer Grade 2.penetrating ulcer Grade 3 complicated by infection Grade 4.gangrene not requiring total foot amputation Grade 5 gangrene requiring leg amputation Above classification assessed in context of sufficient blood supply to heal
Wounds by stage Stage 1 redness of skin that does not turn white with pressure Stage2 abrasion,blister,ulcer..partial thickness..involves epidermis/dermis Stage3 full thickness skin loss into subcut. tissue necrosis present Stage 4 extensive..through fascia into supporting structures (muscle/bone )
SAH Topical Wound Overview RED YELLOW BLACK assessment after proper cleansing
6 simple questions Where is the infection/ulcer? How bad is it? How did it get there? What can be done to make it better? What can be done to make sure it does not recur? What are the co-morbid conditions?
Neurological assessment of diabetic ankle reflexes vibration sensation pain sensation Diminished protective sensation to monofilament testing (10 gram / 5.07 mm Semmes-Weinstein)?
USE OF 10-GRAM MONOFILAMENT
Factors to enhance wound environment in diabetic patients with foot ulceration: Aggressive debridement to remove necrotic tissue and slough Control of infection Optimize oxygenation Avoidance of further trauma Ulcer dressings and topical wound therapy
Infections in diabetic foot ulcers: Foot infection is a common cause for diabetic hospitalization An altered immune responses may mask the clinical severity of infections. Less than 50 % with limb threatening infections have a significant fever or elevated WBC count. ice berg effect quite common
Wound culture techniques: surface cultures from diabetic wounds may not correlate well with deeper culture techniques Deep needle aspiration via non-infected area usually correlates with deep infections The most reliable cultures taken from biopsy or swab after the surface exudate has been removed. Important to distinguish contamination from infection Organisms usually poymicrobial
Infected diabetic foot ulcers: The importance of aerobic/anaerobic culture The more serious the infection, the higher the probability of multiple organisms particularly if a deep infection Milder infections tend to have fewer organisms particularly if superficial Gm(+) cocci is the most common but is the lone ranger in<50%
Osteomyelitis in the diabetic foot Initially plain X Ray may be normal Technetium bone scans 70% reliable with lower specificity Addition of Gallium improves the sensitivity and specificity Indium WBC scanning is best scanning method but more expensive and less readily available. MRI probably best test of bone infection.
Wound Assessment All wounds should be probed for extent and hidden sepsis
Why a moist wound environment? Proven reduction in infection rate Allows natural enzymes to dissolve debris Promotes wound healing (growth factors) Helps mould wound Prevents re-injury of a dry dressing
The role of foot soaks in diabetic foot care Should NOT be done a definite NO... NO Macerates tissues Increases infection Tendency to thermal injury/damage normal healthy tissue
A foot soak gone bad maceration
Diabetic foot ulcers: newer therapies Recombinant human growth factor therapy (Regranex*) Bio-engineered human skin (Dermagraft*) replacements VAC therapy (KCI) These do not replace nor are they first line strategies
Assessment of the diabetic foot General / specific assessment of the patient Documentation & exploration of wound Assess the circulation Debride as necessary Xray as necessary C& S of wound Formulate treatment plan/wound care protocol Follow-up/referral as necessary
Initial Assessment Total Care Considerations Wound Evaluation General Health Assessment Pressure Relief Assessment Psychosocial/Environment Expectations/Goals Defined Comfort/Pain Knowledge/Education Prevention
Diabetic foot assessment The importance of structural deformity (Charcot, hammer or claw toe),limited joint mobility, neuropathy and impaired circulation The physical examination must include a thorough inspection, vascular assessment neuro assessment and check out the footwear
Management of the ulcer Debride..gets rid of the necrotic tissue/callus.allows proper assessment.increases cytokines in the wound(platelets) Off-Load the pressure.reduce friction and shear forces prescription footwear, orthotics,ortho wedge boots,silicone socks Total contact casts and removable casts
Ulcer management Use of antimicrobials..the importance of recognizing and treating the infected ulcer.in pt vs out patient therapy oral vs IV therapy Wound care Avoid abuse of antibiotic topical Tx Extremely important education and followup
Wound care protocols standard wound care management protocols Bioengineered tissue Growth factors
Diabetic wound dressings Promote debridement,repair and growth Reduce the pain Absorb any exudate Maintain humidity but not mascerate Keep out the bacteria
Early treatment of the diabetic foot improves function and quality of life infection control maintain health status reduce costs
Steps in Saving the Diabetic Foot Patient Education Identification of Risk Factors Recognition and Treatment of etiology Wound Management Augmentative Interventions
Patient Education Goal Oriented Problem Centred Offers Feedback Group Discussion Varied Presentation
Identification of Risk Factors prior diabetic ulcer advancing age peripheral vascular disease diabetic neuropathy
Identification of Risk Factors Peripheral Vascular Disease
Identification of Risk Factors Peripheral Neuropathy - motor - autonomic - sensory
Identification of Risk Factors Autonomic Peripheral Neuropathy
Identification of Risk Factors Peripheral Sensory Neuropathy
Identification of Risk Factors Structural Deformity
Structural Deformities Biomechanical Deficiencies - pes cavus - pes planus
Underlying Etiology Extrinsic Intrinsic Trauma Foreign Body Limited Joint Mobility Foot Deformity Improper Footwear Poor Pressure Relief Foot Mechanics Neoplasm Surfaces Infection Ischemia
Recognition and Treatment of Underlying Etiology Intrinsic Cause Limited joint mobility Foot deformity
Recognition and Treatment of Underlying Etiology Intrinsic Cause Foot Mechanics
Principles of Wound Management Debridement Pressure Reduction Removal of Bacterial Burden Promote Healing
Wound Management Pressure Reduction
Wound Management Remove Bacterial Burden
Augmentative Interventions Deflective Padding Plastazote, PPT, Silipos gel Toe muffs, crests pads, MTP cookies, toe separators Crest Pad
Augmentative Interventions Therapeutic Off-Loading Devices Orthowedge boots, IPOS heel boots, air cast boots, contact casting, circular Poseys
Augmentative Interventions Off-Loading Devices IPOS Heel Boot
Augmentative Interventions Off-Loading Devices High-Top Ambulatory Boots
Insoles and Orthotics Soft Density Full Length Cost Effective Regular Monitoring and Maintenance
Augmentative Interventions Footwear Extra-depth and Extra-width P.W. Minor New Balance SAS Soft Spot Clark Birkenstock NAOT
Augmentative Interventions Off-the-Shelf Footwear
Augmentative Interventions Custom Footwear
Diabetic Foot Ulcers are Predictable and Preventable
Foot Disease is the Most Common Complication of Diabetes Leading to Hospitalization Reiber and Kosak
8 commandments of foot care 1) Wash daily Thou shalt. 2) Inspect and lubricate daily 3) Diligent nail care 4) Proper fitting footwear 5) Regular activity and diet 6) Avoid common mistakes and be careful 7 ) Regular medical visits 8) DO NOT SMOKE
Smoking + diabetes = amputation