Transcript Document

Diabetic Foot: A Surgical Look
Hosam Roshdy Zaher, MD,
Assistant Professor & Consultant
of General & Vascular Surgery
Mansoura University
WHO SHOULD
TREAT THE
DIABETIC FOOT?
Is it a debatable issue?
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General Surgeon
Vascular Surgeon
Orthopedic Surgeon
Plastic Surgeon
Podiatrist
May be others?
The Vascular Surgeon
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Are there pedal pulses?
Yes, Sir.
Please refer to General Surgery
No, Sir.
Please check with the doppler sounds
Pedal pulses are audible, Sir
Please refer to the General Surgeon
The Vascular Surgeon
• There are no audible Doppler sounds, Sir.
• A~~h, from where you bring me these cases
• Please try with general surgery again!
• Sir, they wont accept this case
• Ok. Ok. Get the patient inn and I’ll see him/her
later today or tomorrow
The Orthopedic Surgeon
• Does the patient has any osteomyelitis?
• Yes, Sir
• Can you try with General Surgery to take
care of this patient
• They wont accept this patient, Sir
• Ok. Ok. Get the patient inn and consult I.D.
The I.D. Consultant
• Thank you for referral.
• However, I need bone biopsy from the
affected parts
• Please do this and this and this ………
• Antibiotics for at least 6 weeks
The Plastic Surgeon
• Is there any active infection?
• Yes, Sir
• Please refer case to General Surgery, and if they
need us again they can call us
• No, Sir
• Ok. We can see the patient later
• Next day: By the way where is that patient that
you have called me for yesterday?
• He/She is in ward ..and bed..
• One week later: Nurse, where is the patient of
Dr……..
The Podiatrist
• We have a case for you, Sir.
• Ok. Can you call the senior surgical resident
to see the patient first and let him call me
• Please.
• Ok., Sir
• Senior resident & Podiatrist: After a very
long conversation,
The Podiatrist
• Ok. Please consult:
• Vascular Surgery &
• Do MRI
May be Others?
• WHO CARES!
DIFFERENTIATION
OF THE FOOT
DIABETIC FOOT
HEALTHY FOOT
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Nerves let you feel pain, vibration,
pressure, heat, and cold
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Damaged Nerves  difficult to feel
pain, pressure, heat and cold.
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Blood Vessels Carry nutrients and
oxygen to your feet to nourish them
and help them heal from injuries.
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Blocked Blood Vessels bring fewer
nutrients and oxygen to feet  sores
may not be able to heal.
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Bones give your foot shape and help
distribute the pressure from your
body's weight.
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Weakened Bones may slowly shift,
causing foot to become deformed and
changing the way distributes pressure.
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Joints are the connections between
your bones. They help absorb
pressure and allow your foot to move.
Your arch is a group of joints that
provides stability for you entire foot
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Collapsed Joints, especially a
collapsed arch, can no longer absorb
pressure or provide stability. The
surrounding skin may begin to break
down.
What is a diabetic foot?
• Diabetic foot is a disease complex that can
develop in the skin, muscles, or bones of the
foot as a result of the nerve damage, poor
circulation and/or infection that is associated
with diabetes.
• 15% DIABETIC PATIENTS WILL SUFFER FOOT
PROBLEMS
• RISK FACTOR : MAJORITY OF PATIENTS
WITH TYPE 2 DM AND LONG STANDING TYPE
1 DM
• 45% OF ALL MAJOR AMPUTATION CAUSED
BY DIABETIC FOOT SYNDROME
• DEATH CAUSED OF FOOT DIABETIC
17-32%
• GOOD DIABETIC FOOT CARE WILL
DECREASE AMPUTATION IN ½ - ¾
CASES
DIABETIC FOOT SYNDROME
FOOT ABNORMALITIES CAUSED BY
NEUROPATHY, ANGIOPATHY AND
INFECTION IN DIABETES MELLITUS
PATIENT’S
Infection
Neuropathy
Ischemia
What is the etiology of diabetic
foot?
Multifactorial
• Neuropathy
• Ischemia
• Infection
Neuropathy affects more
than 50% of diabetics
• Sensory loss
• Motor loss
• Autonomic neuropathy
Ischemia (PAD)
• More than 50% diabetics get
significant atherosclerotic
disease
• “Large vessel PAD” – often
with tibial involvement with
relative sparing of proximal
and pedal vessels
• “Microcirculatory” disease –
intimal and basement
membrane thickening
DM
Peripheral
neuropathy
Peripheral vascular disease
Increase flow
regulation
motor
Shunting
Power
imbalance
Reduced capillary blood
flow
Autonomic
sweat 
sensory
pain 
proprioception 
Fissuring 
Deformity
Defective response to start foot ulcer and
infection
PATOGENESIS
Combination of PAD &
Neuropathy
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 Risk of injury
Invasive soft tissue infection
Osteomyelitis
Chronic ulceration
Gangrene
Clinical presentation
• Evidence of PAD
Intermittent Claudication
Critical limb Ischemia / Ulcers
• Evidence of Neuropathy
Deformities
Ulcers
• Infection
Cellulitis
Invasive soft tissue infection
Osteomylitis
How do patients with PAD present?
How do patients with neuropathy
present?
How do patients with infection
present?
Evaluation & Management
• Multi-displinary Approach
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Diabetologists
Primary Care Physicians
Specialized Nurses
Social Workers
Diabetes Educators
Foot Care Specialists
Physiotherapists/ Occupational therapists
Radiologists
Vascular Surgeons
DIABETIC FOOT LESION
GRADING SYSTEM - WAGNER
GRADING ULCER
(WAGNER
CLASSIFICATION)
MANAGEMENT GOAL FOR
DIABETIC FOOT
• ACUTE :
 WOUND HEALING
 SAFE THE FOOT FROM AMPUTATION
• CHRONIC :
 TO PREVENT RECURRENCY OF WOUND
Evaluation & Management
• Clinical Assessment
– History
– Physical Examination
Evaluation & Management
• Investigation
– Plain films / Nuclear Medicine
– Non-invasive (Duplex / Digital pressures/ ABI,
CTA, MRA)
– Invasive test (Arteriography)
Investigations
Investigations
Ankle Brachial Index
ABI= Ankle SBP(PT or DP)/ Highest Arm SBP
Ankle Brachial Index
ABI value
Indicates
<0.9
0.8- 0.9
0.5- 0.8
<0.5
<0.25
Abnormal
Mild PAD
Moderate PAD
Severe PAD
Very Severe PAD
The ABI has limited use in evaluating calcified vessels that are not compressible as
in Diabetics
Toe pressure
Segmental pressure
Arterial duplex
Digital Subtraction Angiography
Treatment
Goals of treating patients with Diabetic Foot
Relief symptoms
Improve quality of life
Limb salvage
Prolong survival
Treatment
Treatment
• Preventive Measures
Patient Education
Local- footwear, cotton socks, nail care can
reduce amputation rate by 40 to 80%
Systemic- Risk factors modification
Treatment
• Patient Education
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Importance of risk factors control
Avoidance of trauma and minor cuts
Proper foot care
Medical visit with early signs of infection or
ulcer development
When to Seek Vascular Surgery
Consultation?
Evidence of PAD
- Intermittent Claudication
- Critical Limb Ischemia
Rest Pain
Impeding soft tissue compromise
Tissue Loss
Frank ulceration or gangrene.
Strategies in treating patients with
diabetic foot
Eradication of Infection
• Debridment
• Drainage
• Minor amputations
Strategies in treating patients with
diabetic foot
Improve Lower Limb Circulation
• Conservative (Exercise Program)
• Intervention ( Revascularization)
- Angioplasty +/- Stenting
- Surgical Bypass
Percutanous Transluminal Angioplpasty
PTA
Surgical Bypass
Strategies in treating patients with
diabetic foot
Major amputation
• Primary vs Secondary
• BKA vs AKA
Take home message
• Diabetic Foot is a major and an increasing
public-health problem
• Etiology is Multifactorial
• Multi-displinary approach is the key for better
outcomes
THANK YOU