Principles of management of diabetic foot lesions and its Prevention

Dr AK Verma Department of Endocrine Surgery Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow

Introduction • Foot lesions- 7% of people with Diabetes mellitus • Costly to- both patients and state • Factors delaying wound healing – Impaired wound healing in DM – Barrier to early referral and assessment • Amputations due to Peripheral vascular disease, Neuropathy and severe infection

Introduction Cont.

• Common in- Older patients and those with longer duration • Treatment options-limited, but coordinated care is needed • Infection- mostly secondary to ulcer • • Nature and severity of infection varies

Of all amputations – 80% done in diabetics

Predisposing factors • Old Age, Atherosclerosis • Long standing/ brittle diabetes, poor control • Associated disease states and immunosuppressive states • Post transplantation • Hypoproteinemia and prolonged diseases

Causative factors • Foreign bodies • Improper nail pairing • Nail infections • Sensory and motor loss • Corns, callosities • Foot deformities • Trauma, burns • Bare foot walking and improper shoe wear

Foreign body

Peripheral neuropathy

Fungal infection

Skin Corn Hard

Corn hard after shaving

Skin Fissure

Clinical presentation • Wide clinical spectrum • Localised cellulitis • Nonhealing ulcer • Ulcer with minimal discoloration • Gangrene of the toe/toes • Gangrene of forefoot/whole foot(dry/wet) • Deformities • Deformities with ulcerations

Gangrene

Principles of management-1 I.

II.

A multidisciplany Approach

Resuscitation first, diagnosis later (biochemistry/haematology/radiology/microbiology) General supportive measures -Correction of Anaemia/ hypoproteinemia/renal failure/dehydration -switching over to IV Insulin therapy -high calorie/protein diet -IV broadspectrum poly antimicrobial therapy( covering aerobes and anaerobes) -monitoring of polymicrobial infections by frequent microbial studies

Principles of management-2 III. Local care • Guiding principle:

Limb saving attitude

Assesment of vascularity: Clinical: skin colour, temperature, hairs, nail colour and circulation, pulses.

Poor pulse: best assessed by doppler A/B Index: N=0.8, if <0.5 chances of tissue survival is poor

Doppler ultrasound

• • • Principles of management-3 Localisation of abscess Clinical, Ultrasound, CT/ MRI Assessment of neuropathy touch, temperature, position and joint senses (cotton,blunt,pin, biosthesiometer) Look for other diabetic complications renal, opthalmic, cardiac, neurologic etc

Surgical management-1 • Guiding principle-

Limb saving attitude

– Minimum but adequate surgery – Quick/Emergency debridement under whatever anaesthesia possible –

All dead and necrotic tissue must be removed

– Don’t do primary closure – Frequent daily minor debridements are a must – Limb elevation if edematous

Surgical management-2 • Open tendon sheaths liberally • Excise tendons if necessary • Explore all possible pus pockets • Institute double drainage for larger and deeper pus pockets • Have lots of patience • Frequent OT debridements may be required

Revascularisation procedures • Angioplasty • Angioplasty with stenting • Arterial bypass • Insitu Saphenous vein bypass

Role of orthotics • Pressure of loading-significance • Devices – Casts – Insoles – Custom made shoes – Artificial limbs

Newer aids for wound healing • Platelet derived growth factors( regranex) • Granulocyte stimulating factors(cGSF) • Electrical stimulation-magnetotherapy etc • Plantar pressure measurement and recording systems

Prevention-I •

An ounce of prevention is better than a pound of cure

• Foot rehydration especially at night • Proper foot wear – Well fitting, pressure offloading,washable,soft, no shoe laces.

– No bare foot walking – Socks-cotton, wash daily,wear reversed, change frequently

Prevention-2 • Foot care – Examination at bed time: cut, abrasion, foreign body, redness, blister, callosity/corn and local rise of temperature at any point.

Must be done by some one with good vision in good light

– Pairing of nails – Interdigital web cleaning and examination, use of antiseptic powder

Prevention-3 – Must examine shoe before wearing –

Must be treated like a small newborn child

–

Foot examination should be a part of every clinical visit

– Must contact the doctor at the slightest problem

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