Transcript Diabetic Foot

FOOT PROBLEMS IN DIABETIC
PATIENTS
Diagnosis and management
Objectives:
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Clarify the amplitude of the problem of
diabetic foot
Recognize the different patho-physiologic
mechanisms leading to diabetic foot problems
Clarify the overall management of different
problems related to the diabetic foot
Amplitude of the problem:
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Diabetes mellitus is a rather very common systemic
disease
12-15 million people are diabetics in the US.
20% of these patients will be hospitalized at least once
in their life time with foot problems
Diabetic patients account for more than two thirds of
patients undergoing non-traumatic limb amputation
annually
This will cost a BILLION dollars every year
Grunfeld et al
Patho-physiology
NEOUROPATHY
ISCHAEMIA
INFECTION
Neuropathy:
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One of the triad of the pathological conditions
characteristic of this disease (neuropathy,
nephropathy and retinopathy)
Pathogenesis:
Changes in the vasa nervosa
Metabolic disorders with release of nerve
toxic substance
Neuropathy affects:
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Motor Nerves resulting in:
wasting of small muscles of the foot and
deformities (claw foot)
foot
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Autonomic nerves resulting in:
Dryness of the skin and loss of sweat and
oil secretion which leads to excessive callus
formation and skin cracks
Loss of neurogenic component of
inflammatory response which leads to plunting
of inflammatory response and less severe signs
of a severe infections
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Sensory nerves:
sensory loss of superficial and deep
sensation is the most important part of sensory
affection
Patients are unaware of trauma to the foot
and usually result in pressure sores over
weight bearing points of the foot
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Neuropathic arthropathy:
Joints can be affected by neuropathy
resulting in the so called Charcot foot
It is relatively painless progressive
degenerative arthropathy of single or multiple
joints
caused by loss of proprioceptive and pain
sensation
leads to foot deformity and abnormal
pressure points
Infection:
Patho-physiology:
peripheral neuropathy:
Sensory and autonomic neouropathy provides
site of entry of organisms and blunt neurogenic
immune response
Metabolic state:
Hyperglycaemia an manifest protienurea causes
a state of immuno-suppression
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Infection causes
increased metabolic and
oxygen demands of
tissues and inability to
meet with this demand
will increase tissue
damage and necrosis
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Microbiology:
Usually in limb threatening diabetic foot
infections there is polymicrobial bacterial
infection with gram positive, gram negative,
and anaerobic bacterial infection .
sometimes with very severe life threatening
infections fungus infection is also present
Ischemia:
Diabetes mellitus is an independent risk factor for
atherosclerosis (coronary, cerebral and peripheral)
Usually atherosclerosis affects crural vessel (anterior
tibial, posterior tibial and peroneal) with sparing of
aortoiliac and femoral segments
Ankle vessels runoff are usually patent (posterior tibial
and dorsalis pedis) ,but they may lead to a diseased foot
arches (distal vessel disease)
Medial calcification affects all vessels but the vessels
remain patent in spite heavy calcification
DIAGNOSIS
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Clinical examination:
Careful history taking and thorough general
examination is essential
Careful inspection and palpation of the
foot lesion (look and feel in all aspects of the
foot and between toes). Probing any foot ulcer
or sinus to detect bone affection
Palpation of peripheral pulses is essential
to exclude ischaemia
Imaging studies:
Plain X ray: it is the basic study in all patients with diabetic
foot it can show: osteomylitis, bone fractures, joint
dislocations, foreign bodies, gas due to gas forming
infections, soft tissue inflammatory hypertrophy
MRI scan: very sensitive in detecting the extent of soft tissue
infection and bone and joint involvement
Bone scan and radio-active labeled leukocyte scan are of low
clinical importance
Pedobarography: computerized method to detect points of
high pressure in patients with neuropathic ulcers
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Vascular studies:
Ankle brachial pressure index (ABPI): is usually
of no value in diabetic patients because of calcified
pedal vessels toe pressure is usually used in diabetics
(toe pressure of 30 mm gH indicates good
vascularity)
Duplex scan: can be done to evaluate blood
vessels in non limb threatening infections and in
follow up
Angiography: It is done when planning for
vascular reconstruction in case of ischemic diabetic
infections
MRA: Is used in case of severe renal impairment
and severe dye hypersensitivity which is not
uncommon in diabetics
Treatment
Treatment of neuropathic ulcers:
Avoid pressure over the ulcer
Non weight bearing using crutches, wheel chairs
and sometimes applying slabs and casts. Wearing a
specially designed shoes specially prepared by foot
care persons
Topical applications on the ulcers
trimming of the surrounding callus. Antibiotic
ointments and gels. Applying saline soaked gauze
pads
Proper treatment of infection and ischaemia if present
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Treatment of infection:
Severe limb threatening diabetic foot infection
should be treated as an emergency. Some of theses
infection will require major limb amputation or
may turn to a life threatening infections if not
treated properly
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Treatment consists of:
Surgical drainage and debridement
Antibiotic therapy
Care of general condition and blood sugar
control
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Antibiotic therapy:
In limb threatening diabetic foot infections the
patient should be hospitalized and IV antibiotics
administered to reach an efficient plasma
concentration
It should cover gram positive and negative
bacteria and anaerobes as well
It should be started as empiric treatment and
soon be changed according to culture and
sensitivity
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Surgical drainage:
It is the corner stone
in treatment of
diabetic foot infection.
It should be done as
soon as possible. It
should aim at draining
all pus pockets and
debriding all infected
tissues including bone
and joints
Some hints:
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Skin incision should be longitudinal and further
than infected subcutaneous tissue which is
further opened further than the deeper infected
planes so no pockets will remain
2.
Cartilage and cortical bone do not heal well and
should be removed
3.
Tendons are avascular and should be removed as
hi as possible
4.
Never attempt to close a diabetic foot infection
wound the role is OPEN drainage
5.
When planning your
incisions and
amputations be aware
that the sole of the
foot will be covered
by sole skin and any
remaining ulcer will
not be in a pressure
point ( long posterior
flaps )
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The best dressing is dressings which
maintain a humid environment. Avoid irritant
applications which are in common use like
hydrogen peroxide
Remaining row clean areas can be covered
later by flabs or split thickness skin grafts
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Diabetic foot infection with ischaemia:
Ischaemia with diabetic foot infection is
diagnosed when there is inability to feel the
pedal pulses
It’s a dangerous condition which is usually
a limb threatening and sometimes turn up to be
a life threatening
The patient should be referred to a vascular
surgeon consultation as soon as possible
Urgent vascular reconstruction may be
needed for limb salvage
Any questions…….?
Tank you