BYCHARLES A. ANDERSON

THOMAS S. ROUKIS

DR ALLAH NAWAZPGR S IV

S.H.L

THE DIABETIC FOOT

INTRODUCTION

The prevalence of DM increasing at epidemic

7% american population diabetic

With increased longevity of population,incidence of diabetic related complication also raising.

Include diabetic foot problem as well as related to PAD

Over 1 million amputations performed per year

Cont…

Feet of diabetics are affected with

Neuropathy,PAD,foot deformity,infections, ulceration and gangrene

Diabetic fooot infections represent a medical emergency

Etiology of Diabetic foot problems

Neuropathy includes

Sensory

Motor

Autonomic

DM also associated with increased risk of PAD

Diabetic foot infections

Any breach in the cutaneous integument of foot in diabetics severe soft tissue or osseous infection

Initial evaluation begins with a detailed history & physical examination

History & examination

H/o any foot trauma

Persistently raised or widely shifting blood glucose level

Constitutional symptoms (nausea,emesis,tachycardia,fever with chills,lethargy & pain

Physical findings like cellulitis,lymphangitis,ulceration or purulent discharge

Cont…

A multidisciplinary team vital and necessary to patient’s treatment

A nutrionist,psychologist,social worker & certified prosthetist or orthotist will play a significant role in patient treatment & recovery

Laboratory evaluation

CBC

BSR & Hb A1c

Prealbumin & Albumin level

LFTs & RFTs

Elevated inflammatory markers,i.e ESR & C-reactive proteins

S/E & coagulation profile

Cont…

Blood cultures

Urinanalysis

Radiographs of feet

MRI & bone scintigraphy

Diagnosing osteomylitis

Any Pt with chronic wound especially deeper than dermal layer

“probe to bone test” for open wounds

In one study +ve predictive value of 89% and a negative predictive value of 56%

Bone biopsy is the gold standard

Osseous specimen either taken percutaneously using a trephine or during surgical intervention

Cont…

Radiograph of both feet

5-7 days require to develop radiolucency & 10-14 days for first signs of sequestrum & involucrum

Bone scintigraphy confirm the diagnosis

MRI an accurate modality for diagnosing osteomylitis

CT Scan & USG

Treatment

Main determinant of Antibiotic therapy is severity of DM foot infection

Classified infections as non –limb-threatening or limb threatening

Non limb threatening infections

Presence of superficial ulcer that does not probe deep to bone & has less than 2cm of surrounding cellulitis in a Pt with no signs of systemic toxicity & absence of leukocytosis

These can usually be treated in OPD with minor surgical debridement and oral antibiotics

Limb threatening infections

Presence of oedematous foot with full thickness ulcer with gangrene & purulence upon expression and has more than 2 cm of surrounding cellulitis or lymphangitis in Pt with systemic signs of toxicity.

These require hospitalization,surgical debridement & prolonged I.V antibiotics

Diabetic foot ulcers

Pt may present with ulceration without infections

Vascular status of a patient is critical element for wound healing

Edema is a significant negative healing factor

Location of diabetic foot wound will usually lead to underlying cause & most appropriate treatment

Cont…

An ulcer about posterior aspect of heel is due to pressure effect

“heel boot” whether firm or soft not routinely used for many reasons

”heel suspension pillow cocoon”continueously suspends the heels off of the bed even with Pt movement

Cont…

An ulcer about the planter foot is almost the result of

Excessive pressure and time b/w foot & contact surface

Dense neuropathy

Deformity of foot

Strict non Wt bearing of the involved limb through the use of gait aides

Cont..

Pressure and time can be reduced with the use of a properly applied and well –padded dressing that extends from the toes to knees

Modalities such as wedged postoperative shoes,removable walking boots and total contact casting are also available

Diabetic foot ulcer cont…

Wound characteristics are also considered

University of Texas at San Antonio ulcer classification system has been validated

As the stage & grade increase,likelyhood of requiring surgical intervention increases exponentially

University of texas at san antonio ulcer classification system

stage Grade 0 Ggrade 1 Grade 2 grade3

A Pre or postulcerative lesion completely epithelized

Superficial wound not involving capsule,tendon or bone

Wound involving capsule or tendon

Wound peneterating bone or joint

B infected infected infected Infected

C ischemic ischemic ischemic ischemic

D Infected and ischemic

Infected and ischemic

Infected and ischemic

Infected and ischemic

Recommendations

Pt with diabetes clean their feet daily for 3-5 minutes with a washcloth & liquid soap

pair of shoes gair for outdoor use as well as separate pair of shoes for indoors

wounds cleansing compounds are good means of maximizing hygiene of involved limb

Wound dressings specifically designed to address various problems

Surgical management of diabetic foot infections

Vascular anatomy.Hidalgo and show described four zones of planter aspect of foot

Proximal planter area

Midplanter area

Lateral foot

Distal foot

Cont…

Superficial Br of medial planter A,deep medial planter A and lateral planter A supply the medial,central and lateral portions of planter aspect of foot.

Planter common digital & individual digital arteries supply the planter aspect of forefoot

Calcaneal Br of post.tibial and peroneal arteries supply the heel

Foot compartments

These include

1:Skin

2:Medial

3:Superficial central

4:Deep central

5:Lateral

6-9:Interosseoi

10:calcaneal

Incision placement

Knife should extend through the skin,dermis, superficial fascia and adipose tissue

For medial border of foot:1st metatarsal head mediallyinferior aspect of navicular tuberosity at high point of medial arch midpoint B/w post. And planter heel and inferior aspect of medial malleolus

Decompression of medial,superficial central,deep central & calcaneal compartment as well as tarsal tunnel

Cont…

For lateral border of foot:

Centre of 5th metatarsal headinferior aspect of 5th metatarsal basemidpoint b/w achilles tendon and post. Border of fibula at the level of ankle joint.

Decompression of the lateral,superficial central,deep central and calcaneal compartment as well as peroneal tendons

Cont…

For dorsal aspect of the forefoot:two incisions

1st:medial border of 2nd metatarsal

2nd:lateral border of 4th metatarsal

Both should extend from metatarsal head to base

1st incision will decompress 1st & 2nd interosseous space

2nd incision will decompress 3rd & 4th spaces

Cont…

For planter aspect of foot:

Single longitudinal incision extend from just proximal to Wt.bearing surface of forefoot and culminates just distal to Wt.bearing surface of heel along imaginary line b/w 2nd toe & centre of heel

Allow decompression of every compartment of foot except dorsal aspect once planter fascia has been incised

Drawback is prolonged non-Wt bearing to limit cicatrix formation

debridement

Most important initial step is to perform a timely and complete surgical debridement

Gentle retraction 7 meticulous soft tissue handling

debridement without the use of torniquet

Bone culture obtained through a bone trephine if suspicion of osteomylitis or exposed bone followed by application of PMMA-ALC

Cont…

After debridement ,wound is irrigated with copious amount of N/S to reduce No. of bacteria

Meticulous hemostasis is achieved via cautery and ligation

Acc. To author, use of PMMA-ALC beads simple means of promoting asepsis,filling dead spces,preventing peri-articular soft tissue contraction and maintaining a moist environment within the wound

PMMA-ALC Beads

Fashioned by one of the surgical member at the time wound is irrigated

These should be B/w 5 & 10 mm in diameter and are strung by hand onto a No.2 nylon suture

Beads are placed to cover all the vital structures

Debriment is followed by well padded bulky dressing from toes to knee

Peripheral arterial disease

DM is associated with increased risk of PAD

An infection or ulceration once present increases the demand for for blood supply.

With PAD may be an inability to meet that demand leadind to further tissue breakdown

Presence of PAD in diabetics increases the risk of amputation

Assessment of PAD in diabetic patients

Diabetics usually not give typical history of claudication b/c of associated neuropathy or lack of activity

Routine exam of diabetic include

Complete foot examination & vascular exam.distal pulses should be checked

An ABPI must be obtained

Toe pressures are a more accurate measure of perfusionin diabetic foot

Cont…

Vascular consultation indications are

An ABPI less than 0.7

Toe pressure less than 40mm Hg

TcPO2 <30mm Hg

Nonhealing foot ulcer

Treatment of PAD in diabetics

PAD associated with systemic disease process of atherosclerosis

Close association b/w PAD and coronary artery disease

Pts are at high risk for systemic complications & wound problems

The Madigan Army Medical Centre developed an endovascular philosphy to re-establish adequate perfusion

Cont…

Endovascular options include

Percutaneous angioplasty

Cryoplasty

Resectional or laser atherectomy

Performed under L/A,minimal physiologic insult to pts,can be repeated,sephanous vein can be saved,low morbidity & mortality

Over a period of 12 months,22 out of 30 pts were technically successful (92%)

Edema and venous insufficiency

Edema from any etiology is detrimental to healing of foot ulcers or surgical incisions

Edema may be due to venous insufficiency or other medical ailments

Edema sec. to venous insufficiency can be treated surgically,although the main step is external compression

Edema sec. to cardiac dysfunction is treated by improving cardiac performance & diuresis

summary

The incidence of diabetes is increasing.

Lower extremity complications of diabetes such as neuropathy,ulceration,infection and PAD are common and can lead to significant morbidity including major amputation

The recognition & treatment of these complication is important

General surgeon should have a good understanding of pathophysiology and treatment of complication associated with diabetic foot

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