THE DIABETIC THE DIABETIC FOOTFOOT

DR.SEIF I M ELMAHIDR.SEIF I M ELMAHI MD, FRCSIMD, FRCSI

University of Khartoum, University of Khartoum, SudanSudan

CONTENTCONTENT DefinitionDefinition EpidemiologyEpidemiology Social & Economic factorsSocial & Economic factors Pathophysiology of foot ulcerationPathophysiology of foot ulceration Diabetic NeuropathyDiabetic Neuropathy Peripheral Vascular Disease & DiabetesPeripheral Vascular Disease & Diabetes Biomechanics of Foot WearBiomechanics of Foot Wear The Diabetic Foot Ulcer Outcome & ManagementThe Diabetic Foot Ulcer Outcome & Management Neuro-osteoarthropathyNeuro-osteoarthropathy Amputation in Diabetic PatientAmputation in Diabetic Patient Prevention of Foot ProblemPrevention of Foot Problem

Diabetic FootDiabetic Foot

Definition:Definition: Infection, ulceration or Infection, ulceration or

destruction of deep tissues associated destruction of deep tissues associated with neurological abnormalities & with neurological abnormalities & various degrees of peripheral vascular various degrees of peripheral vascular diseasesdiseases in the lower limbin the lower limb

((based on WHO based on WHO definition)definition)

EpidemiologyEpidemiology

40% - 60% of all non traumatic lower 40% - 60% of all non traumatic lower limb amputationlimb amputation

85% of diabetic related foot 85% of diabetic related foot amputation are preceded by foot ulceramputation are preceded by foot ulcer

4 out of 5 ulcer in diabetics are 4 out of 5 ulcer in diabetics are precipitated by trauma precipitated by trauma

4% -10% is the prevalence of foot 4% -10% is the prevalence of foot ulcer in diabeticsulcer in diabetics

EpidemiologyEpidemiology

In Sudan:In Sudan: Prevalence of DM ? 6 – 12 %Prevalence of DM ? 6 – 12 % DSF inpatient KTH :DSF inpatient KTH :

30% - 40% risk of major 30% - 40% risk of major amputationamputation

8% - 20% mortality 8% - 20% mortality

Social & Economic FactorsSocial & Economic Factors Diabetic foot complications are Diabetic foot complications are

expensive : (expensive : (cost of healing 7000-10000 USD)cost of healing 7000-10000 USD)

((healing with amp. 43000-healing with amp. 43000-63000USD)63000USD)

In Khartoum : (4 weeks dressing cost In Khartoum : (4 weeks dressing cost 110000SD) 110000SD)

Intervention of foot care is cost Intervention of foot care is cost effective in most societies effective in most societies

Scarce information regarding long Scarce information regarding long term prognosis term prognosis

Pathophsiology of Foot UlcerationPathophsiology of Foot Ulceration

NeuropathicNeuropathicIschemicIschemicNeuro -ischemicNeuro -ischemic

STAGES OF ULCER DEVELOPMENTSTAGES OF ULCER DEVELOPMENT

STAGES OF ULCER DEVELOPMENTSTAGES OF ULCER DEVELOPMENT

Diabetic NeuropathyDiabetic Neuropathy

Sensorimotor & peripheral Sensorimotor & peripheral sympathatic neuropathy are major sympathatic neuropathy are major risk factors for ulcerrisk factors for ulcer

History & careful foot History & careful foot examination are are mandatory to diagnose neuropathymandatory to diagnose neuropathy

Up to 50%of type2Up to 50%of type2 diabetic patient diabetic patient have significant neuropathy & at risk have significant neuropathy & at risk of foot ulcerof foot ulcer

Periphral vascular disease& Periphral vascular disease& diabetic PVDdiabetic PVD

PVD is the most important factors related to is the most important factors related to outcome of diabetic foot ulceroutcome of diabetic foot ulcer

PVD is diagnosed by simple clinical examinationPVD is diagnosed by simple clinical examination non invasive vascular test determinesnon invasive vascular test determines probability

of healingof healing Symptoms of ischemia may be masked by Symptoms of ischemia may be masked by

neuropathyneuropathy Microangiopathy shouldn't be accepted as Microangiopathy shouldn't be accepted as

primary cause of ulcerprimary cause of ulcer Conservative approach for treatmentConservative approach for treatment Outcome of revascularization is similar to that in Outcome of revascularization is similar to that in

non-diabeticnon-diabetic

Biomechanics of foot wearBiomechanics of foot wear Biomechanical abnormalities are Biomechanical abnormalities are

consequence of neuropathy, they lead to consequence of neuropathy, they lead to abnormal foot pressureabnormal foot pressure

Foot deformity & neuropathy increase the Foot deformity & neuropathy increase the risk of ulcerrisk of ulcer

Pressure relief is essential for ulcer healing Pressure relief is essential for ulcer healing and/or preventionand/or prevention

Frequent inspection of shoes & insoles is Frequent inspection of shoes & insoles is mandatorymandatory

Appropriate foot wear significantly reduce Appropriate foot wear significantly reduce ulcer recurrence ulcer recurrence

Diabetic Foot InfectionDiabetic Foot Infection

Infection in diabetic foot is limb threateningInfection in diabetic foot is limb threatening Signs of infection may be absent in diabetic Signs of infection may be absent in diabetic

pt. with foot ulcerpt. with foot ulcer Superficial infection is usually caused by Superficial infection is usually caused by

gram +ve cocci, deep infection is poly gram +ve cocci, deep infection is poly microbial microbial

Surgical debridment is essential in acute Surgical debridment is essential in acute deep infectiondeep infection

Osteomylitis( diagnoses & treatment)Osteomylitis( diagnoses & treatment)

Neuro-osteoarthropathyNeuro-osteoarthropathy

Non- infective pathologyNon- infective pathology Should be suspected in any swollen Should be suspected in any swollen

hot erythematous foothot erythematous foot Differentiation from infection is Differentiation from infection is

important to prevent misdiagnosis & important to prevent misdiagnosis & possible amputationpossible amputation

Treatment should aim at preventing Treatment should aim at preventing severe deformitysevere deformity

Diabetic Foot Ulcer TreatmentDiabetic Foot Ulcer Treatment

Multidisciplenary approachMultidisciplenary approachStaging dictate the treatment Staging dictate the treatment

optionoptionContinuity of care & life long Continuity of care & life long

observationobservation

Amputation in Diabetic PatientAmputation in Diabetic Patient Increased minor\major amputation Increased minor\major amputation

increased the no. of deformed feetincreased the no. of deformed feet Minor amputation is needed :Minor amputation is needed :

*Gangrene*Gangrene

*As part of debriment*As part of debriment

*for correction of foot deformities*for correction of foot deformities Minor amputation doesn’t Minor amputation doesn’t

significantly compromise walking significantly compromise walking abilityability

Major AmputationMajor Amputation

Risk of loss walking abilityRisk of loss walking ability MortalityMortality Risk of contra-lateral amputationRisk of contra-lateral amputation Strict indicationStrict indication Careful choice of the levelCareful choice of the level

How To Prevent Foot ProblemsHow To Prevent Foot Problems

5 corner stones5 corner stones Regular inspection & examination of Regular inspection & examination of

foot & foot wearfoot & foot wear Identification of high risk patientIdentification of high risk patient Education of patient, family & health Education of patient, family & health

care providerscare providers Appropriate foot wearAppropriate foot wear Treatment of non ulcerative Treatment of non ulcerative

pathology pathology

SENSORY NEUROPATHYSENSORY NEUROPATHY

Diabetic NeuropathyDiabetic Neuropathy

PERIPHRAL VASCULAR DISEASEPERIPHRAL VASCULAR DISEASE

Biomechanics of foot wearAREAS AT Biomechanics of foot wearAREAS AT RISK OF ULCERATIONRISK OF ULCERATION

FOOT WEARFOOT WEAR

FOOT WEARFOOT WEAR

OSTEOMYLITISOSTEOMYLITIS

Diabetic Foot Ulcer Treatment Diabetic Foot Ulcer Treatment ModalitiesModalities

Microbiological controlMicrobiological controlWound controlWound controlVascular controlVascular controlMechanical controlMechanical controlMetabolic controlMetabolic controlEducational controlEducational control

Staging of Diabetic FootStaging of Diabetic Foot

StageStage Clinical conditionClinical condition 1 Normal1 Normal

2 High risk2 High risk

3 Ulcerated3 Ulcerated

4 cellulitic4 cellulitic

5 Necrotic5 Necrotic

6 Major 6 Major amputationamputation

Assessment of Diabetic FootAssessment of Diabetic Foot

NeuropathyNeuropathy IschemiaIschemia DeformityDeformity CallusCallus SwellingSwelling Skin breakdownSkin breakdown InfectionInfection NecrosisNecrosis

NEURO-OSTEOARTHROPATHY(NEURO-OSTEOARTHROPATHY(CHARCOT CHARCOT FOOT)FOOT)

NEURO-OSTEOARTHROPATHY(NEURO-OSTEOARTHROPATHY(CHARCOT CHARCOT FOOT)Neuro-osteoarthropathyFOOT)Neuro-osteoarthropathy

PODIATRYPODIATRY