Front linemanagement of the Diabetic Foot

Sam Fratesi MD

Diabetes + Smoking = Amputatio

n

Smoking + diabetes = amputation

Almost 2 million Canadians have diabetes

In amputated diabetics…50% ulcer developcontralateral limb <2 years

50% contralateral amputation within 5 years

3 year mortality after 1st amputation..50%

•15% of diabetics will develop a foot ulcer in theirlifetime

• amputation in the diabetic is 15- 20 times higherthan the non-diabetic

• every year 1 in every 250 diabetics will undergoamputation

Multifactorial etiology of diabetic foot ulcer

diabetic foot ulcer

trauma

infection

Non-complianceneuropathy

impaired cell immunity

Arterial insufficiency

Diabetic ulcers

A N G I O P A T H Y N E U R O P A T H Y I N F E C T I O N

E t i o l o g y o f s k i n b r e a k d o w n

• 85% of leg amputations in the diabeticpreceded by a foot ulcer

•Major cause of a diabetic related hospitaladmission is a foot related problem

•60 % of diabetics with foot ulceration haveneuropathy without clinically significantarterial disease

•20% have ulcers primarily due to arterialdisease

• 20 % have ulcers secondary to acombination of both neuropathy andarterial disease

Diabetic neuropathy

a u t o n o m i c s e n s o r y m o t o r

P a t h o p h y s i o l o g y

Skinabnormality

,immune deficiencypoor circulation

Continuous/repetitivetrauma Foot

deformity/abnormalpressure points

METARSAL HEAD PROMINENCE AND ULCERATION

ulceration is over the plantar surface of themetatarsal heads.

HAMMER-TOE DEFORMITY

Claw-toedeformity withloss of functionof intrinsicmuscles of foot

CHARCOT'S FOOT

Progressive neuropathy +Repetitive trauma + osteoporosis

ISCHEMIC FOOT ULCER

Diabetic ulcer risk

Peripheral neuropathy

Foot deformity

Limited joint movement

Elevated plantar pressure

Prior ulcer/amputation

Peripheral vascular disease

Susceptibility to infection

Structuraldeformity

Autonomic neuropathy

Sensory neuropathy

Insensate foot

Motorneuropathy

Combined motor/sensory neuropathy

Tissue loss in the diabetic foot

Diabetic foot

Callus/trauma

ulceration

Failure to heal

infection

amputation

High foot pressure

Factors that may affect healing in the diabetic patient:

• Metabolic control• Infection• Ischemia• Continuing trauma• Patient education and compliance• Concurrent medical problems/medication• Wound environment• Multidisciplinary foot care program

Atherosclerosis of the lower limb in the diabetic:

Diabetes>20 years ……> 50% lose peripheral pulse

Diabetics have small vessel disease plus moretrifurcation disease than non-diabetics

Distal revascularization has saved many diabetic limbs

Smoking + diabetes = amputation

Wagner’s classification of foot ulcers

Grade 0……..the “ at risk foot ”

Grade 1…….superficial ulcer

Grade 2…….penetrating ulcer

Grade 3……complicated by infection

Grade 4…….gangrene not requiring total foot amputation

Grade 5……gangrene requiring leg amputation

Above classification assessed in context of sufficient bloodsupply to heal

Wounds by stage

Stage 1…redness of skin that does notturn white with pressure

Stage2…abrasion,blister,ulcer..partialthickness ..involves epidermis/dermis

Stage3…full thickness skin loss intosubcut. tissue…necrosis present

Stage 4…extensive..through fascia intosupporting structures (muscle/bone )

SAH Topical Wound Overview

RED

YELLOW

BLACK

assessment after proper cleansing

Where is the infection/ulcer?

How bad is it ?

How did it get there?

What can be done to make it better?

What can be done to make sure it does not recur?

What are the co-morbid conditions?

6 simple questions

Neurological assessment of diabetic

• ankle reflexes

•vibration sensation

•pain sensation

• Diminished protective sensation tomonofilament testing (10 gram /5.07 mm Semmes-Weinstein) ?

USE OF 10-GRAM MONOFILAMENT

Factors to enhance wound environment indiabetic patients with foot ulceration:

• Aggressive debridement to remove necrotictissue and slough

• Control of infection

• Optimize oxygenation

• Avoidance of further trauma

• Ulcer dressings and topical wound therapy

Infections in diabetic foot ulcers:

• Foot infection is a common cause for diabetichospitalization

• An altered immune responses may mask the clinicalseverity of infections.

• Less than 50 % with limb threatening infections have asignificant fever or elevated WBC count.

• “ice –berg” effect quite common

Wound culture techniques:

• surface cultures from diabetic wounds may notcorrelate well with deeper culture techniques

• Deep needle aspiration via non-infected area usually correlates with deep infections

• The most reliable cultures taken from biopsy or swab after the surface exudate has been removed.

•Important to distinguish contamination from infection

•Organisms usually poymicrobial

Infected diabetic foot ulcers:

The importance of aerobic/anaerobic culture

The more serious the infection , the higher theprobability of multiple organisms particularly if adeep infectionMilder infections tend to have fewer organismsparticularly if superficial

Gm(+) cocci is the most common but is the” loneranger” in<50%

Osteomyelitis in the diabetic foot

•Initially plain X Ray may be normal

• Technetium bone scans 70% reliable with lowerspecificity

• Addition of Gallium improves the sensitivity andspecificity

• Indium WBC scanning is best scanning method butmore expensive and less readily available.

• MRI probably best test of bone infection.

Wound Assessment

All wounds should be probed for extent andhidden sepsis

Why a moist wound environment?

Proven reduction in infection rate

Allows natural enzymes to dissolve debris

Promotes wound healing (growth factors)

Helps mould wound

Prevents re-injury of a dry dressing

The role of foot soaks in diabetic foot care

Should NOT be done …a definite NO... NO

• Macerates tissues

•Increases infection

• Tendency to thermal injury/damage normal healthytissue

A foot soak gone bad

maceration

Diabetic foot ulcers:newer therapies

• Recombinant human growth factor therapy (Regranex*)

• Bio-engineered human skin replacements(Dermagraft*)

•VAC therapy (KCI)

•These do not replace nor are they first line strategies

Assessment of the diabetic foot

General / specific assessment of the patient

Documentation & exploration of wound

Assess the circulation

Debride as necessary

Xray as necessary

C& S of wound

Formulate treatment plan/wound care protocol

Follow-up/referral as necessary

Initial AssessmentInitial Assessment

Total Care Considerations

Wound Evaluation

General Health Assessment

Pressure Relief Assessment

Psychosocial/Environment

Expectations/Goals Defined

Comfort/Pain

Knowledge/Education

Prevention

Diabetic foot assessment

The importance of structuraldeformity (Charcot, hammer or clawtoe) ,limited joint mobility, neuropathyand impaired circulation

The physical examination mustinclude a thorough inspection,vascular assessment neuro assessmentand…… check out the footwear

Management of the ulcer Debride..gets rid of the necrotic

tissue/callus….allows properassessment….increases cytokines inthe wound(platelets)

Off-Load the pressure….reducefriction and shear forces…prescription footwear, orthotics,orthowedge boots ,silicone socks……

Total contact casts and removablecasts

Ulcer management

Use of antimicrobials..the importance ofrecognizing and treating the infectedulcer….in pt vs out patient therapy…oral vs IV therapy

Wound care Avoid abuse of antibiotic topical Tx

Extremely important…education and followup

Wound care protocols

standard wound care managementprotocols

Bioengineered tissue

Growth factors

Diabetic wound dressings

Promote debridement,repair and growth Reduce the pain Absorb any exudate Maintain humidity but not mascerate Keep out the bacteria

improves function and quality of life infection control maintain health status reduce costs

Early treatment of the diabetic foot

Steps in Saving the Diabetic Foot

• Patient Education• Identification of Risk Factors• Recognition and Treatment of etiology• Wound Management• Augmentative Interventions

Patient Education

• Goal Oriented• Problem Centred• Offers Feedback• Group Discussion• Varied Presentation

Identification of Risk Factors

prior diabetic ulcer

advancing age

peripheral vascular disease

diabetic neuropathy

Identification of Risk Factors

Peripheral Vascular Disease

Identification of Risk Factors

Peripheral Neuropathy - motor

- autonomic- sensory

Identification of Risk Factors

Autonomic Peripheral Neuropathy

Identification of Risk Factors

Peripheral Sensory Neuropathy

Identification of Risk Factors

Structural Deformity

Structural Deformities

Biomechanical Deficiencies- pes cavus- pes planus

Underlying Etiology

Trauma Foreign Body Improper Footwear Poor Pressure Relief

Surfaces

Limited Joint Mobility Foot Deformity Foot Mechanics Neoplasm Infection Ischemia

Extrinsic Intrinsic

Recognition and Treatment ofUnderlying Etiology

Intrinsic Cause

Limited joint mobility

Foot deformity

Recognition and Treatment ofUnderlying Etiology

Intrinsic Cause

Foot Mechanics

Principles of Wound Management

Debridement

Pressure Reduction

Removal of Bacterial Burden

Promote Healing

Wound Management

Pressure Reduction

Wound Management

Remove BacterialBurden

Augmentative Interventions

Deflective PaddingPlastazote, PPT, Silipos

gelToe muffs, crests pads,

MTP cookies, toeseparators

Crest Pad

Augmentative Interventions

Therapeutic Off-LoadingDevices

Orthowedge boots,

IPOS heel boots, air cast boots,

contact casting, circular Poseys

Augmentative Interventions

Off-Loading Devices

IPOS Heel Boot

Augmentative Interventions

Off-Loading Devices

High-Top Ambulatory Boots

Insoles and Orthotics

Soft Density

Full Length

Cost Effective

Regular Monitoring andMaintenance

Augmentative Interventions

FootwearExtra-depth and

Extra-width P.W. Minor New Balance SAS Soft Spot Clark Birkenstock NAOT

Augmentative Interventions

Off-the-Shelf Footwear

Augmentative Interventions

Custom Footwear

Diabetic Foot Ulcers arePredictable and Preventable

Foot Disease is the Most Common Complicationof Diabetes Leading to Hospitalization

Reiber and Kosak

8 commandments of foot care

Thou shalt….1) Wash daily

2) Inspect and lubricate daily

3) Diligent nail care

4) Proper fitting footwear

5) Regular activity and diet

6) Avoid common mistakes and be careful

7 ) Regular medical visits

8) DO NOT SMOKE

Smoking + diabetes = amputation