Diabetic Foot: A Surgical Look

Hosam Roshdy Zaher, MD ,

Assistant Professor & ConsultantGeneral & Vascular Surgery of

Mansoura University

WHO SHOULD TREAT THE

DIABETIC FOOT?

Is it a debatable issue?

• General Surgeon

• Vascular Surgeon

• Orthopedic Surgeon

• Plastic Surgeon

• Podiatrist

• May be others?

The Vascular Surgeon

• Are there pedal pulses?

• Yes, Sir.

• Please refer to General Surgery

• No, Sir.

• Please check with the doppler sounds

• Pedal pulses are audible, Sir

• Please refer to the General Surgeon

The Vascular Surgeon

• There are no audible Doppler sounds, Sir.

• A~~h, from where you bring me these cases

• Please try with general surgery again!

• Sir, they wont accept this case

• Ok. Ok. Get the patient inn and I’ll see him/her later today or tomorrow

The Orthopedic Surgeon

• Does the patient has any osteomyelitis?

• Yes, Sir

• Can you try with General Surgery to take

care of this patient

• They wont accept this patient, Sir

• Ok. Ok. Get the patient inn and consult I.D.

The I.D. Consultant

• Thank you for referral.

• However, I need bone biopsy from the

affected parts

• Please do this and this and this ………

• Antibiotics for at least 6 weeks

The Plastic Surgeon• Is there any active infection?• Yes, Sir• Please refer case to General Surgery, and if they

need us again they can call us• No, Sir• Ok. We can see the patient later• Next day: By the way where is that patient that

you have called me for yesterday?• He/She is in ward ..and bed..• One week later: Nurse, where is the patient of

Dr……..

The Podiatrist

• We have a case for you, Sir.

• Ok. Can you call the senior surgical resident to see the patient first and let him call me

• Please.

• Ok., Sir

• Senior resident & Podiatrist: After a very long conversation,

The Podiatrist

• Ok. Please consult:

• Vascular Surgery &

• Do MRI

May be Others?

• WHO CARES!

DIFFERENTIATION OF THE FOOT

HEALTHY FOOTHEALTHY FOOT

• Nerves let you feel pain, vibration, pressure, heat, and cold

• Blood Vessels Carry nutrients and oxygen to your feet to nourish them and help them heal from injuries.

• Bones give your foot shape and help distribute the pressure from your body's weight.

• Joints are the connections between your bones. They help absorb pressure and allow your foot to move. Your arch is a group of joints that provides stability for you entire foot

DIABETIC FOOTDIABETIC FOOT

• Damaged Nerves difficult to feel pain, pressure, heat and cold.

• Blocked Blood Vessels bring fewer nutrients and oxygen to feet sores may not be able to heal.

• Weakened Bones may slowly shift, causing foot to become deformed and changing the way distributes pressure.

• Collapsed Joints, especially a collapsed arch, can no longer absorb pressure or provide stability. The surrounding skin may begin to break down.

What is a diabetic foot?

• Diabetic foot is a disease complex that can develop in the skin, muscles, or bones of the foot as a result of the nerve damage, poor circulation and/or infection that is associated with diabetes.

• 15% DIABETIC PATIENTS WILL SUFFER FOOT PROBLEMS

• RISK FACTOR : MAJORITY OF PATIENTS WITH TYPE 2 DM AND LONG STANDING TYPE 1 DM

• 45% OF ALL MAJOR AMPUTATION CAUSED BY DIABETIC FOOT SYNDROME

• DEATH CAUSED OF FOOT DIABETIC 17-32%

• GOOD DIABETIC FOOT CARE WILL DECREASE AMPUTATION IN ½ - ¾ CASES

DIABETIC FOOT SYNDROME

FOOT ABNORMALITIES CAUSED BY NEUROPATHY, ANGIOPATHY AND INFECTION IN DIABETES MELLITUS PATIENT’S

Infection

Neuropathy Ischemia

What is the etiology of diabetic foot ?

Multifactorial• Neuropathy

• Ischemia

• Infection

Neuropathy affects more than 50% of diabetics

• Sensory loss • Motor loss • Autonomic neuropathy

Ischemia (PAD)• More than 50% diabetics get

significant atherosclerotic disease

• “Large vessel PAD” – often with tibial involvement with relative sparing of proximal and pedal vessels

• “Microcirculatory” disease – intimal and basement membrane thickening

Peripheral vascular diseasePeripheral neuropathy

DM

Increase flow regulation

Shunting

Reduced capillary blood flow

motor sensoryAutonomic

pain

proprioception Power

imbalance

Deformity

sweat

Fissuring

Defective response to start foot ulcer and infection

PATOGENESIS

Combination of PAD & Neuropathy

Risk of injury• Invasive soft tissue infection• Osteomyelitis• Chronic ulceration• Gangrene

Clinical presentation • Evidence of PAD Intermittent Claudication Critical limb Ischemia / Ulcers• Evidence of Neuropathy Deformities Ulcers• Infection Cellulitis Invasive soft tissue infection Osteomylitis

How do patients with PAD present?

How do patients with neuropathy present?

How do patients with infection present?

Evaluation & Management

• Multi-displinary Approach– Diabetologists– Primary Care Physicians – Specialized Nurses– Social Workers– Diabetes Educators– Foot Care Specialists– Physiotherapists/ Occupational therapists – Radiologists– Vascular Surgeons

DIABETIC FOOT LESION GRADING SYSTEM - WAGNER

GRADING ULCER(WAGNER

CLASSIFICATION)

MANAGEMENT GOAL FOR DIABETIC FOOT

• ACUTE :WOUND HEALING SAFE THE FOOT FROM AMPUTATION

• CHRONIC :TO PREVENT RECURRENCY OF WOUND

Evaluation & Management

• Clinical Assessment – History– Physical Examination

Evaluation & Management

• Investigation– Plain films / Nuclear Medicine– Non-invasive (Duplex / Digital pressures/ ABI,

CTA, MRA)– Invasive test (Arteriography)

Investigations

Investigations

Ankle Brachial Index

ABI= Ankle SBP(PT or DP)/ Highest Arm SBP

Ankle Brachial Index

ABI valueIndicates

<0.9Abnormal

0.8 -0.9Mild PAD

0.5 -0.8Moderate PAD

<0.5Severe PAD

<0.25Very Severe PAD

The ABI has limited use in evaluating calcified vessels that are not compressible as in Diabetics

Toe pressure

Segmental pressure

Arterial duplex

Digital Subtraction Angiography

Treatment

Goals of treating patients with Diabetic Foot

Relief symptomsRelief symptomsImprove quality of lifeImprove quality of lifeLimb salvageLimb salvageProlong survivalProlong survival

Treatment

• Preventive Measures Patient Education

Local- footwear, cotton socks, nail care can reduce amputation rate by 40 to 80%

Systemic- Risk factors modification

Treatment

• Patient Education

– Importance of risk factors control– Avoidance of trauma and minor cuts– Proper foot care– Medical visit with early signs of infection or

ulcer development

Treatment

When to Seek Vascular Surgery Consultation?

Evidence of PAD - Intermittent Claudication - Critical Limb Ischemia Rest Pain Impeding soft tissue compromise Tissue Loss Frank ulceration or gangrene.

Eradication of Infection• DebridmentDebridment• DrainageDrainage• Minor amputations Minor amputations

Strategies in treating patients with diabetic foot

Improve Lower Limb Circulation• Conservative (Exercise Program)Conservative (Exercise Program)• Intervention ( Revascularization)Intervention ( Revascularization) - Angioplasty +/- Stenting- Angioplasty +/- Stenting - Surgical Bypass - Surgical Bypass

Strategies in treating patients with diabetic foot

Percutanous Transluminal AngioplpastyPTA

Surgical Bypass

Major amputation• Primary vs SecondaryPrimary vs Secondary• BKA vs AKA BKA vs AKA

Strategies in treating patients with diabetic foot

Take home message

• Diabetic Foot is a major and an increasing public-health problem

• Etiology is Multifactorial• Multi-displinary approach is the key for better

outcomes

THANK YOU