Lidia Ionescu, Cozmin Radulescu, Daniel Guta, Irina

Trifescucl.III chirurgie, UMF Iasi

The prevelence of DM –rising dramatically worldwide

Largely related to increasing rates of obesity WHO- 5% of the world’s pop. DM- 2025 The rising prevalence+increased longevity of

pop.- rise in DM-associated complications. One of the most feared and frequent-

amputation The sequence: ulceration of an insensate,

diformed foot- wound infection

Considerable morbidity Occasionally mortality- gas gangrene-

septic shock Repeated and prolonged hospital

admissions Costly treatment

9% foot infection-2 years of follow-up, despite:• Educational sessions• Therapeutic shoes• Follow-up in a foot clinic• Ready access to podiatric care

DM-underlying cause of 60% amputations in developed countries

Norway study-the rate of amputation 32 times higher than among non-DM pts.

Postop. mortality: 10%-15%:• advanced age, • coronary and peripheral vascular disease, • renal failure

Risk factor Mechanism of injury or impairmentPeripheral motor neuropathy Abnormal foot anatomy and biomechanics, with clawing of toes, high

arch, and subluxed metatarsophalangeal joints, leading to excess pressure, callus formation, and ulcers

Peripheral sensory neuropathy Lack of protective sensation, leading to unattended minor injuries caused by excess of pressure or mechanical or thermal injury

Peripheral autonomic neuropathy Deficient sweating leading to dry, cracking skin

Neuro-osteoarthropathic deformities Abnormal anatomy and biomechanics, leading to excess pressure, especially in the midplantar area

Vascular insufficiency Impaired tissue viability, wound healing, and delivery of neutrophils

Metabolic derangements Impaired immunologic (especially neutrophil) function and wound healing, and excess collagen cross-linking

Patient disabilities Reduced vision, limited mobility, and previous amputation

Maladaptive patient behaviors Inadequate adherence to precautionary measures and foot inspection and hygiene procedures, poor compliance with medical care, inappropriate activities, excessive weight-bearing, and poor footwear

Health care system failures Inadequate patient education and monitoring of glycemic control and foot care

Obtaining proper specimens, avoid:• Missing true pathogens• Isolating contaminating organisms

Debride and cleanse the wound before taking a specimen for culture

Obtain tissue specimens from ulcers by curettage Aspirate purulent secretions Biopsy deep tissue or bone infections Avoid sending wound swab for culture Obtain blood cultures if patient is seriously ill Label and send specimens promptly in sterile

containers or transport media for aerobic and anaerobic cultures

Request Gram-stained smear of specimen

Foot infections- potentially catastrophic outcome

Management must be: • timely, • rational, • well coordinated.

Initial assessment- severity and extent of the infection Ischaemia of the affected limb confers a poor prognosis, the

vascular status must be delineated early in the assessment of the inf.

It can be difficult to assess the extent of an inf. without carrying out appropriate debridement, with the goal of removing all necrotic tissue

Drain abscesses or remove necrotic soft tissue Antibiotics are necessary but rarely sufficient for treating

diabetic foot inf., they are best seen as adjunctive not primary, therapy in treating these infections

Coordinated, multidisciplinary approach: diabetologist, infection specialist, vascular surgeon, plastic surgeon,podiatrist.

When a pt. presents with a foot wound, the clinician should determine: • whether or not it is infected • if infected, how severely• If hospital admission is needed• If urgent surgery is required• If parenteral and broad-spectrum antibiotics

are indicated

Mild infection: present pus or > 2 signs of inflammation but:• extent of cellulitis<2 cm. around the wound• limited to skin and superf. sc. tissues, • no other local complications. • no systemic illness

Moderate infection: inf. in systemically well and metabolically stable pt. who has:• cellulitis extending>2cm., • lymphangitis, • spread beneath the superf. fascia,• deep tissue abscess, • gangrene, • involvement of muscle, tendons, joint, bone

Severe infection: infection in a pt. with systemic toxicity or metabolic instability: • fever, chills, • tachycardia, • hypotension, • confusion, • leukocytosis, • acidosis, • severe hyperglycaemia, • azotaemia

Foot ischeamia may increase the severity of any infection

The rates of hospitalization and amputation increase with infection severity

The goals of therapy for patients with diabetic foot infection are :• the eradication of clinical evidence of infection • the avoidance of soft tissue loss and

amputations. Good clinical response can be expected in

80%- 90% of mild to moderate infections and in 60%- 80% of severe infections or in cases of osteomyelitis.

Relapses occur in 20%- 30% of patients.

Removal of non-viable tissue and surrounding callus to eliminate a sourse of bacterial colonization in the underlying tissue

Properly done, allows full assessment of the extent and depth of ulceration and tissue necrosis

Adequate debridement must precede the application of topical wound-healing agents, and dressings.

Debridement on a regular basis is thought to improve the rate of wound healing

Failure of the treating clinician to adequately debride a wound:

- lack of training, - lack of knowledge , - lack of time, is a frequent cause of healing failure.

The need for surgery must be carefully considered early in the evaluation process

Mild infections- surgery unlikely Severe infections

• excision of necrosis until healthy, bleeding tissues are encountered

• Pus must be drained• Joint resection/partial amputation of the foot

may be needed: osteomyelitis, septic arthritis, gangrene.

Aim- to stop the progression of infection

Amputations to the level of viable soft tissue and bone

All post-surgical pts. require careful podiatric follow-up and attention to any orthotic or prosthetic needs.

Many dressings on the market:• Hydrogels- dry to minor draining wounds• Hydrocolloids- moderate draining wounds• Polyurethane foams- superabsorbent• Calcium alginates- heavy exudative wounds• Collagen dressings- heavily draining wounds• Antimicrobial dressings (silver, iodine)• Skin replacements• Vacuum-assisted closure dressings- negative

pressure wound therapy

To facilitate healing:• Should prevent desiccation• Absorb excess fluid• Protect the wound from contamination and

trauma

The type of the dressings selected depends upon:• Wound’s size• Depth• Location • Surface characteristics

PM, 69 years old, Vetrisoaia-Husi, DM-type I-for 34 years

Emergent hospital admission- april 2004 Dg.- severe sepsis, plantar necrotizing fasciitis Referred from another hospital, where he refused

amputation. 1 week history of acute inflammatory signs

around an old foot ulcer Surgical treatment- limited plantar incisions-

extended infection+systemic complications.

On admission: fever,chills, confused, pale, poor urinary output but cardio-vascular stable

Local examination:• 2 plantar incissions and retromaleolar, foul

smelling secretions, necrotic subcut. tissues• Above knee cellulitis• Edema of the thigh and external genitalia organs• Inguinal lymphadenopathy• Peripheral pulses, present but weak

Severe septis:• WBC=33200/mmc• Sec. anemia, Hb=8,2g/dl., Ht=25%• Hyperpgycemia-256mg/dl• Renal failure-urinary output<50ml./h.• Urea=76mg/dl, creatinine=1,13mg/dl• Hyponatremia=129mEq/l

Correction of deficits Antibiotherapy iv- quinolone+flagyl G-stained smear of specimen=+/-G cocci. Emergent surgical treatment under iv GA:

• Enlargement of previous incisions• Debridements till muscular layerCultures of necrotic tissue- enteroccocusPersistent fever and high WBC- infectionist-

imipeneme 4g/day, 10 days

Repeated surgical debridements After 3 weeks- clean wounds,

granulating tissue But, large soft-tissue loss at the sole After 1 month- repeated skin grafting After 1 month-plastic surgeon- cross-leg

to cover the calcanean region defect After 3 weeks-separation of the cross-leg

Hospital stay- 4 months and 3 weeks Large amounts of dressings Time-consumer treatment Costly treatment BUT, the leg was saved and the

patient can walk and work in agriculture.