Diabetic foot disease

By:Dr. Ismail NaamehGeneral Surgeon

DIABETIC FOOT

DISEASE

CONTENTS

❶DEFINITION.❷EPIDEMIOLOGY.❸ETIOLOGY.❹FOOT EXAMINATION.❺DIABETIC FOOT ULCER MANAGEMENT.❻DIABETIC FOOT CARE DUIDELINES.

❶DEFINITION

●diabetic foot disease (DFD) can be defined as a group of syndromes in which neuropathy, ischemia, and infection lead to tissue breakdown or ulceration possibly resulting in amputation. ●Diabetic foot lesions frequently result when 2 or more risk factors are present.

❷EPIDEMIOLOGY• 15% of diabetics will develop a foot ulcer.• 4 out of 5 ulcers in diabetic are precipitated by trauma.• 85% of diabetic foot amputations are preceded by foot

ulcer.• 50% of all non-traumatic lower limb amputation are 2 ADFD.• Every 20 seconds a lower limb is amputated due to DFD.• Mortality following amputation increases with level of

amputation and ranges from 50% to 68% at 5 years.

❸ETIOLOGYWhy diabetics are different?

The cause of foot problems and faulty wound healing in diabetes can be attributed to three predisposing factors:

1-Peripheral neuropathy, 2-Peripheral vascular (arterial) disease and tissue hypoxia,3- and abnormal cellular and inflammatory pathways.As well as;Hyperglycemia,Foot edema,And foot deformity.

:Diabetic neuropathy• More than 50% of diabetic patients have some form of neuropathy.• Neuropathy may predispose the foot to ulceration through its effects

on the sensory, motor, and autonomic nerves.• The loss of protective sensation ( pressure, pain and temp.) renders

the patient vulnerable to physical, chemical, and thermal trauma.(sensory neuropathy is the major component of nearly all DFD. It is asso. with a 7- folds increase in risk of ulceration).

• Motor neuropathy → weakness and atrophy of foot muscles → altering foot structure →deformity and altered biomechanics.

• Autonomic neuropathy is asso. with dry skin → fissures, cracking, and callus.

PAD):)PERIPHERAL ARTERY DISEASE

• The incidence of PAD in diabetic patients is at least 4 times that of nondiabetics.

• 20% of diabetic patients > 40 years.• 30% of diabetic patients >50 years.• Hypertension, smoking, and dyslipidemia ↑ the

risk of atherosclerosis in diabetes.• PAD →circulation reduction (macro and micro

vessels→ Claudication, rest pain and vascular ulceration.

Abnormal cellular and inflammatory pathways: the diabetics have abnormalities in

cellular function ( neutrophils and fibroblasts).

humoral responses to wound healing (cytokine production,…) are affected.

the inflammatory proliferative phase frequently gets “stuck”.

All are allowing for repeated injury, infection, and further inflammation.

❹FOOT EXAMINATION

Who is at risk of developing foot ulcer?

steps of examination

• Full history & examination.• Foot examination: - inspection. - loss of sensation. - vascular status. - identifying infection. - Ulcer examination.

FOOT EXAMINATIONVISUAL INSPECTION

• Color: red, pale, matted, ……• Foot shape and toe nails.• deformity: hammer or claw toes, bunion, ….• Callus, corns, blisters,……• Ulceration :( current or previous).• Infection : swelling, skin breakdown,…

FOOT EXAMINATIONVISUAL INSPECTION

Ingrowing nail Hammer toe

FOOT EXAMINATIONVISUAL INSPECTION

bunion Corn & callus

FOOT EXAMINATIONVISUAL INSPECTION

Dry skin: Marceration:

FOOT EXAMINATION(VISUAL INSPECTION)

Charcot’s foot Clawed toes

FOOT EXAMINATIONNEUROPATHY ASSESSMENT

Testing touch pressure sensation with a monofilament

FOOT EXAMINATIONNEUROPATHY ASSESSMENT

Testing vibration sensation with a biothesiometer:

Testing vibration sensation by tuning fork ( standard: 128 c\s):

FOOT EXAMINATIONNEUROPATHY ASSESSMENT

• Pressure- specified sensory device: measures the cutaneous sensibility of hallax pulp. ( the most accurate).

FOOT EXAMINATIONPAD. ASSESSMENT

Taking temp. of the foot.Palpation of arterial pulses (Fem. Pop. DP.

And PT).Ankle brachial index (ABI).Toes pressure (TP).Transcutaneous oximetry (TCpo2).Asking about : claudication and rest pain.

FOOT EXAMINATIONPAD. ASSESSMENT

Tem. Taking: Arterial palpation:

FOOT EXAMINATIONPAD. ASSESSMENT

Taking Brachial pressure: Taking Ankle pressure;

FOOT EXAMINATIONPAD. ASSESSMENT

Taking toe pressure:

• Cost-effective• Convenient and efficient• Used when arteries are

caLcified.

FOOT EXAMINATIONPAD. ASSESSMENT

Duplex scan:

• In significant vascular disease.

FOOT RISK CATEGORIESClinic follow-up Risk profile category

Every year normal 0

3-6 months Sensory neuropathy 1

1-3 months Sensory neuropathy , deformity&\Or

Peripheral arterial disease

2

1-4 weeks Sensory neuropathy & previous DFU or amputation 3

DIABETIC FOOT INFECTION• Diabetic patient have poor defense against infection.• Minor cut and abrasion can turn into infection.• It is essential to distinguish between localized and

generalized foot infection

DIABETIC FOOT INFECTION● Diabetic foot infection typically take one of the

following forms:- Cellulitis- Deep-skin and soft-tissue infection- Acute osteomyelitis- Chronic osteomyelitis. ● cultures should be taken only from clinically

infected wounds.

DIABETIC OSTEOMYELITIS● Suspected on;- Prolonged or recurrent ulcer.- Deep ulcer- Difficult ulcer to heal(< 2mothes) despite optimal treatment.- X-Ray is not diagnosed in early phase.( bone scan or MRI).

DIABETIC FOOT ULCEREXAMINATION OF THE ULCER

• Classification• Ischemia, deformity• Size, depth, location,• Ulcer bed color• Exposed bone, necrosis. Gangrene• Infection• Local pain• Exudate• Ulcer edge Digitally photographing at the 1st consultation and

periodically thereafter to document progress.

USUAL LOCATIONS OF DFU.

Typical neuropathy ulcer

• Painless.• Surrounded by callus.• asso. with good foot

pulses.• At the soles or tips of

toes.

Typical vascular ulcer

• Painful.• Not Surrounded by

callus.• Asso. with absent or

poor foot pulses.• At the edge of the foot

or toes.

❺MANAGEMENT OF DIABETIC FOOT ULCER

VIPS V= Vascular supply is adequate

I= Infection control is achieved P= Pressure offloading S= Sharp\surgical debridement

MANAGEMENT OF DIABETIC FOOT ULCER

V= Vascular supply is adequate

○ A patient with acute limb ischemia is a clinical emergency.

○ Revasculrization is to be considered in case of decreased perfusion or impaired circulation.

MANAGEMENT OF DIABETIC FOOT ULCER

I = Infection control and local wound care)Antibiotics & wound dressing)

General principles of bacterial management At initial presentation of infection it is important to assess its severity, take appropriatecultures and consider need for surgical procedures. Optimal specimens for culture should be taken after initial cleansing and debridementof necrotic material. Patients with severe infection require empiric broad-spectrum antibiotic therapy,pending culture results. Those with mild (and many with moderate) infection can betreated with a more focused and narrow-spectrum antibiotic. Patients with diabetes have immunological disturbances; therefore even bacteria regardedas skin commensals can cause severe tissue damage and should be regarded as pathogens whenisolated from correctly obtained tissue specimens. Gram-negative bacteria, especially when isolated from an ulcer swab, are oftencolonizing organisms that do not require targeted therapy unless the person is at riskfor infection with those organisms. Blood cultures should be sent if fever and systemic toxicity are present. Even with appropriate treatment, the wound should be inspected regularly for earlysigns of infection or spreading infection. Clinical microbiologists/infectious diseases specialists have a crucial role; laboratoryresults should be used in combination with the clinical presentation and history toguide antibiotic selection. Timely surgical intervention is crucial for deep abscesses, necrotic tissue and forsome bone infections.

MANAGEMENT OF DIABETIC FOOT ULCER

• All dressings are not a substitute for sharp debridement, managing systemic infection, offloading devices, and diabetic control.

• The optimal dressing is the one can maintain a balanced wound environment (not too moist or too dry).

• There is no single dressing to suit all scenarios.

local wound care

percautions indication action Type of dressing

SensitivityOsmotic effect (drawing pain)

Sloughy low to moderate exuding wound, critically colonized wound or clinical signs of infection

Rehydrate wound bedAntimicrobialAutolytic debridement

honey

SensitivityShort-term useDo not use on dry necrotic tissue.

critically colonized wound or clinical signs of infection.Low to high exuding wound

Antimicrobial Iodine

SensitivityDiscolourationD\C after 2 weeks.

critically colonized wound or clinical signs of infection.Low to high exuding wound.

Antimicrobial silver

Do not use on highly exuding woundsor where anaerobic infection is suspectedMay cause maceration

Dry/low to moderate exuding woundsCombined presentation with silver forantimicrobial activity

Rehydrate wound bedMoisture controlautolytic debridementCooling

Hydrogels

May dry out if left in place for too long.sensitivity

Low to high exuding wounds

Protect new tissue growthAtraumatic to periwound skin

Low-adherentwound contactlayer (silicone)

MANAGEMENT OF DIABETIC FOOT ULCERP = Pressure offloading

In patient with peripheral neuropathy, it is important to offload at – risk areas of the foot in order to redistribute pressure.

*Total contact cast: the gold standard * Removable cast walkers * Scotch cast boots * Healing sandals * Crutches, walkers and wheel chairs.

MANAGEMENT OF DIABETIC FOOT ULCER

• Contraindications of total contact cast: Ischemia Infected DFUs osteomyelitis

P = Pressure offloading

MANAGEMENT OF DIABETIC FOOT ULCERP = Pressure offloading

Removable cast walker Scotchcast boot

MANAGEMENT OF DIABETIC FOOT ULCERP = Pressure offloading

crutches wheelchair

MANAGEMENT OF DIABETIC FOOT ULCER

Healing sandal walker

P = Pressure offloading

FOOT ULCER MANAGEMENT(DEBRIDEMENT)

● TYPES: • SURGICAL\SHARP• LARVAL• AUTOLYTIC• HYDROSURGERY• ULTRASONIC

FOOT ULCER MANAGEMENT(SURGICAL DEBRIDEMENT)

• Regular & local sharp debridement is the gold standard technique.

• Tools: scalpel, scissors, and\or forceps.• The benefits are: removal of necrotic\sloughy tissue and callus, drainage of secretions and pus, stimulating healing, and reducing pressure.

FOOT ULCER MANAGEMENT(OTHER DEBRIDEMENT METHODS)

Larval therapy:• Using the greenbottle fly larvae; they can

achieve rapid, atraumatic removal of moist, slimy slough, and can ingest pathogenic organisms present in the wound.

• Needs only for minimal training.• Not indicated in neuropathic ulcers.

FOOT ULCER MANAGEMENT(LARVAL DEBRIDEMENT)

Green bottle fly Larvae in the wound

FOOT ULCER MANAGEMENT(LARVAL DEBRIDEMENT)

FOOT ULCER MANAGEMENT(OTHER DEBRIDEMENT METHODS)

• Hydrosurgical debridement: is alternative to surgical method, by creating of high-energy cutting beam by forcing water or saline into a nozzle.

• Autolytic debridement: is a natural process that uses a moist wound dressing to soften and remove devitalized tissues.

• Ultrasonic debridement.

ADVANCED THERAPIESAdjunctive treatments such as negative pressure wound therapy (NPWT), biologicaldressings, bioengineered skin equivalents, hyperbaric oxygen therapy, plateletrich plasma and growth factors may be considered, if appropriate and where

available.for DFUs that are not progressing. These techniques require advanced clinicaldecision making and should be carried out only by practitioners with appropriateskills and anatomical knowledge.However, such therapies represent considerable greater product cost than

standard therapy.. These costs may be justified if they result in improved ulcer healing,reduced morbidity, fewer lower-extremity amputations and improved patientfunctional status. There is a good level of evidence for some biological skinequivalents as well as for the use of NPWT in DFU patients without significantinfection. More recently, NPWT with instillation therapy (NPWTi) using antisepticagents (eg PHMB) has become available. Although there are limited dataon its benefits, it could be considered when there is a need for wound cleansing or

treatment with tropical antimicrobial.

❻DIABETIC FOOT CARE GUIDELINES

DIABETIC FOOT CARE(PATIENT EDUCATION)

DO NOT WALK BAREFOOT

DIABETIC FOOT CARE(PATIENT EDUCATION)

Use a magnifying hand mirror Inspect your feet daily

DIABETIC FOOT CARE(PATIENT EDUCATION)

Moisturize your foot Cut nails carefully

DIABETIC FOOT CARE(PATIENT EDUCATION)

Wear clean, dry, and right type of socks

After washing, make feet dry with soft towel

DIABETIC FOOT CARE(PATIENT EDUCATION)

Look at your feet before walking

Clean your shoes before you put them on

Thank youTHANK YOU