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THE DIABETIC

FOOTDR.SEIF I M ELMAHI

MD, FRCSI

University of Khartoum, Sudan

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CONTENT

Definition

Epidemiology

Social & Economic factors

Pathophysiology of foot ulceration

Diabetic Neuropathy

Peripheral Vascular Disease & Diabetes

Biomechanics of Foot Wear

The Diabetic Foot Ulcer Outcome & Management

Neuro-osteoarthropathy

Amputation in Diabetic Patient

Prevention of Foot Problem

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Diabetic Foot

Definition:

Infection, ulceration or

destruction of deep tissues associatedwith neurological abnormalities & various

degrees of peripheral vascular diseasesin

the lower limb

(based on WHO definition)

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Epidemiology

40% - 60% of all non traumatic lower limb

amputation

85% of diabetic related foot amputation

are preceded by foot ulcer

4 out of 5 ulcer in diabetics are

precipitated by trauma

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

diabetics

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Epidemiology

In Sudan:

Prevalence of DM ? 6 12 %

DSF inpatient KTH :30% - 40% risk of major amputation

8% - 20% mortality

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Social & Economic Factors

Diabetic foot complications are expensive :(cost of healing 7000-10000 USD)

(healing with amp. 43000-63000USD)In Khartoum : (4 weeks dressing cost 110000SD)

Intervention of foot care is cost effective in

most societies

Scarce information regarding long termprognosis

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Pathophsiology of Foot Ulceration

Neuropathic

Ischemic

Neuro -ischemic

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STAGES OF ULCER DEVELOPMENT

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STAGES OF ULCER DEVELOPMENT

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Diabetic Neuropathy

Sensorimotor & peripheral sympathaticneuropathy are major risk factors for ulcer

History & careful foot examination aremandatory to diagnose neuropathy

Up to 50%of type2 diabetic patient have

significant neuropathy & at risk of footulcer

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Periphral vascular disease& diabetic

PVD

PVD is the most important factors related to outcome ofdiabetic foot ulcer

PVD is diagnosed by simple clinical examination

non invasive vascular test determines probability of

healing Symptoms of ischemia may be masked by neuropathy

Microangiopathy shouldn't be accepted as primary causeof ulcer

Conservative approach for treatment Outcome ofrevascularization is similar to that in non-

diabetic

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Biomechanics of foot wear

Biomechanical abnormalities are consequenceof neuropathy, they lead to abnormal footpressure

Foot deformity & neuropathy increase the risk of

ulcer Pressure relief is essential for ulcer healing

and/or prevention

Frequent inspection of shoes & insoles is

mandatoryAppropriate foot wear significantly reduce ulcer

recurrence

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Diabetic Foot Infection

Infection in diabetic foot is limb threatening

Signs of infection may be absent in diabetic pt.

with foot ulcer

Superficial infection is usually caused by gram+ve cocci, deep infection is poly microbial

Surgical debridment is essential in acute deep

infection Osteomylitis( diagnoses & treatment)

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Neuro-osteoarthropathy

Non- infective pathology

Should be suspected in any swollen hoterythematous foot

Differentiation from infection is importantto prevent misdiagnosis & possibleamputation

Treatment should aim at preventingsevere deformity

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Diabetic Foot Ulcer Treatment

Multidisciplenary approach

Staging dictate the treatment option

Continuity of care & life longobservation

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Amputation in Diabetic Patient

Increased minor\major amputationincreased the no. ofdeformed feet

Minor amputation is needed :

*Gangrene

*As part of debriment

*for correction of foot deformities

Minor amputation doesnt significantlycompromise walking ability

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Major Amputation

Risk of loss walking ability

Mortality

Risk of contra-lateral amputation Strict indication

Careful choice of the level

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How To Prevent Foot Problems

5 corner stonesRegular inspection & examination of foot &

foot wear

Identification of high risk patient

Education of patient, family & health careproviders

Appropriate foot wear

Treatment of non ulcerative pathology

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SENSORY NEUROPATHY

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Diabetic Neuropathy

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PERIPHRAL VASCULAR DISEASE

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AREAS AT RISKBiomechanics of foot wear

OF ULCERATION

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WEARFOOT

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FOOT WEAR

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OSTEOMYLITIS

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Diabetic Foot Ulcer Treatment

Modalities

Microbiological control

Wound control

Vascular controlMechanical control

Metabolic control

Educational control

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Staging of Diabetic Foot

Stage Clinical condition

1 Normal

2 High risk3 Ulcerated

4 cellulitic

5 Necrotic6 Major amputation

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Assessment of Diabetic Foot

Neuropathy

Ischemia

Deformity

Callus

Swelling

Skin breakdown

Infection

Necrosis

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NEURO-OSTEOARTHROPATHY(CHARCOTFOOT)

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CHARCOTOSTEOARTHROPATHY(-NEUROosteoarthropathy-NeuroFOOT)

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PODIATRY

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