Diabetic foot

diabetic foot

1. Recent Advances in Management of Chronic Non healing Diabetic Foot Ulcers Ashok Damir MD, Foot Fellowship, Chicago , USA, Senior Diabetic Foot Specialist & Stem Cells Therapist Aakanksha Aggarwal DNB Resident

2. JIMSA October - December 2011 Vol. 24 No. 4

3. Introduction 15 % of diabetics will develop Diabetic foot ulcer once in their lifetime. Approximately 14% of diabetic ulcers lead to amputation . Degree of metabolic control , presence of ischemia or infection, and continuing trauma to feet from excessive plantar pressure or poorly fitting shoes affect development and healing.

4. Risk Factors for Diabetic Foot Ulcer General / Systemic contributions Local issues Uncontrolled hyperglycemia Peripheral neuropathy Duration of diabetes > 10 years Structural foot deformity Peripheral vascular disease Trauma / ill fitted shoes Blindness or visual loss Callus Chronic renal disease History of prior ulcer / amputation Older age Prolonged elevated pressures High body mass index Limited joint mobility

5. Aetiology I schemic , neuropathic or combined neuro -ischemic abnormalities Only 10% of Diabetic foot ulcers are pure ischemic ulcers 90% are caused by neuropathy, alone or with ischemia Peripheral sensorimotor and autonomic neuropathy is the most common pathway for development of foot problems in diabetic patients  high foot pressure, foot deformities, and gait instability  foot ulceration

6. Pathophysiology

7. Diabetic Foot Lesions Classification

8. Wagner Meggitt classification Grade Lesion No open lesion 1 Superfcial ulcer 2 Deep ulcer to tendon or joint capsule 3 Deep ulcer with abscess, osteomyelitis, or joint sepsis 4 Local gangrene – forefoot or heel 5 Gangrene of entire foot

9. Advanced treatments Topical growth factors Bioengineered skin grafts VAC ( vaccum assisted closure) therapy HBOT (hyperbaric oxygen therapy) Available in India now Evidence of improved healing compared to standard wound care

10. Management Microbiological Control Wound Control Metabolic control Vascular Control Mechanical Control Educational Control

11. Microbiological Control Most of the Diabetic Foot Infections are poly microbial Broad spectrum Antibiotics for longer duration Poor immune response in diabetics hence normal skin commensals can cause serious infection

12. Wound Control Irrigate the wound with saline or diluted solution of Povidone iodine. VASHE WOUND CLEANSING SOLUTION Solution of HOCl (kills gram + ve , gram – ve , anaerobes and fungi) Gauze soaked in VASHE solution wrapped around wound for 10 -15 mins .

13. DEBRIDEMENT ( REMOVAL OF DEVITALIZED TISSUE FROM ULCER) Sharp, B lunt, Surgical, Chemical & Auto debridement Two new modalities i.e . Ultrasonic debridement & Biodebridement (aka Maggot treatment) ULTRASONIC DEBRIDEMENT Ultrasonic formation & collapse of vapor bubbles that fragments & emulsifies the necrotic tissue without disturbing the viable tissue . removal of particulate matter and reduction of bacterial counts

14. Hardly any blood loss Deep and tunnelling wounds where debridement with other technique is difficult

15. BIODEBRIDEMENT OR MAGGOT Rx Medicinal maggots of Lucilia sericata (Green Bottle fly )

16. Do not eat or disturb normal host tissue Good debdridement with removal of dead necrotic tissue and elimination of infection Costly & difficult to get, short shelf life, patient can have uncomfortable crawling sensation

17. VAC (VACCUM ASSISTED CLOSURE ) / NPWT (NEGATIVE PRESSURE WOUND THERAPY) Granufoam Dressing Plastic Tubing Canister Computerized T reatment Unit Cleaning and debriding  special granufoam dressing applied connected to special computerised treatment unit with plastic tubing (125 mmHg negative pressure) Reduces oedema , exudates and bacterial load, regeneration of granulation tissue & neo vascularisation.

18. AUTOLOGEL-AUTOLOGUS PLATELET RICH PLASMA (PRP) GEL Principle : Platelets contain components & properties for wound healing & Plasma contains fibrin matrix Procedure : 5 to 30 ml patient’s blood is centrifuged & Platelet Rich Plasma is separated PRP taken into a syringe having different reagents [ Thrombin(CaCl2) & Vitamin C ] that activate platelets & make gel consistency  A utologel . Gel applied over wound twice a week for 12 weeks ( Vickie R. Driver etal . that 68.4% of those wounds which were treated with Autologel healed in comparison to 42.9% of Control wounds )

19. O2 MISLY Patient puts lower limb in a canister of O2 Misly machine & wound is exposed to 4 Cycles of 100 % O2 ( 5 mins . each ) alternatively with Vapor of water & antibiotic (10 mins . each ) . Twice a week for 12 to 20 weeks. Ubbink DT et al found that in comparison to standard wound care, proportion of healed wounds with use of O2 Misly were 200% better at 12 to 20 week.

20. LLLT(LOW LEVEL LASER THERAPY ) Wound exposed to Low Level Laser Therapy which activates Microcirculation & Macrophages leading to Anti-inflammatory , Analgesic , Regenerative, Bacteriostatic & Bactericidal clinical effects. Martinez -Sanchez G et al. Found Low Level Laser Therapy very effective in healing of Chronic Non-healing diabetic Foot Ulcer.

21. GROWTH FACTORS

22. Platelet derived growth factor ( PDGF) and Epidermal growth factor (EGF ) approved by US FDA Most commonly used plermin ( rh PDGF BB , Recombinant human Platelet derived growth factor ) has c hemotactic , mitogenic , angiogenic , and stimulatory effects and help in wound healing if used in non infected superficial wounds.

23. OZONE THERAPY Colourless , pungent- odor gas , disinfects , oxidizes, deodorizes and decolorizes Peripheral Ozone Therapy is very effective for badly-infected and non - healing Ulcers ( chronic DFUs). ‘ Bagging’ A fter preparing the wound, limb is covered with a plastic bag & a tube from Ozone generator is tightly secured in upper portion of bag. Wound is exposed to Ozone for 20 to 30 mins

24. Initially higher concentration (60-90ug/ml ) is used to control infection and later on lower concentration (30-40ug/ml) is used for wound healing.

25. HYPERBARIC O2 (HBO) THERAPY

26. Monoplace HBOT Chamber Two types of HBO chambers are available : Monoplace & Multiplace Chambers Monoplace chamber : one person can lie down inside glass chamber exposed to pressurised oxygen for a prescribed limit of time. Multiplace chamber is like a big Oil-tanker in which number of patients can simultaneously be exposed to HBO .

27. Patient is placed in Monoplace / Multiplace HBO Chamber & he breaths 100 % oxygen under increased (2 to 3 times) atmospheric pressure for 90 to 120 mins . This Increases tissue oxygen tension, angiogenesis , fibroblast proliferation, collagen deposition and enhanced bacterial killing. G iven for 5 days a week & total such 20 to 40 treatments are given depending upon size & severity of wound. Improved wound healing & reduced rate of amputations were observed in significant number of cases of DFU by Stone JA et al

28. SKIN GRAFTS – APLIGRAF If it ’ s a large sized wound, superficial & well granulated , it needs skin grafting. N atural skin grafts or Bioengineered grafts Apligraf is Bioengineered Epidermis & Dermis Graft, developed from foreskin of Newborn . Indication : Chronic n on healing (non infected) DFU or Superficial Venous Ulcers

29. METABOLIC CONTROL Controlling Blood sugar and other general parameters are equally important. If wound is small & superficial  can use OHAs Start i nsulin if wound is large, infected, necrotic & If patient has septicaemia , looks toxic and or has DKA.

30. VASCULAR CONTROL If two or more than 2 peripheral arteries are impalpalpable & or ABI (Ankle Brachial Index) is low  Peripheral Vascular Doppler & Angiography A rterial occlusion less than 10 cm then different options available are : Intraarterial Thrombolysis, Endarterectomy & Angioplasty Arterial occlusion more than: Vascular Grafts (Natural or Synthetic ) are applied to bypass the occlusion & to achieve good circulation distal to occlusion to promote healing of ulcer .

31. MECHANICAL CONTROL- OFF LOADING Offloading is cornerstone of managing Chronic n on healing DFU. Different offloading devices could be Crutches , Wheel Chair , offloading s hoes, scotch c ast boot , Removable Cast Walker (RCW) & Air Cast walker. TCC (Total Contact Cast) is just like applying plaster around fracture of foot or leg . TCC can be made of Plaster of Paris(POP) or Fibreglass .

32. SUMMARY Most Common Cause of hospitalization in Diabetics is Diabetic foot p roblems . Minor ulcer can lead to Amputation so one should be cautious from the beginning. Newer & more advanced techniques are now available for better wound care including VAC therapy, Hyperbaric Oxygen Therapy , Growth Factors, Bioengineered Skin grafts , Maggot’s therapy etc. If Diabetic Foot Ulcer is not improving one should refer case to Podiatrist or specialist . Apart from blood sugar control, treatment of ulcer involves debridement , offloading, appropriate dressings, vascular maintenance and infection control.

33. Thank You