DIABETIC FOOT grading and management clinical

DIABETIC FOOT grading and management clinical

1. Diabetic Foot PRESENTED BY: DR. SAUJANYA JUNG PANDEY 2ND YEAR RESIDENT GENERAL SURGERY

2. CONTENTS INTRODUCTION RISK FACTORS CLINICAL MENIFESTATIONS EVALUATION MANAGEMENT

3. fig.A severe diabetic foot infection, with marked infection, necrosis and soft-tissue loss.

4. Diabetes mellitus: Abnormal carbohydrate metabolism - hyperglycemia. impairment in insulin secretion peripheral resistance to the action of insulin. Symptomatic hyperglycemia — classic symptoms (thirst, polyuria, weight loss, blurry vision) and RBS > 200 mg/dL or higher. Asymptomatic hyperglycemia — FPG values ≥126 mg/dL Two-hour plasma glucose ≥200 mg/dL ( 75g OGTT ) HbA1C values ≥6.5 percent

5. Complications macrovascular disease -atherosclerosis microvascular disease -retinopathy -nephropathy -neuropathy

6. Di a betic Foot Cause of morbidity in DM Aetiological agents: Staphylococcus aureus, beta- haemolytic streptococci and aerobic gram-negative bacilli, Pseudomonas,Anaerobes Lifetime risk of a foot ulcer ~ 34 % High rate of hospital readmission, and a /w 2.5-fold risk of death Preventable initiating event, such as minor trauma

7. Foot amputations, in ~ 20 % foot ulcers Frequent evaluation of the feet for early identification Systematic screening - neuropathic and vascular involvement Careful inspection reduces morbidity Increased risk of infection and ulceration, and trauma

8. Risk assessment Complications and associated risks Infections- approx. 1/3 rd , leading to sepsis, gangrene amputation and death Hospitalization and amputation- 20% Recurrent foot ulcerations- ½ recur within 5 years Mortality- strong predictor, 30-50% 5 year mortality

9. Risk Factors Previous foot ulceration Neuropathy (loss of protective sensation) Foot deformity Vascular disease Medications- SGLT2 Age, race, ethnicity Low income areas

10. CLINICAL MANIFESTATIONS Spectrum of involvement localized superficial skin involvement or infection of the skin or deeper skin structures E xtend ing to joints, bones, and the systemic circulation Skin and soft tissue infection Cardinal sign s of inflammation pus in an ulcer or sinus tract sensory neuropathy-diminished sensation -non tender Nonpurulent drainage, friable or discolored granulation tissue, and undermining of wound edges

11. Cutaneous bullae, soft tissue gas, skin discoloration, or a foul odor- necrotizing infections. gangrene, severe ischemia, or tissue necrosis- limb-threatening infection. fever, chills, hypotension, and tachycardia – severe infection Osteomyelitis — can occur with or without evidence of local soft tissue infection. Imaging- cortical erosion, periosteal reaction, mixed lucency , and sclerosis

12. Evaluation History & Examinations Duration of diabetes Overall glycemic management Presence of micro or macrovascular disease History of prior foot injury  deformities or prior ulcers, lower limb bypasses or amputation, claudication, cigarette smoking. The total neuropathy symptom score: 0 to 2 – Normal 3 to 4 – Mild 5 to 6 – Moderate 7 to 9 – Severe

13. Scoring system What is the sensation felt? – Burning, numbness, or tingling (2 points); fatigue, cramping, or aching (1 point). What is the location of symptoms? – Feet (2 points); calves (1 point); elsewhere (no points). Have the symptoms ever awoken you at night? – Yes (1 point). What is the timing of symptoms? – Worse at night (2 points); present day and night (1 point); present only during the day (no points). How are symptoms relieved? – Walking around (2 points); standing (1 point); sitting or lying or no relief (no points). Maximum is 2 points.

14. Monofilament Test

15. Ipswich touch test a quicker and simpler method lightly and briefly (1 to 2 seconds) touch the tips of the 1 st , 3 rd and 5th toes of both feet with the index finger. Reduced sensation : ≥2 of 6 insensate areas (counting both feet). Sensitivity - 77 - 78.3 percent S pecificity - 90 - 93.9 percent P PV- of 81.2 to 89 percent and NPV of 77 to 92.8 percent

16. Vibration testing 128 Hz tuning fork  bony prominence at the dorsum of the first toe, just proximal to the nail bed. Ask the patient to report the perception of both the start of vibration sensation and the cessation of vibration on dampening. conducted twice on each great toe. The sensitivity and specificity of vibration are 53 and 99 percent, respectively.

17. Evaluation of Ulcer Signs of infection erythema warmth tenderness swelling Imaging Plain radiographs can detect structural foot deformities, soft tissue gas, and foreign bodies

18. Evaluation of peripheral artery disease ABI testing, which can detect macrovascular, but not microvascular, peripheral artery disease.

19. The normal ABI is 0.9 to 1.3 An ABI <0.9 has 95 percent sensitivity for detecting peripheral artery disease

20. Management Blood cultures Imaging Careful clinical assessment with optimisation of organ function prompt empirical antibiotics Bone biopsy for culture in extensive/ complex infection Surgical debridement followed by antibiotics in severe infections.

21. General management General approach comprehensive assessment of the ulcer and the patient’s medical condition Evidence of infection, underlying neuropathy, peripheral artery disease, edema, malnutrition, and any bony deformities should be actively sought For evidence of arterial insufficiency, referral to a vascular specialist. Local ulcer care includes sharp debridement and proper wound coverage

22. Ulcer with frequent pressure and stress  pressure reduction with mechanical offloading. including total contact casts, cast walkers, wedge shoes, and bedrest. surgical correction- hammertoe corrections, bunion corrections, Achilles tendon or gastrocnemius lengthening, and Charcot foot reconstructions.

23. Allowable time course for primary healing measurements of a patient’s ulcer size should be taken at every visit so that comparisons can be made and progress documented Coordination of care Coordination among Clinical teams may include podiatric, vascular, plastic and orthopedic surgeons,also assisted by shoe specialists/prosthetists, physical therapy, nurse specialists, and nutritionists/dietitians. In addition, primary care physicians, infectious disease physicians, nephrologists, and diabetologists all play significant roles in limb preservation units

24. Follow-up care and ulcer prevention Ulcer recurrence is 40 percent at one year, 66 percent at three years, and up to 75 percent at five years

25. Intensive glucose control might reduce incidence of new ulceration by more than 23 percent

26. LOCAL CARE Debridement Sharp debridement, involves the use of a scalpel or scissors to remove necrotic tissue As an alternative, application of a hydrogel (Elemental silver, is bactericidal; it binds to bacterial cell membranes, disrupts the bacterial cell wall, and causes cell leakage (International Consensus, 2012).

27. Enzymatic debridement by collagenase

28. Autolytic debridement,using a semiocclusive or occlusive dressing to cover the ulcer so that necrotic tissue is digested by enzymes Larval therapy (‘maggot therapy’ or ‘biosurgery’, involves the use of larvae of the greenbottle fly, introduced to a wound to remove necrotic, sloughy and/or infected tissue )

29. Dressing

30. Negative pressure wound therapy vacuum-assisted closure (VAC), involves the application of controlled subatmospheric pressure to the surface of the ulcer. Increases wound perfusion Reducing edema Reducing the local bacterial burden Increasing the formation of granulation tissue

31. Skin grafts and substitutes Human skin grafts Bioengineered skin substitutes (eg, Dermagraft, Apligraf, TheraSkin, Graftskin, EpiFix, Zelen, Graftjacket, Hyalograft 3D, Kaloderm, OrCel)

32. Growth factor Promote cellular proliferation and angiogenesis and thereby improve ulcer healing Platelet-derived growth factor as a gel preparation(becaplermin) approved by the US Food and Drug Administration Its use has been limited by high cost and by postmarketing reports of an increased rate of mortality secondary to malignancy

33. Hyperbaric oxygen therapy — Hyperbaric oxygen therapy (HBOT) may be associated with improved healing as a component of diabetic ulcer management

34. REFERENCES Bailey & Love's Short Practice of Surgery, 27th Edition Sabiston Textbook Of Surgery Bailey & Love’s Short Practice of Surgery, 27th Editi Bailey & Love’s Short Practice of Surgery, 27th Edition

35. THANK YOU