DIABETIC FOOT,WHICH IS ABOUT THE WHOLE PATIENT AND NOT JUST THE HOLE IN THE PATIENT AND IN WHICH PATIENT HAVE TO TAKE CARE OF THEIR FEET LIKE THEIR FACE

AS INDIA EMERGES AS DIABETIC CAPITAL OF THE WORLD,HERE WE WILL TRY TO LEARN ABOUT THE MOST COSTLY COMPLICATION OF DIABETES MELLITUS i.e DIABETIC FOOT(DF).DF IS THE LEADING CAUSE OF NON TRAUMATIC AMPUTATIONS

1. DIABETIC FOOT IT’S ABOUT THE ‘WHOLE’ PATIENT AND NOT JUST A ‘HOLE’ IN THE PATIENT PRESENTER: MODERATOR: SMITA S PAWAR DR VIBHUTI BHUSHAN JUNIOR RESIDENT PROFESSOR DEPT OF GENERAL SURGERY DEPT OF GENERAL SURGERY IGIMS , PATNA IGIMS , PATNA

2. OUTLINE INTRODUCTION DEFINITION CLASSIFICATION AND STAGING PATHOGENESIS CLINICAL FEATURES DIAGNOSIS AND EVALUATION MANAGEMENT PREVENTION GUIDELINES CONCLUSION REFERENCES

3. DIABETIC FOOT

4. INTRODUCTION DIABETES -Most common cause of NON TRAUMATIC AMPUTATION of Lower limbs. Accounts for >70% of Lower limb Amputations. Most common ulcer sites are TOES(DORSAL/PLANTAR SURFACE) followed by the PLANTAR METATARSAL HEADS . DIABETIC FOOT ULCER(DFU) conditions include Chronic ulcers , Superficial and Deep Infections of the foot and Osteomyelitis.

5. DEFINITIONS(AS PER IWGDF GUIDELINES,2023) DIABETIC FOOT:Infection,Ulceration /Destruction of Tissues of the foot associated with NEUROPATHY and/or PERIPHERAL ARTERIAL DISEASE(PAD) in the lower extremity of a person with (a history of)DIABETES MELLITUS(DM). DIABETIC NEUROPATHY:The presence of symptoms or signs of nerve dysfunction in a person with (a history of) DM,after exclusion of other causes. NEURO-OSTEO ARTHROPATHY(CHARCOT FOOT):Non infectious destruction of bone and joint(s) associated with neuropathy,which,in the acute phase,is associated with signs of Inflammation. FOOT DEFORMITY:Structural abnormalities of the foot,such as Hammer Toes,Mallet toes,Claw toes,Hallux valgus,Prominent Metatarsal Heads,Pes Cavus,Pes Planus and Residuals of Charcot Neuro-osteoarthropathy IWGDF-The International Working Group on the Diabetic Foot

6. CLASSIFICATION AND STAGING A Standard Classification is useful for Assessing the Etiology Designing Appropriate Treatment Assessing the Depth of the Disease Predicting Prognosis Monitoring course of the Disease Process

7. CLASSIFICATION AND STAGING Staging used according to Clinical Condition: EDMOND AND FOSTER Most Widely used and which grades Diabetic Foot on SEVERITY OF ULCER PENETRATION: MEGGITT-WAGNER’S CLASSIFICATION Best for communication among Healthcare Professionals and to Optimise the Process of Referral-SINBAD System Best when Resources exist in addition to an appropriate level of Expertise: WIfI System

8. EDMOND AND FOSTER CLASSIFICATION STAGE CLINICAL CONDITION 1 NORMAL 2 HIGH RISK 3 ULCERATED 4 CELLULITIC 5 NECROTIC 6 MAJOR AMPUTATION

9. CLASSIFICATION OF DIABETIC FOOT

10. SINBAD SYSTEM CATEGORY DEFINITION SCORE SITE FOREFOOT MIDFOOT AND HINDFOOT 1 ISCHEMIA PEDAL BLOOD FLOW INTACT;ATLEAST 1 PALPABLE PULSE CLINICAL EVIDENCE OF REDUCED PEDAL FLOW 1 NEUROPATHY PROTECTIVE SENSATION INTACT PROTECTIVE SENSATION LOST 1 BACTERIAL INFECTION NONE PRESENT 1 AREA ULCER ULCER<1 CM2 ULCER>=1 CM2 1 DEPTH ULCER CONFINED TO SKIN AND SUBCUTANEOUS TISSUE ULCER REACHING MUSCLE,TENDON /DEEPER 1 TOTAL POSSIBLE SCORE 0-6

11. WIfI SYSTEM GRADE DFU GANGRENR NO ULCER NO GANGRENE 1 SMALL,SHALLOW ULCER(S) ON DISTAL LEG/FOOT,NO EPOSED BONE UNLESS LIMITED TO DISTAL PHALANX NO GANGRENE 2 DEEPER ULCER WITH EXPOSED BONE,TENDON,NOT INVOLVING HEEL/CALCANEUM GANGRENOUS CHANGES LIMITED TO DIGITS 3 ETENSIVE,DEEP ULCER INVOLVING FORFOOT+/-MIDFOOT,HEEL ULCER+/-CALCANEAL INVOLVEMENT EXTENSIVE GANGRENE INVOLVING FOREFOOT AND/OR MIDFOOT WITH HEEL NECROSIS WOUND

12. WIfI SYSTEM(CONT’D ) GRADE ABI(ANKLE BRACHIAL INDEX) ANKLE SYSTOLIC PRESSURE TP(TOE PRESSURE),TcPO2(TRANS CUTANEOUS PARTIAL O2 PRESSURE) >=0.80 >100 >=60 1 0.6-0.79 70-100 40-59 2 0.4-0.59 50-70 30-39 3 <=0.39 <50 <30 ISCHEMIA

13. WIfI SYSTEM(CONT’D) GRADE CLINICAL MANIFESTATIONS NO SYMPTOMS/SIGNS OF INFECTION LOCAL INFECTION PRESENT,AS DEFINED BY THE PRESENCE OF AT LEAST 2 OF THE FOLLOWING ITEMS LOCAL SWELLING/INDURATION ERYTHEMA>0.5 TO <=2 CM AROUND THE ULCER LOCAL TENDERNESS/PAIN LOCAL WARMTH PURULENT DISCHARGE(THICK,OPAQUE TO WHITE/SANGUINOUS SECRETION) 1 LOCAL INFECTION INVOLVING ONLY THE SKIN AND SC TISSUE EXCLUDE OTHER CAUSES OF INFLAMMATORY RESONSE OF THE SKIN(E.G-TRAUMA,GOUT,ACNAP,FRACTURE,THROMBOSIS,VENOUS STASIS) 2 LOCAL INFECTION(AS DESCRIBED ABOVE) WITH ERYTHEMA >2 CM/INVOLVING STRUCTURES DEEPER TO SKIN AND SC TISSUE NO SYSTEMIC INFLAMMATORY RESPONSE SIGNS(AS DESCRIBED BELOW) 3 LOCAL INFECTION WITH THE SIGNS OF SIRS,AS MANIFESTED BY 2/MORE OF THE FOLLOWING TEMPERATURE>38° C OR <36° C HEART RATE >90 BPM RR>20 CPM/PaCO2<32 mmHg WBC COUNT>12000 OR <4000 MM3 OR 10%IMMATURE(BAND )FORMS FOOT INFECTION

14. CLASSIFICATION &TYPICAL FEATURES OF DFU ACCORDING TO ETIOLOGY FEATURE NEUROPATHIC ISCHAEMIC NEUROISCHAEMIC SENSATION SENSORY LOSS PAINFUL DEGREE OF SENSORY LOSS CALLUS/NECROSIS CALLUS + AND OFTEN THICK NECROSIS COMMON MINIMAL CALLUS ;PRONE TO NECROSIS WOUND BED PINK AND GRANULATING;SURROUNDED BY CALLUS PALE AND SLOUGHY WITH POOR GRANULATION POOR GRANULATION FOOT TEMPERATURE AND PULSES WARM WITH BOUNDING PULSES COOL WITH ABSENT PULSES COOL WITH ABSENT PULSES OTHER DRY SKIN AND FISSURING DELAYED HEALING HIGH RISK OF INFECTION TYPICAL LOCATION WEIGHT BEARING AREAS OF THE FOOT SUCH AS METATARSAL HEADS,HEEL,OVER THE DORSUM OF CLAWED TOES TIPS OF TOES,NAIL EDGES AND BETWEEN THE TOES AND LATERAL BORDER OF THE FOOT MARGINS OF THE FOT AND TOES PREVALENCE 35% 15% 50%

15. FOOT DEFORMITIES

16. FACTORS CONTRIBUTING TO FOOT ULCERATION INTRINSIC FACTORS EXTRINSIC FACTORS BONY PROMINENCES WALKING BAREFOOT LIMITED JOINT MOBILITY INAPPROPRIATE FOOTWEAR DEFORMITIES FALLS AND ACCIDENTS CALLUS FORMATION MECHANICAL PRICKS LIKE NAIL PREVIOUS FOOT ULCER THERMAL INJURY CHARCOT NEUROARTHROPATHY ACTIVITY LEVEL

17. NEUROPATHY SENSORY MOTOR 1)LOSS OF PAIN SENSATION 1)WEAKNESS AND WASTING OF INTRINSIC FOOT MUSCLES 2)UNNOTICED TRAUMA(THERMAL, 2) FOOT DEFORMITIES CHEMICAL,MECHANICAL)FOOT 3) ABNORMAL GAIT DEFORMITIES 3)PROGRESSION OF LESION UNCHECKED 4)CALLUS FORMATION AUTONOMIC 5)TISSUE NECROSIS AND DAMAGE BENEATH CALLUS 1) DECREASED SWEATING 6)DEVELOPMENT OF CAVITIES FILLED 2) DRY AND BRITTLE SKIN WITH SEROUS FLUID 3) FISSURE AND CRACKS 7)ERUPT ONTO SURFACE 4) SECONDARY INFECTION ULCERATION

18. ANGIOPATHY MACRO angiopathy MICRO angiopathy ↓ ↓ Atherosclerosis of Large Arteries Thickening of Capillary Basement Membrane ↓ ↓ Increased peripheral Resistance Decreased Capillary Permeability ↓ ↓ ↓ ↓ → DECREASED PERFUSION OF FOOT STRUCTURES DECREASED IMMUNE CELLS INFILTRATION AND ANTIBIOTIC EFFECT POOR WOUND HEALING GANGRENE

19. IMMUNE DYSFUNCTION Impaired defenses against Infections Decreased LEUKOCYTE MIGRATION Decreased PHAGOCYTOSIS Decreased INTRACELLULAR KILLING Decreased CHEMOTAXIS

20. APPROACH TO DIABETIC FOOT DIAGNOSIS AND EVALUATION IDENTIFICATION OF RISK FACTORS HISTORY FOOT ULCER PHYSICAL EXAMINATION AMPUTATION INVESTIGATIONS CHARCOT’S ARTHROPATHY THREATENING INFECTIONS

21. HISTORY GENERAL & MEDICAL HISTORY FOOT HISTORY ULCER HISTORY PRESENTING FOOT COMPLAINT & DURATION DURATION OF DM,MANAGEMENT & CONTROL CVS,RS,OPHTHALMIC EVALUATION OTHER CO-MORBIDITIES PERSONAL HISTORY CURRENT MEDS AND ANTIBIOTIC USE ALLERGIES PAST MEDICAL AND SURGICAL HISTORY CULTURAL HABITS-WALK BAREFOOT/WETS FEET AT WORK/WEAR SOCKS PATIENTS PERCEPTION OF DM,NECESSITY OF WEIGHT & DIET CONTROL DAILY ACTIVITY & CURRENT FOOT STATUS FOOTWEAR-SLIPPER,SHOES,SANDALS/FITNESS FOOT CARE/NAIL CARE CALLUS FORMATION DEFORMITIES AND PREVIOUS FOOT SURGERY NEUROPATHY AND ISCHEMIC SYMPTOMS SKIN AND NAIL PROBLEMS-SWEATY FEET/FUNGAL INFECTIONS/BLISTERS/INGROWN TOE NAIL SITE,SIZE,DURATION,ODOUR,TYPE OF DRAINAGE PRECIPITATING EVENT /TRAUMA RECURRENCES ASSOCIATED INFECTIONS FREQUENCY OF HOSPITALIZATIONS AND TREATMENT GIVEN WOUND CARE/MEASURES TO REDUCE PLANTAR PRESSURE PATIENT COMPLIANCE PREVIOUS FOOT TRAUMA/SURGERY FEATURES OF CHARCOT’S JOINT

22. PHYSICAL EXAMINATION GENERAL EXAMINATION LOCAL EXAMINATION SIGNS OF INFLAMMATION MUSCULOSKELETAL STATUS OF FOOT AND LEG SKIN AND NAILS OF FOOT NEUROVASCULAR STATUS PATIENT’S FOOTWEAR

23. LOCAL EXAMINATION MUSCULOSKELETAL STATUS SKIN AND NAILS NEUROVASCULAR STATUS PATIENT’S FOOTWEAR ATTITUDE & POSTURE OF L/L AND FOOT FOOT DEFORMITIES LIMITED JOINT MOBILITY TENDO ACHILLES CONTRACTURES/EQUINES/FOOT DROP GAIT EVALUATIONMUSCLE GROUP STRENGTH TESTINGPLANTAR PRESSURE ASSESSMENT SKIN APPEAREANCE-COLOR,TETURE,TURGOR,QUALITY,DRY SKIN CALLUS,FISSURE,CRACKS NAIL APPEARANCEDYSTROPHIC,ATROPHY,ONYCHOMYCOSIS,HYPERTROPHY,PARONYCHIA PRESENCE OF HAIR ULCERATION,GANGRENE,INFECTION INTERDIGITAL LESIONS TINEA PEDIS NEUROLOGICAL STATUS VIBRATION PERCEPTION-128 Hz TUNING FORK PRESSURE & TOUCH-COTTON WOOL PAIN-PIN PRICK TWO POINT DISCRIMINATION TEMP PERCEPTION-HOT AND COLD DEEP TENDON REFLEES-ANKLE ,KNEE CLONUS TESTING BABINSKI TEST VASCULAR STATUS PULSES EDEMA+/- TEMP GRADIENT COLOR CHANGES CHANGES OF ISCHEMIA TYPE AND CONDITION OF SHOES/SANDALS FITNESS(LOOSE/TIGHT) SHOE WEAR,PATTERN OF WEAR FOREIGN BODIES

24. INVESTIGATIONS BIOCHEMICAL VASCULAR AND PLANTAR FOOT PRESSURE FOOT IMAGING NEUROLOGICAL CBC HbA1c FBS,PPBS ESR BLOOD UREA SERUM ELECTROLYTES WOUND AND BLOOD CULTURE URINE R&M URINE C&S DOPPLER SEGMENTAL ARTERIAL PRESSURE ABI TOE PRESSURE (> TRANS CUTANEOUS OXYGEN TENSION CT ANGIOGRAPHY(AFTER RFT IS NORMAL) INFRARED DERMAL THERMOGRAPHY PLAIN RADIOGRAPH CT SCAN RADIOISOTOPE TC BONE SCAN MRI SEMMES WEINSTEIN NYLON MNOFILAMENT (10 GM) TEST

25. NYLON MONOFILAMENT TEST SINGLE MOST PRACTICAL MEASURE OF RISK ASSESSMENT COST EFFECTIVE

26. INFRARED DERMAL THERMOGRAPHY RED-GOOD PERFUSION BLUE-POOR PERFUSION

27. MANAGEMENT INCLUDES 5 ASPECTS METABOLIC CONTROL Effective Blood sugar control,Neuropathy Treatment MECHANICAL CONTROL Reduce risk of Trauma,Treat Deformities,Pressure Offloading VASCULAR MANAGEMENT INFECTION PROPHYLAXIS AND TREATMENT PATIENT EDUCATION

28. TREATMENT NEUROPATHIC FOOT ISCHEMIC FOOT NEURO-ISCHEMIC FOOT Removal of Callus Eradication Of Infection(M/C-staphylococci) Reduction Of Weight Bearing forces,often requiring bed rest with foot elevated(For e.g TCC(Total Contact Cast) Infection Control Angioplasty/Bypass –For Limb Salvage Amputation Rest Pain Can Be Relieved By PARAVERTEBRAL LUMBAR BLOCK PARENTERAL NARCOTICS BELOW KNEE AMPUTATION(LAST RESORT)

29. TIME FRAMEWORK FOR MANAGING DFU T-TISSUE DEBRIDEMENT I-INFLAMMATION AND INFECTION CONTROL M-MOISTURE BALANCE(OTIMAL DRESSING SELECTION) E-EPITHELIAL EDGE ADVANCEMENT AND PRESSURE OFFLAODING

30. EPITHELIAL EDGE ADVANCEMENT Debride edges of Ulcer to remove potential physical barriers to growth of Epithelium across ulcer bed Adjunctive therapies like NPWT(Negative Pressure Wound Therapy),Biological Dressings, Bioengineered Skin Equivalents, Hyperbaric Oxygen Therapy , Platelet rich plasma and Growth factors can be considered

31. PRESSURE OFFLOADING In Patients with Peripheral Neuropathy,it is important to offload at risk areas of the foot in order to redistribute pressures evenly. The Gold standard is the TOTAL CONTACT CAST(TCC) which redistributes pressures evenly over the entire plantar surface of foot TCC are C/I in patients with ischemia because of risk of inducing further DFU. They are not appropriate for patients with Infected DGU/Osteomyelitis because you cannot inspect the wound daily In these patients,one can use Removable cast , Walkers,Scotch Cast, Boots,Healing Sandals,Crutches

32. DIFFERENT TYPES OF CASTS TOTAL CONTACT CAST SCOTCH CAST

33. PREVENTION GUIDELINES Foot must be examined thoroughly at the onset of DM and annually thereafter Identification of Critically Ischemic foot is necessary Patient Awareness about the need of Appropriate Footwear LOW RISK FOOT(with Normal sensation and palpable Pulses) Individual Foot care Education AT RISK FOOT(Neuropathy/absent pulses/others) Enhance Foot Care Education Feet Examination every 6 monthly HIGH RISK FOOT(with Ischemia/Deformity/skin changes/Previous Ulcer) 3 months follow up Intensified foot care Education Rehabilitation for deformities/Disability

34. REFERENCES IWGDF GUIDELINES 2023 WHO GUIDELINES ON DIABETES 2022 MAMC SURGERY UPDATE 2023 BAILEY AND LOVE’S SHORT PRACTICE OF SURGERY 28 TH EDITION

35. THANKYOU DIABETICS SHOULD TREAT THEIR FEET LIKE THEIR FACE