management Diabetic foot

Senior resident breakfast tutorial at National Orthopaedic Hospital Kano,Nigeria.

1. DISCUSS THE MANAGEMENT OF DIABETIC FOOT By Dr Kabiru Salisu NOHD KANO 8 th oct . 2015

2. Outline Introduction - Epidemiology - Pathogenesis - Pathology -Classification Management - History - Examination - Investigation - Treatment Conclusion References

3. Introduction Diabetic foot, Is a spectrum of pathological entities that affect the foot of a diabetic patient as a result of its complications Diabetic foots are common throughout the world Resulting in high morbidity, mortality and major economic burden

4. Management of diabetic foot is multi-disciplinary Diabetic foot ranges from foot at risk to frank gangrene

5. Epidemiology Diabetic foot , affect 15% of all diabetic globaally , 15–20% may require amputation NHS 2005 showed prevalence of Diabetic foot (DF) of 25 % among patients with DM in Nigeria DFU account for up to 24% mortality in patients with DM

6. Ogbera & Fasanmade et al, reported 41.5% of DM patients have foot at risk Type II diabetes account for 98.1% Mean duration before development of DF is 10.8yrs Neuropathy was the commonest risk factor 76%

7. Pathogenesis Diabetic foot result from either; Peripheral Neuropathy 80 – 90% Peripheral vascular disease 30-40% Neuroischaemic disease Peripheral Neuropathy Sensory Motor Autonomic

8. 2- Peripheral vascular disease - Micro or Macro angiopathy

9. 3- Neuroischaemic foot; is the commonest

10. Pathology The natural history of diabetic foot was studied it was explained by the following stages STAGE 1- Normal foot

11. Stage 2 : High risk foot - Duration of diabetes >10yrs - Poor glycemic control - Neuropathy - PVD - Foot deformity, dryness and callousity - Decreased immunity - Previous healed ulceration - Previous amputation - Retinopathy

12. Stage 3 : Ulcerated foot Stage 4 : Infected foot Cellulitis Abscess Osteomylitis

13. Stage 5 : Necrotic foot Stage 6 : Unsalvageable

14. CLASSIFICATION Wagner’s Stage 0 = Foot at risk Stage 1 = Superficial ulcer/blister Stage 2 = Deep ulcers Stage 3 =Deep ulcer with abscess, osteomyelitis , Stage 4 = Fore-foot gangrene Stage 5 = Hind-foot gangrene

15. University of Texas

16. Brodsky Classification Based on depth, ischemia and gangre UMEBESE AND OGBEMUDIA- DFSS which predict salvagability

17. History Presentation could be Emergency or Elective - Emergency- Sepsis/ Septicaemia or Shock - DKA or HHS - Elective – Detailed history and examination - Onset and progression - Risk factor (Numbness, Parasthesia , foot deformity, visual difficulties, pain, claudication , rest pain)

18. Purulent discharge, bony spicules Dark discoularation Detailed of diabetic onset, care and control Determine other complications of DM Other relevant medical history

19. Examination Absence of hair, callosity Temperature; Cold or Warmth Discolouration; Pale, Dark Deformities; Ulcer characteristics; Site, size, shape, etc Discharge; Colour, Odour

20. Neurological Examination Pain - Light Touch Vibration test Temperature Semmes- weinstein monofilament test Vascular Assessment - peripheral pulses - Ankle Brachial index

21. Investigations 1- Blood Sugar / long term control - RBS , FBS, Glycated HB 2- Wound Swab, Tissue biopsy for M/C/S 3- Doppler / Duplex USS 4- X- rays

22. 5- Angiography 6- other - U,E & Cr CXR - ECG

23. Prevention of DF Good diabetic care Life style modification stop smoking weight loss Avoidance of high fat Protective foot wears

24. Foot care Inspect his feet every day& after prolonged walking Avoid walking barefoot any time Avoid wearing shoes without socks Buy shoes of the correct size Avoid wearing new shoes for > 1h per day Change shoe 2-3 times a day Wash and dry feet every day Moisturing oil or cream for dry skin Cut nails straight

25. www.smso.net

26. Object found in shoes of patient with neuropathy

27. TREATMENT Multidisciplinary Medical Good Glycaemic control Control co-morbidities Control infection

28. Wagner grade 0 Foot at risk 1- Determine risk factors and treat 2- Observe preventive measures above 3- Prophylactic bypass surgery 4- Osteotomies to correct deformity

29. Wagners Grade 1 & 2 Superficial and deep ulcer 1- Debridement - Surgical, Autolytic , larval 2- Dressing Honey, iodine, film, foam, hydrocolloids, hydrogel , alginates 3- prophylactic Antibiotic 4- skin grafting or flap cover

30. 4- Pressure offloading Total contact cast Removable total contact splint

31. Scotch cast boot is a lightweight, well-padded fiberglass cast, extending from just below the toes to the ankle, and it is worn with a cast sandal

32. 5- Therapeutic foot wear

33. Others Crutches Walkers Wheelchairs

34. Wagners Grade 3 Deep infection, abscess or OM I & D Serial surgical debridement Wound irrigation with antibiotics Sequestrectomy Other measures as above

35. Wagner grade 4 ; fore foot gangrene Conservative amputations Revascularisation procedures Two staged Amputation is recommended

36. Wagner Grade 5 Gangrene involved major portion of the foot or hind foot No conservative amputation is possible Major amputation should be offered Knee should be preserved as much as possible

37. Other indications of amputation in DF - Ischaemic rest pain that cannot be managed by analgesia or revascularisation A life-threatening foot infection eg gas gangrene Severe foot destruction by COM A non-healing ulcer that is accompanied by a higher burden of disease - Malignant transformation of ulcer

38. Post Amputation care Most patients develop DFU on the contra- lateral limb within 18 mths of amputation mortality up to 20- 50% within 3yr Multi-specialist foot care team is required Foot care education should be given to the patient Follow up every 1-3month Foot inspection / PVD assessment at every visit All preventive measures should be taken

39. CONCLUSION Diabetic foot is a global pandemic with high morbidity, mortality and socioeconomic burden. Poor patient education, poor preventive care and lack of multi- specialist DF care units are the major concern in our community thus, the need to improve our knowledge, specialisation and care of DF.

40. References Ogbera AO, Adedokun A, Fasamade OA. The foot at risk in nigerian with diabetes mallitus - The Nigerian snerio . Int J endocranol metab 2005;4:165-173 Boulton AJM, Connor H, Cavanagh PR ( Eds ), The Foot in Diabetes (3rd edn ). Chichester: Wiley , 2000; 131–142 Akinkugbe OO, Akinyanju OO. Final report – National Survey on non-communicable diseases in Nigeria. Federal Ministry of Health. Lagos, 1997; 65-8 Mccollister EC.surgery of the musclocutenous system volume4. churchill-livingstone.chapter 153; p4189 – 4212 Chadwik P, Edmonds M, Mccardle J et al. Best practice Guidelines: wound management in diabetic foot ulcers. Wounds international 2013; p1-23

41. Rodriques J & Mitta N. Diabetic foot andgangrene . Department of surgery Goa medical collage India. www.intechopen.com ; p1-144 Ogbera A, Fansanmade O,Ohwovoriolae A. The diabetic in Nigeria: High costs, Low awareness and lack of care. Diabetic Voice 2006; 51(3)30 - 32 Faisal MA. Diabetic foot ppt. www.smso.net Dalasu OO, Salawu FK, Jimoh AO et al. Diabetic foot care: Self reported knowladge and practice among patients attending tertiary hospital in Nigeria. Ghana Med J 2011;45(2)60-62 Katilombos N, Dounis E, Tsopogas P and Tentolouris N. Atlas of diabetic foot. John wiley & sons 2013;p1- 231

42. Thank you for listening