The diabetic foot; state of the art

By
Dr.Mahmoud Zaghloul raslan, md
Consultant surgeon,Meeqat Hospital
Medinah Munawarah-KSA

1. The Diabetic foot:
state of the art
BY
MAHMOUD ZAGHLOULRASLAN, MD
CONSULTANT SURGEON, MGH
MADINA

2. Defining the magnitude of
the problem

3. -The incidence of diabetes mellitus DM is
increasing globally.
-Patients with DM have a 12-25% lifetime risk of
developing a foot ulcer.
-Foot ulcers have become a major and increasing
public health problem.
-The related morbidities, impairment of life quality
of patients together with the implied costs for their
management have attracted the attention of health
care providers.

4. -Fortunately, most of foot problems in patients
with DM can be prevented with careful foot
care.
-If complications do occur, daily attention will
ensure that they are detected before they
become serious.
-It may take time and effort to build good
foot care habits, but self-care is essential.
-In fact, when it comes to foot care, the
patient is a vital member of the medical team.

5. -According to the Centers for Disease Control and
Prevention, 7.8% of the United States population had DM in
2007, which equals almost 24 million persons.
-In 2007, DM and its complications cost the US $174
billion; $116 billion in direct costs and $58.3 billion in
indirect costs such as disability and loss of productivity.
-Peripheral vascular and neurologic complications that
are closely linked to foot ulceration, account for 31% and
24% of the expenses respectively.

6. -Every year, 82,000 limb amputations are
performed in patients with DM in US.
-The majority of these amputations are
performed in the elderly.
-Amputations resulting from DM may be
due to multiple etiologies including foot
ulcers, ischemia and heel ulcers.

7. -Although amputation may become necessary in
certain cases of ischemia or infection, ablative
surgery is rarely necessary for treatment of
neuropathic ulceration and is to be avoided.
-Decreased limb length correlates with increased
energy expenditure for ambulation.
-Amputation in a diabetic patient is associated with
a 50-66% incidence of contralateral amputation
within 5 years.

8. Possible diabetic foot complications:
•Skin changes (Dermopathy)
•Poor circulation (Angiopathy)
•Nerve damage (P.neuropathy)
•Deformities (Chacot’sarthropathy)
•Infection
•Gangrene

9. PREVENTING FOOT PROBLEMS IN DIABETICS
-Controlling blood sugar levels
-Quit smoking
-Avoid activities that can injure the feet
-Use care when trimming the nails
-Wash and check the feet daily
-Choose socks and shoes carefully
-Ask for foot exams

10. Pathogenesis

12. Clinical picture

13. History

14. Examination

20. Investigations

24. Classification

25. Management

26. GRADE 0 LESIONS
—Counseling regarding preventive foot
care should be given to any patient
whose feet are at risk for ulcer
development, particularly patients with
existing neuropathy.

27. GRADE 1 AND 2 LESIONS
—Extensive debridement, good local wound care,
relief of pressure on the ulcer, and control of
infection (when present) are believed to be
important components of therapy for grade 1 and 2
foot ulcers.

28. -Method of debridement
May be mechanical, chemical and/or biological.
-Local wound care:
After debridement, ulcers should be kept clean and
moist but free of excess fluids. Moisture accelerates tissue
healing.
Dressings should be selected based upon wound
characteristics, such as the extent of exudate, desiccation,
or necrotic tissue.

29. Modern dressing

30. Off-loading

31. -Mechanical off-loading
-Total contact cast
Effective for relief of pressure to allow diabetic ulcer
healing.

32. -Cast walkers
Cast walkers appear to have a similar
ability to off-load the foot compared
with total contact casting.

33. -Therapeutic shoes
After healing of the ulcer is achieved, extra-depth and -width shoes with
orthotic inserts are often prescribed to prevent recurrent ulceration.

34. -Wedge shoes
Also called half shoes, are available as a
forefoot wedge and heel wedge shoes to
off-load the forefoot and heel,
respectively

35. -Knee walkers
Knee walkers are ambulatory assist
devices that may be indicated for anyone
with a lower extremity issue where weight
bearing needs to be avoided .

36. GRADE 3 LESIONS

37. Assessment for peripheral artery disease
-Clinically, by asking about H/O symptoms
suggesting LL ischemia and looking for its physical
signs and by ABI measurement.
-Doppler US as a non-invasive test to assess LL
vascularity.
-MRI angiography or arteriography if indicated in
Doppler +ve

38. Assessment for osteomyelitis
-Clinically, osteomyelitis is likely to be present if bone can be seen at
the floor of a deep ulcer, or if it can be easily detected by probing the
ulcer with a sterile, blunt stainless steel probe.
-Radiologic tests
Radiologic tests may be useful if the diagnosis of osteomyelitis remains
uncertainincluding bone scan.
-Bone biopsy C/S
If clinical and radiographic assessments fail to provide a diagnosis, then
bone biopsy can be considered.

39. -Treatment
Debridement and local wound care
As described before
Antimicrobial therapy
Parenteral antibiotic therapy based upon the culture results has
traditionally been given for four to six weeks in patients with
osteomyelitis. The optimal regimen and when to transition to
oral therapy are dependent upon the clinical features of each
case.

40. Mechanical off-loading
—Mechanical off-loading relieves pressure on
the ulcer and enhances healing.
Revascularization
—Revascularization plays an important role in the
management of diabetic foot ulcers in patients
with documented peripheral artery disease (to
avoid the need for amputation)

41. GRADE 4 AND 5 LESIONS

42. —Patients with these more advanced lesions require
urgent hospital admission and surgical management. The
following advanced therapies may be used in addition to the
previous management lines. However, amputation may
sometimes be required.
ADVANCED THERAPIES:—
Negative pressure wound therapy
Negative pressure wound therapy (NPWT), also called
vacuum-assisted closure (VAC), involves the application of
controlled subatmosphericpressure to the surface of the
wound. NPWT enhances wound healing by increasing
wound perfusion, reducing edema, reducing the local
bacterial burden and increasing the formation of granulation
tissue.

43. Vacuum assisted closure (VAC)

46. Hyperbaric oxygen therapy (HBOT)
—Hyperbaric oxygen therapy, as a component of diabetic ulcer
management, may be associated with improved healing but the
indications for hyperbaric oxygen in the treatment of nonhealing
diabetic foot ulcers remain uncertain.

49. Ultrasonic wound therapy

53. Other agents
—Use of honey, larva (muggets) and herbs have been reported with
promising results.
Skin substitutes
—Human skin equivalents have been studied in diabetic patients with
noninfected, nonischemicchronic plantar ulcers .
Growth factors
—A platelet-derived growth factor gel preparation (becaplermin) is
approved by the US Food and Drug Administration as an adjuvant
therapy for diabetic foot ulcers . It promotes cellular proliferation and
angiogenesis and thereby improves wound healing.

54. Multimodal treatment

55. Charcot’s foot

63. Amputation

64. Health education

68. Summary and recommendations
-Diabetic foot complications are common and serious.
-They represent a major impact on patients’ health. In addition,
they can affect adversely both patients and the society
economically and socially.
-Fortunately, most of these complications can be prevented by
controlling the blood sugar level and daily foot care.
-Health education programs for the patients, relatives and the
whole society are mandatory to improve the prognosis. In these
programs all authorities should share including heath care centers,
cultural centers, mosques and media.

69. Summary and recommendations (cont.)
-Screening of high risk groups is essential to detect the
complications early.
-Management of diabetic foot complications needs a specialized
center with general, vascular, plastic, orthopedic surgery facilities
together with podiatrist, dietirianand internists and
endocrinologists to achieve a favorable outcome.
-The earlier the diagnosis and management the better the
prognosis
-Encourage the medical research activities that may lead to
development of new diagnostic and management tools for better
prognosis