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THE DIABETIC FOOTTHE DIABETIC FOOT

Channa RatnatungaChanna RatnatungaDepartment of SurgeryDepartment of Surgery

University of PeradeniyaUniversity of Peradeniya

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5-15% of Diabetics develop foot 5-15% of Diabetics develop foot ulcersulcers

70% of healed Diabetic ulcer are 70% of healed Diabetic ulcer are likely to recur within 5 yearslikely to recur within 5 years

85% of non traumatic lower limb 85% of non traumatic lower limb amputations follow diabetic foot amputations follow diabetic foot ulcersulcers

DIABETIC FOOTDIABETIC FOOT

PREVALANCE AND PROGNOSISPREVALANCE AND PROGNOSIS

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Why do Diabetics sustain trauma Why do Diabetics sustain trauma to feet?to feet?

Extrinsic -Extrinsic - Poor visionPoor vision

Falls due to joint immobilityFalls due to joint immobility

CVAsCVAs

Oedema due to Cardiac Oedema due to Cardiac causescauses

Intrinsic -Intrinsic -

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Intrinsic Causes of Diabetic Intrinsic Causes of Diabetic Foot UlcerationFoot Ulceration

NeuropathyNeuropathyArterial DiseaseArterial DiseaseAbnormal tissue response Abnormal tissue response

to trauma and sepsisto trauma and sepsis

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NeuropathyNeuropathy Sensory Sensory – loss of pressure, – loss of pressure,

pain, temperature and joint pain, temperature and joint sense. i.e. removes warning sense. i.e. removes warning signalssignals

MotorMotor – weakness and – weakness and atrophy of intrinsic muscles atrophy of intrinsic muscles of foot, hence altered foot of foot, hence altered foot structure and leading to structure and leading to deformity and altered deformity and altered biomechanicsbiomechanics

AutonomicAutonomic – AV shunting – AV shunting affects maintenance of skin affects maintenance of skin integrity and vascular tone. integrity and vascular tone. i.e. warm, dry, fissured footi.e. warm, dry, fissured foot

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Pes Cavus

Ulceration at the tip

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Charcot footCharcot footLong duration Diabetic neuropathy

Hyperaemic response

Osteopenia

Local fractures

Inflammatory response

Proprioception – Deformity

0.2% of Diabetics

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Arterial DiseaseArterial Disease MacrovascularMacrovascular – –

Atherosclerosis Atherosclerosis (Tibial) 4 to 20 times (Tibial) 4 to 20 times greater risk than in greater risk than in non-diabeticsnon-diabetics

MicrovascularMicrovascular - - MicroangiopathyMicroangiopathy

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Arterial DiseaseArterial DiseaseMacrovascular DiseaseMacrovascular Disease

Atherosclerosis -Atherosclerosis - Male/ Female ratio equalMale/ Female ratio equal Advanced diseaseAdvanced disease Spontaneous ulcerationSpontaneous ulceration

(Critical ischaemia common(Critical ischaemia common PregangrenePregangrenedue to multi-segment disease)due to multi-segment disease)

Neuropathy – no rest painNeuropathy – no rest pain GangreneGangrene

Systemic diseaseSystemic disease Coronaries, CerebralsCoronaries, Cerebrals CalcificationCalcification Unreliable AB indexUnreliable AB index Collateral diseaseCollateral disease Poor reservePoor reserve AngiographyAngiography often foot vessels often foot vessels

preservedpreserved

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Arterial DiseaseArterial DiseaseMicrovascular DiseaseMicrovascular Disease

Early onset of micro-vascular Early onset of micro-vascular dysfunctiondysfunction

Affects arterioles an capillaries of Affects arterioles an capillaries of several organsseveral organs

Basement membrane thickening Basement membrane thickening may impair oxygen diffusionmay impair oxygen diffusion

Reduced tissue response to sepsisReduced tissue response to sepsis

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Diabetic Microangiopathy

Foot ulceration is not due to microangiopathy

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NeuroischaemiaNeuroischaemia

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In a Diabetic foot In a Diabetic foot Wound healing is affected by..Wound healing is affected by..

1. 1. Growth factors deficiencyGrowth factors deficiency Impaired fibroblast responseImpaired fibroblast response Abnormalities of Extracellular matrixAbnormalities of Extracellular matrix

2. 2. Alterations in..Alterations in.. Neuroinflammatory responseNeuroinflammatory response Hyperaemic responseHyperaemic response Thermoregulatory responseThermoregulatory response

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Diabetic footDiabetic footInfections IInfections I

Cell mediated immunity depressedCell mediated immunity depressed Phagocytic function of multinuclear Phagocytic function of multinuclear

leukocytes affectedleukocytes affected Leucocyte migration at microcirculatory Leucocyte migration at microcirculatory

level is affectedlevel is affected Hyperglycaemia associated with Hyperglycaemia associated with

mycotic infections could contributemycotic infections could contribute

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Painless collection of pusPainless collection of pus Tracking of pus along tendon sheathsTracking of pus along tendon sheaths Staphylococcus aureusStaphylococcus aureus is common is common Foot compartmentsFoot compartments

Diabetic footDiabetic footInfections IIInfections II

Deep interosseous space

Medial plantar space

Central plantar space

Lateral plantar space

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CLINICAL ASSESSMENT OFCLINICAL ASSESSMENT OF A DIABETIC FOOT I A DIABETIC FOOT I

Glycaemic controlGlycaemic control SmokingSmoking Renal diseaseRenal disease Poor social circumstancePoor social circumstance

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CLINICAL ASSESSMENT OF A CLINICAL ASSESSMENT OF A DIABETIC FOOT IIDIABETIC FOOT II

Extent of NeuropathyExtent of Neuropathy Vibration sense – using tuning forkVibration sense – using tuning fork Discriminating touch – 10g monofilament Discriminating touch – 10g monofilament

Nylon Nylon Ankle jerksAnkle jerks

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CLINICAL ASSESSMENT OF A CLINICAL ASSESSMENT OF A DIABETIC FOOT IIIDIABETIC FOOT III

Extent of IschaemiaExtent of Ischaemia Pulse examination – Aortoiliac and Pulse examination – Aortoiliac and

FemPop bruitsFemPop bruits Skin color, TemperatureSkin color, Temperature ABPIABPI X ray medial calcinosisX ray medial calcinosis

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CLINICAL ASSESSMENT OF A CLINICAL ASSESSMENT OF A DIABETIC FOOT IV DIABETIC FOOT IV

Extent of Neuroischaemia and sepsisExtent of Neuroischaemia and sepsis

WargnerWargner 1-5 a Global Severity Score 1-5 a Global Severity Score

1:1: Superficial ulceration limited to dermis Superficial ulceration limited to dermis 2:2: Ulceration down to fascia or bone without Ulceration down to fascia or bone without

abscess or abscess or osteomyelitisosteomyelitis 3:3: Deep ulcers with abscess or osteomyelitis Deep ulcers with abscess or osteomyelitis 4:4: Localised gangrene confined to the toes or Localised gangrene confined to the toes or

forefootforefoot 5:5: Gangrene requiring immediate major (above Gangrene requiring immediate major (above

ankle) amputationankle) amputation

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Extent of InfectionExtent of Infection

Is Due to..Is Due to.. Walking on pusWalking on pus Tracking of pus along tendonsTracking of pus along tendons Foot compartmentsFoot compartments Septicaemia Septicaemia

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MANAGEMENT MANAGEMENT OF DIABETIC FEETOF DIABETIC FEET

Prevention Prevention Patient and Physician EducationPatient and Physician Education

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DIABETIC FOOTDIABETIC FOOTTen CommandmentsTen Commandments

For patientFor patient Don’t walk barefootDon’t walk barefoot Inspect the feet dailyInspect the feet daily No hot fomentationNo hot fomentation Correct footwearCorrect footwear Don’t weight bear (unsupported) on the affected footDon’t weight bear (unsupported) on the affected foot Do not sit cross-leggedDo not sit cross-legged Don’t remove footwear during travelingDon’t remove footwear during traveling Cut nails regularly (trim square)Cut nails regularly (trim square) No home surgeryNo home surgery Clean the feet twice a dayClean the feet twice a day

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DIABETIC FOOTDIABETIC FOOTSix principles of prevention of Six principles of prevention of

foot ulcersfoot ulcers For PhysicianFor Physician

PPodiatric careodiatric care PPulse examinationulse examination PProtective shoesrotective shoes PPressure reductionressure reduction PProphylactic surgeryrophylactic surgery PPreventive educationreventive education

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Protective footwearProtective footwear

Accommodation and cushioningAccommodation and cushioning Wide toe boxWide toe box Extra depthExtra depth Total contact insolesTotal contact insoles Rocker soleRocker sole WedgingWedging

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ShoesShoes Heel to toe length, Arch length, WidthHeel to toe length, Arch length, Width Measure both feetMeasure both feet Fit while weight bearingFit while weight bearing Check for the positioning of the first MP Check for the positioning of the first MP

jointjoint Allow half a inch between end of the Allow half a inch between end of the

longest toe and the end of shoelongest toe and the end of shoe Sniff fit around the heelSniff fit around the heel

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Therapeutic footwearTherapeutic footwear

Bed rest, crutches, wheel chair, knee Bed rest, crutches, wheel chair, knee caliperscalipers

Total contact cast, Scotchcast bootsTotal contact cast, Scotchcast boots Half shoes, Half sandalsHalf shoes, Half sandals OrthosesOrthoses

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ManagementManagement

Wound careWound care Deep swabbing, Deep swabbing, Pus culture & ABSTPus culture & ABST Hb, TransfusionsHb, Transfusions Hyperbaric OHyperbaric O22

X raysX rays MRIMRI Leukocyte tagged scansLeukocyte tagged scans

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ManagementManagement Other measuresOther measures

Weight reductionWeight reduction Aggressive debridement and drainage of Aggressive debridement and drainage of

tissue spacetissue space IV antibioticsIV antibiotics

PenicillinPenicillinCo-amoxyclavCo-amoxyclavMetronidazoleMetronidazoleClindamycinClindamycin

Cultured skin dermisCultured skin dermis Leukocyte colony stimulating factorsLeukocyte colony stimulating factors

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Management Management

Other proceduresOther procedures Rest injured areaRest injured area Prophylactic surgery to correct Biomechanical Prophylactic surgery to correct Biomechanical

damagedamage RevascularizationRevascularization

AngioplastyAngioplasty Distal venous bypassDistal venous bypass

Prevention of recurrent ulcerationPrevention of recurrent ulceration AmputationAmputation

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Thank youThank you