diabetic foot - duke university · gangrene with and without vascular insufficiency • 1920’s...
TRANSCRIPT
Surgery Multidisciplinary Vascular Conference
Friday July 31, 2009
Diabetic FootMani A Daneshmand, MD
Senior Assistant Resident-2
Department of General and Thoracic Surgery
Duke University Medical Center
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Outline
• Case Presentation
• History and Etiology of Diabetic Foot Ulcers
• Clinical Workup/Management
• Surgical Considerations
• Outcomes
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History of Present Illness
• 47 year old female• Presented complaining of acute loss of sensation in
right leg• 2 days prior to admission noticed an ulcer on the
plantar aspect of left foot• PMH
– Chronic Back Pain, Migraines, CAD, HTN, HL, IDDM, DM Neuropathy, Urinary Incontinence
• PSH– CABG 2003, IOL 2000
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Physical Examination
• T 37.2 BP 165/73 P 112 RR 18• Heart RR 3/6 Holosystolic EM at RUSB• Extremities:
– Right: No C/C/E, Palpable DP, Palpable FA, no ulcers
– Left: No C/C/E, Palpable DP, Palpable FA, GSV harvest scar, ulcer on plantar surface laterally, with purulent drainage, cyanosis of 4th and 5th
digits, erythema to ankle
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History of the Diabetic Foot
• Marchal de Calvi in 1852 first associated gangrene with diabetes
• 1864 Marchal de Calvi associated diabetes with peripheral nerve damage
• Treves in 1884 described surgical debridement for treatment of foot ulcers, off-loading of pressure for treatment and prevention, and education about footcare and foot wear
• Laffon 1885 associated plantar neuropathic ulceration with diabetes
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History of the Diabetic Foot
• Godlee 1893-the first distinction regarding prognostic and therapeutic differences in the treatment of gangrene with and without vascular insufficiency
• 1920’s diabetic foot disease replaced hyperglycemic coma as the major cause of diabetic mortality
• McKeown and Lawrence 1941-Ray amputation• McKittrick 1944-Transmetatarsal amputation
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Etiology of Diabetic Foot Disease
• Neuropathy– Progressive and irreversible– Ischemia to vasa nervorum– Autonomic neuropathy
• Stiff, dry, scaly skin• Vasculopathy
– Macrovascular Disease (Arteriosclerosis)• 45% of patients with diabetes for 20 years• Commonly below knee and diffuse• Circumferential calcification
– Microvascular Disease• Capillary diffusion abnormality
• Infection
ACS Surgery Chapter 7
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Interaction of Micro and Macrovessel Dissease
JACC 53(5):S35 2009
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Arterial Gene Expression in Diabetes
Vascular 16(4):225 2008
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Arterial Gene Expression in Diabetes
Vascular 16(4):225 2008
All Rights Reserved, Duke Medicine 2007
Patterns of Infection
• Mild, superficial Ulcerations– Aerobic Gram Possitive Cocci (Staph/Strep)
• Deep Ulcers and Threatened Limbs– Polymicrobial
• Aerobic Gram Positive Cocci• Aerobic Gram Negative Bacilli
– E. Coli, Klebsiella, Enterobacter, Proteus, Psuedomonas
• Anareobes– Bacteriodes fragilis, peptostreptococcus
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Antibotic Coverage
• Initially Dual Regiment– Cephalosporin or Beta-Lactam– Bactrim or tetracycline
• Alternatively– Fluoroquinolone– Linezolid
• Culture Specific Coverage
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Charcot Foot
• Described in 1868 by Charcot• Pathological fractures and/or dislocations of the mid-
foot resulting in deformity and functional change• Incidence as high as 37% among patients with
diabetic neuropathy• Neurotraumatic Theory
• Repetitive microtrauma• Neurovascular Theory
• Sympathetic neuropathy results in hyperemia resulting in increased osteoclast activity and bone resorption
Diabetes Metab Res Rev 20(Suppl1):S4 2004 J Bone Joint Surg [Br] 91-b(1):7 2009
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Charcot Foot
• Gradual healing over several months
• Total contact cast to maintain a plantigrade foot
• When there is radiographic evidence of bone healing, the patient is fitted with an accomidative shoe with a molded insole
Diabetes Metab Res Rev 20(Suppl1):S4 2004 J Bone Joint Surg [Br] 91-b(1):7 2009
All Rights Reserved, Duke Medicine 2007
Brodsky’s Depth-Ischemia Classification
J Bone Joint Surg [Br] 91-b(1):7 2009
All Rights Reserved, Duke Medicine 2007
Brodsky’s Depth-Ischemia Classification
J Bone Joint Surg [Br] 91-b(1):7 2009
All Rights Reserved, Duke Medicine 2007
Tibial Angioplasty-Limb Salvage
Ann Vasc Surg 2009 ePUB DOI: 10.1016/j.avsg.2009.05.007