10/20/2018

Diabetic Foot Causes, Symptoms, Diagnosis,Treatment and Surgical management

By Dr.Narumalar MBBS., DGO, MS - General Surgery - Mon Feb 21, 2:14 pm

DIABETIC  FOOT:

Definition:

The foot of a Diabetic patient that has the potential risk of pathologic consequences including infection, ulceration and / or destruction of deep tissues associated with neurologic abnormalities, various degrees of peripheral vascular disease, and / or metabolic complications of diabetes in the lower limb” — W.H.O.

Risk Factors for Ulceration:

•          Peripheral sensory neuropathy

•           Structural foot deformity

•           Trauma and improperly fitted shoes

•           Callus

•           History prior ulcers / amputations

•           Prolonged, elevated pressures

•           Limited joint mobility

•           Uncontrolled hyperglycemia

•           Duration of diabetes

•           Blindness / partial sight

•           Chronic renal disease

•           Older age

© 2008 Nucleus Medical Art, Inc.

Peripheral Neuropathy:

Sensory Disorders Motor Deficiency

Superficial                                                                          Intra osseous atropy

Intra osseous atropy                                                      Imbalance in extensor  and flexor of feet

Deep                                                                                    Change in architecture of  feet  with  deformations

Loss of sensation                                                            Abnormal bio-mechanical load leading to

thinning of  fat pad cover

metatarsal head  and non-cognition

of  ulcer

PERIPHERAL VASCULAR DISEASE:

Atherosclerosis obliterans

Cholesterol emboli

Decreased delivery of  O2 ,  antibiotics,  nutrients

INFECTION:

Common  complication  of  diabetic  wounds

Formation  of  Micro thrombi   and  Ischemic

Necrosis           Gangrene

There is impaired leucocyte function influenced by hyperglycemia

Aerobic  gram -positive  staphylococci  and streptococci  are  the  causes  of  infection

Anaerobic  infection  is  common

Antibiotic  therapy – according  to  c/s

Parental  antibiotics : Sepsis

Leukocytosis

PAD

Uncontrolled  diabetes

PREVENTION:

Detection  of  patients  at  risk:

•          Detection of  Neuropathy

•          Detection  of  Arteriopathy

•          Detection of  Deformations

Active  Prevention:

•          Education  of  diabetic  patients  before the appearance  of  risk  factors

•          Regular  check-up  for patients of  foot  ulcer and

•          Appearance of new lesions –   Mycoses

–   Hyperkeratosis

–   Crack  in  heel

Detection  of  Patients at risk:

•          History  of  foot  ulcer / amputation

•          Peripheral Neuropathy

•          Arteriopathy  of  lower limbs

•          Deformation  of  the  foot

Detection  of  Neuropathy:

•          Functional  signs     – pain, cramps, nocturnal paresthesia

•          Hyperesthesia

•          Surface  sensitivity – heat  and  pain

•          Surface  sensitivity – tactile                                                                                                                                 (SW mono filament)

•          Deep  sensitivity    – position  and   vibration

•          Motor  sign              – muscular weakness,  osteo tendinous, non- reflex

•          Electro physiological  criteria

Detection  of  Arteriopathy:

•          Interrogation

•          Inspection  of  the  feet

•          Palpation  of  pulse

•          Inspection  for  vascular  murmurs – superficial  femoral  murmur, very  specific

Differences  between  Neuropathic Foot  and  Arteriopathic Foot:

NEUROPATHIC  FOOT ARTERIOPATHIC  FOOT

•          Warm  feet, less  perspiration                                             Cold  feet,  pale  on  elevation,  cyanosis

on  inclining

•          Insensitivity                                                                                 Normal  sensitivity

•          Absence  of  osteotendinous reflexes                             Intermittent ( inconsistant ) limping

•          Hyperkeratosis                                                                          Week, atrophic foot,  thickened nails,

lack  of  hair

Diabetic foot – Usual locations of ulcers:

Diabetic  Foot – Mechanisms  of  Injury – Illustration  of  ulcer due to  repetitive  stress:

DIAGNOSTIC  PROCEDURES:

•          LABORATORY  TESTING : Routine

•          IMAGING  STUDIES :

1. Plain Radiographs

– osteomyelitis, osteolysis, fractures, dislocation, etc.

2. CT scan

– Resolution  of  bone   with  osseous  fragmentation  sublaxation  well  visualised

3. Three phase technetium  Scans

– for early  detection  of  osteomyelitis,  fractures,  charcot  arthropathy

4. Gallium 67  citrate

– of  value  in  acute  osteo  arthropathy

5. Indium III  Leucocytes  scans  and  TC 99   labelled  White  Cell  Scan

– differentiates  osteomyelitis  and  neuropathic  arthropathy

6. MRI

– aids  in  diagnosis  of  : Osteomyelitis, deep abscess,  septic  joint  and  tendon  rupture

Diabetic Foot- Neurologic  examination  of  lower extremity:

Osteomyelitis : Patient with severe neuropathy secondary to diabetes  develops  a large ulcer with associated infection. Bone is visible at the base.

Management of  Diabetic Foot  Lesions:

•          TYPES  OF  DIABETIC  LESIONS :

Neuropathic  Ulcer

Neuropathic  Arthropathy

Neuro Ischemic Ulcer

•          INFECTED  DIABETIC  FOOT:

Superficial Cellulitis

Necrotic  Infection

Osteomyelitis

•          EVALUATION  OF  PROGNOSTIC FACTORS:

Evaluation  of  Ischemia

Evaluation  of  Infection

Diabetic foot – Wagner classification system:

Grade Lesion

0                              Pre ulcer, no open lesions, may

have deformity or cellulitis

1                              Superficial ulcer

2                              Deep ulcer to tendon, joint capsule

3                              Deep ulcer with abscess,  osteomyelitis, or joint capsule

4                              Localised gangrene – forefoot or heel

5                              Gangrene of entire foot

Diabetic foot ulcers-  Therapeutic objectives:

•          Debridement

•          Pressure relief (off-loading)

•          Appropriate wound management

•          Management of infection

•          Management of ischaemia

•          Medical management  of  hyperglycemia & comorbidities

•          Surgical management

OFFLOADING   MODALITIES:

•          Wheel Chair

•          Crutches

•          Walker

•          Total Contact Cast

•          Bi-valved Cast

•          Prefabricated Walking brace

•          Unna Boot with walking brace

•          Total Contact  custom walking brace

•          Patellar tendon-bearing brace

•          Posterior splint

•          Surgical shoe with insert

Total Contact Cast:

•          Provide good pressure  relief  for ulcers

•          Provide  stability  for Charcot joints

•          Effective  for  use on “non-compliant” patients  who might otherwise  remove the  splint  and  not wear  anything  on their  foot

Diabetic foot – Types of debridement:

•          Autolytic – occurs naturally

•          Enzymatic – collagenase, papain, etc.

•          Mechanical – wet-to-dry dressings,  high pressure irrigation,   pulsed lavage

•          Surgical – scalpel, tissue nippers,  curettes

Diabetic foot – Wound care products:

•          Transparent films

•          Hydrogels

•          Foam

•          Hydrocolloids

•          Calcium alginates

•          Gauze pads

•          Collagen dressings

•          Antimicrobial dressings

•          Enzymes

Becaplermin:

•          Recombinant DNA platelet-derived growth factor.

•          50% increase in healing rate compared to placebo.

Bioengineered tissues:

•          Human dermal replacement (Dermagraft)

•          Human skin equivalent (Apligraf)

Diabetic foot- Management of Infection:

Management:

•          Incision & drainage

•          Empiric / culture directed antibiotics

•          Soft tissue/bone/joint resection, amputations

Evaluation:

•          Labs: CBC, DC, Glucose, Glycosylated  Hb

•          Cultures

•          Radiographs

•          Vascular testing

Common Pathogens in Diabetic Foot Infections:

•          AEROBES

•          Gram +

Staphylococcus  aureus

(methicillin – sensitive and resistant)

Staphylococcus epidermidis

(coagulase negative staphylococci)

Streptococcus species

Enterococcus

(Strep, faecalis, Group D Streptococcus)

Corynebacterium species (Diptheroids)

•          Gram –

Proteus mirablis, Proteus vulgaris, Escherichia coli, Klebsiella species, Serratia species,

Enterobactoer aeruginosa, Acetobacter species

•          ANAEROBES

Peptococcus magnus

Peptostreptococcus species

Bacteroides fragilis

Bacteroides species

Clostridium perfringens

Clostridium species

•          OTHERS

Candida albicans

Candida species

Diabetic foot infections – Empirical antibiotic therapy

Limb-threatening

•          Ampicillin/sulbactum

•          Ceftazidime or cefotaxime + Clindamycin

•          Fluoroquinolone + Clindamycin

Life-threatening

•          Ampicillin/sulbactum + Aztreonam.

•          Vancomycin + Metronidazole + Ceftazidime

•          Vancomycin + Metronidazole + Fluoroquinolone

Diabetic foot- Management of ischaemia:

•          Pentoxyphylline, clopidogrel

•          Low molecular weight heparin for hemodilution and defibrogenation

•          Vascular reconstructive surgery

•          Balloon angioplasty

Diabetic foot- Surgical management :

Curative Surgery:

•          Aim – removing areas of chronically increased peak pressure

•          Operations – exostectomy, digital arthorplasty, sesemoidectomy, metatarsal head resections, joint resections, partial calcanectomy

Ablative Surgery:

•          Aim – removal of all infected & necrotic tissue to the level of viable soft tissue and bone

•          Synonymous with amputation

Diabetic foot – Prevention program:

•          Podiatric care – risk assessment,   footcare

•          Protective shoes – well cushioned, custom molded

•          Pressure reduction –  cushioned  insoles, custom  orthoses,   computerized  or  Harris mat

•          Prophylactic surgery –  correct  structural deformities –  hammertoes,  bunions,Charcot

•          Preventive Education – Patient, Physician

Adjunct Therapies  for  the  Treatment  of  Diabetic Foot  Wounds:

•          Living  skin  equivalents

•          Autologous  growth  factors

•          Recombinant  growth  factors

•          Hyperbaric Oxygen

•          Electrical  stimulation

•          Granulocyte – stimulating  factor

DO’s:

– Wash feet daily

– Inspect  feet  and toes, especially  in – between, daily

– Wear thick, soft socks

– Cut  toe -nails  straight across

– Be  measured  and  fitted  each  time you buy a new pair of shoes

– Lose weight

– Exercise

DONT’s:

Never  go  barefoot

– Avoid  high  heels,  sandals  and  shoes  with

pointed toes

– Don’t  smoke  and  drink  only  in  moderation

– Avoid  soaking  your  feet

– Don’t  wear  anything  that  is  too tight

around the legs

– Never  use  heating  pads  or  hot  water

bottles  on  cold feet

– Avoid  over  the  counter  medications  for

corns, calluses,  or  warts.

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