? Explain etiopathogenesis of diabetic foot ulcer
? Wagner grades
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? Understand Charcot's foot
? Explain prevention strategies to patient
Definition
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A foot with a constellation of pathologic changes
affecting the lower extremity in diabetics, often
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leading to amputation and/or death due tocomplications; the common initial lesion leading to
amputation is a nonhealing skin ulcer, induced by
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regional pressure, pathogenically linked to sensory
neuropathy, ischemia, infection
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-Extent
? 20 million DM patients in India ( 2 Crore)
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? DM largest cause of neuropathy? Half don't know
? Foot ulcerations is most common cause of hospital
admissions for Diabetics
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? Expensive to treat, may lead to amputation and need for
chronic institutionalized care
? After amputation 30% lose other limb in 3 years
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? After amputation 2/3rds die in five years? Type II can be worse
? 15% of diabetic will develop a foot ulcer
Pathophysiology
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? Vascular disease
? Neuropathy
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? Sensory? Motor
? Autonomic
Neuropathy
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? Changes in the vasonervosum with resultingischemia ? cause
? Increased sorbitol in feeding vessels block flow
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and causes nerve ischemia
? Intraneural accumulation of advanced
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products of glycosylationAbnormalities of all three neurologic systems
contribute to ulceration
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Vascular Disease
? 30 times more prevalent in diabetics
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? Diabetics get arthrosclerosis obliterans or "leadpipe arteries"
? Calcification of the tunica media
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? Endothelial changes
? Often increased blood flow with lack of elastic
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properties of the arterioles? Not considered to be a primary cause of foot
ulcers
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Autonomic Neuropathy
? Regulates sweating and perfusion to the limb
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? Loss of autonomic control inhibits
thermoregulatory function and sweating
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? Result is dry, scaly and stiff skin that is prone tocracking and allows a portal of entry for bacteria
Autonomic Neuropathy
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Motor Neuropathy? Mostly affects forefoot ulceration
? Intrinsic muscle wasting ? claw toes
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? Equinus contracture
Sensory Neuropathy
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? Loss of protective sensation? Starts distally and migrates proximally in
"stocking" distribution
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? Large fibre loss ? light touch and proprioception? Small fibre loss ? pain and temperature
? Usually a combination of the two
Sensory Neuropathy
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? Two mechanisms of Ulceration? Unacceptable stress few times
? rock in shoe, glass, burn
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? Acceptable or moderate stress repeatedly
? Improper shoe s
? deformity
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Patient Evaluation
? Medical
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? Vascular? Orthopedic
? Identification of "Foot at Risk"
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Patient Evaluation
Semmes-Weinstein Monofilament Aesthesiometer
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? 5.07 (10g) seems to be threshold
? 90% of ulcer patients can't feel it
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? Only helpful as a screening toolPatient Evaluation
? Medical
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? Optimized glucose control? Decreases by 50% chance of foot problems
Patient Evaluation
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? Vascular? Assessment of peripheral pulses of paramount
importance
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? If any concern, vascular assessment
D
E
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LH
I
S
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? ABI (n>0.45)
U
CM
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? Sclerotic vessels
? Toe pressures (n>40-50mmHg)
? TcO2 >30 mmHg
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? Expensive but helpful in amp. level
Patient Evaluation
? Orthopedic
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? Ulceration
? Deformity and prominences
? Contractures
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DE
L
H
I
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S
U
CM
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Patient Evaluation
? X-ray
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? Lead pipe arteries? Bony destruction (Charcot or osteomyelitis)
D
E
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LH
I
S
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U
CM
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Patient EvaluationD
E
L
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HI
S
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UCM
Patient Evaluation
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? Nuclear medicine? Overused
? Combination Bone scan and Indium scan can
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be helpful in questionable cases (i.e. Normal X-
rays)
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DE
L
H
I
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S
? Gallium scan useless in these patients
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UCM
? Best screen ? indium ? and if Positive ? bone
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scan to differentiate between bone and softtissue infection
Patient Evaluation
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? CT can be helpful in visualizing bony anatomy forabscess, extent of disease
? MRI has a role instead of nuclear medicine scans
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in uncertain cases of osteomyelitis
D
E
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LH
I
S
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U
CM
Ulcer Classification
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Wagner's Classification
0 ? Intact skin (impending ulcer)
1 ? superficial
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2 ? deep to tendon bone or ligament3 - osteomyelitis
D
E
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LH
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S
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U
CM
4 ? gangrene of toes or forefoot
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5 ? gangrene of entire footClassification
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Type 2 or 3D
E
L
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HI
S
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UCM
Classification
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Type 4D
E
L
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HI
S
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UCM
Treatment
? Patient education
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? Ambulation
? Shoe ware
? Skin and nail care
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DE
L
H
I
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S
? Avoiding injury
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UCM
? Hot water
? F.B's
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Six intervention demonstrate efficacy in
diabetic foot management
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1- off loading2- Debridement and drainage
3- wound dressing
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4- appropriate use of antibiotic
5- revascularization
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6- limited amputationTreatment
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? Wagner 0-2? Total contact cast
? Distributes pressure and allows patients to continue
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ambulation? Principles of application
? Changes, Padding, removal
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? Antibiotics if infected
Treatment
Treatment
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? Wagner 0-2
? Surgical if deformity present that will
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reulcerate? Correct deformity
? exostectomy
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Treatment? Wagner 3
? Excision of infected bone
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? Wound allowed to granulate? Grafting (skin or bone) not generally effective
Treatment
? Wagner 4-5
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? Amputation
? ? level
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? 5 P's? 3D's
Treatment
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? After ulcer healed
? Orthopedic shoes with accommodative
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(custom made insert)? Education to prevent recurrence
Charcot Foot
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? More dramatic ? less common 1%
? Severe non-infective bony collapse with
secondary ulceration
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? Two theories
? Neurotraumatic
? Neurovascular
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Charcot Foot? Neurotraumatic
? Decreased sensation + repetitive trauma =
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joint and bone collapse
? Neurovascular
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? Increased blood flow increased osteoclastactivity osteopenia Bony collapse
? Glycolization of ligaments brittle and fail
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Joint collapseClassification
? Eichenholtz
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? 1 ? acute inflammatory process
? Often mistaken for infection
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? 2 ? coalescing phase? 3 - consolidation
Indications for Amputation
? Uncontrollable infection or sepsis
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? Inability to obtain a plantar grade, dry foot thatcan tolerate weight bearing
? Non-ambulatory patient
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? Decision not always straightforwardConclusion
? Multi-disciplinary approach needed
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? Going to be an increasing problem? High morbidity and cost
? Solution is probably in prevention
? Most feet can be spared...at least for a while
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Prevention
? Diabetic control
? Foot care
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Diabetic foot successfully treated !!