Diabetic Foot - Duke University · gangrene with and without vascular insufficiency • 1920’s diabetic foot disease replaced hyperglycemic coma as the major cause of diabetic mortality

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

All Rights Reserved, Duke Medicine 2007

Outline

• Case Presentation

• History and Etiology of Diabetic Foot Ulcers

• Clinical Workup/Management

• Surgical Considerations

• Outcomes


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


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


Physical Examination


Radiology


Radiology


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


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


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


Arterial Anatomy of the Foot


Interaction of Micro and Macrovessel Dissease

JACC 53(5):S35 2009


Tunica Media Calcification


Patterns of Macroangiopathy


Mechanism of Macroangiopathy

JACC 53(5):S35 2009


Arterial Gene Expression in Diabetes

Vascular 16(4):225 2008


Arterial Gene Expression in Diabetes

Vascular 16(4):225 2008


Microangiopathy

Microcirculation 14(4):363 2007


Microangiopathy

JACC 53(5):S35 2009


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


Antibotic Coverage

• Initially Dual Regiment– Cephalosporin or Beta-Lactam– Bactrim or tetracycline

• Alternatively– Fluoroquinolone– Linezolid

• Culture Specific Coverage


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


Charcot Foot

Diabetes Metab Res Rev 20(Suppl1):S4 2004


Charcot Foot

J Bone Joint Surg [Br] 91-b(1):7 2009


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




Infection-Physical Examination


Infection-Bone Destruction


Brodsky’s Depth-Ischemia Classification



Brodsky’s Depth-Ischemia Classification



Compartments of the Foot



Debridement of the Foot




Ischemia


Tibial Angioplasty-Limb Salvage

Ann Vasc Surg 2009 ePUB DOI: 10.1016/j.avsg.2009.05.007


Tibial Bypass-Limb Salvage

Arch Surg 135:452 2000


Tibial Bypass-Acute vs Chronic

Ann Vasc Surg 18:321 2004


Tibial Bypass-PTFE vs GSV

Ann Vasc Surg 18:321 2004




Ray Amputation


Mid-foot Amputations


Below Knee and Above Knee Amputation

Surgery

Diabetic Foot - Duke University · gangrene with and without vascular insufficiency • 1920’s diabetic foot disease replaced hyperglycemic coma as the major cause of diabetic mortality

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