Dr.Edwin Stephen

The Diabetic FootThe Diabetic FootThe Diabetic FootThe Diabetic Foot

Dr.Edwin StephenDr.Edwin Stephen

The Diabetic FootThe Diabetic Foot

Collection of Collection of foot problems foot problems which are which are not unique to, not unique to, but occur more but occur more commonly in commonly in diabetic patientsdiabetic patients

FactsFacts

Commonest cause of hospitalization in Commonest cause of hospitalization in DMDM

US 2/3US 2/3rdrd of non traumatic of non traumatic amputationsamputations

FactsFacts

Indian figures not knownIndian figures not known2004 Surgery Dept Stats 2004 Surgery Dept Stats 14% admissions – diabetic foot infections 14% admissions – diabetic foot infections

( S2 )( S2 )Surgery amputationsSurgery amputations

DM DM 87%87%majormajor 4040minorminor 6363

OthersOthers 13%13%major major 0909minorminor 1414

Aetiology of the Diabetic FootAetiology of the Diabetic Foot

NeuropathyNeuropathy

Reduced response to infectionReduced response to infection

IschaemiaIschaemia

NeuropathyNeuropathy

Up to 50% of type 2 diabetic patients Up to 50% of type 2 diabetic patients havehave

significant neuropathy and at-risk feetsignificant neuropathy and at-risk feet

International Consensus on the Management and the International Consensus on the Management and the Prevention of the Diabetic Foot (2003)Prevention of the Diabetic Foot (2003)

Assessment of Assessment of NeuropathyNeuropathy

Neuropathic Foot ChangesNeuropathic Foot Changes

Clawing/Retraction of Clawing/Retraction of minor digitsminor digits

Atrophy of plantar fatty Atrophy of plantar fatty padpad

Restricted ROM of jointsRestricted ROM of joints

Muscle wastingMuscle wasting

Warm feet Warm feet

Changes to joint Changes to joint alignmentalignment

Skin anhydrosisSkin anhydrosis

Charcot ArthropathyCharcot Arthropathy

High Index of High Index of suspicionsuspicion

DiabeticDiabetic

Hot / red / swellingHot / red / swelling

Trauma - minor / Trauma - minor / majormajor

Pain + / -Pain + / -

Architectural Architectural DisruptionDisruption

Ulcer + / -Ulcer + / -

Management of Diabetic Management of Diabetic NeuropathyNeuropathy

Look for it!Look for it! Tight glycaemic controlTight glycaemic control PainfulPainful

medicationmedication referral to neurologistreferral to neurologist

Intensive podiatry/orthotic inputIntensive podiatry/orthotic input Pressure Off-LoadingPressure Off-Loading

Pressure Off-LoadingPressure Off-Loading

Total Contact CastDiabetic Air

Walker

Aetiology of the Diabetic FootAetiology of the Diabetic Foot

NeuropathyNeuropathy

Reduced response to infectionReduced response to infection

IschaemiaIschaemia

Diabetic Foot InfectionDiabetic Foot Infection

Polymicrobial - gram (+) cocci, gram (-) Polymicrobial - gram (+) cocci, gram (-) bacilli and anaerobesbacilli and anaerobes

Redness and swelling may not be Redness and swelling may not be presentpresent

Suspect if deterioration in glycaemic Suspect if deterioration in glycaemic controlcontrol

Unusual foot pain with no fracture etcUnusual foot pain with no fracture etc

Diabetic Foot SepsisDiabetic Foot Sepsis

Surgical principlesSurgical principles

Drain pus urgently / immediatelyDrain pus urgently / immediately

Xray foot Xray foot

Assess perfusionAssess perfusion

Debride necrotic tissueDebride necrotic tissue

Revascularise early if requiredRevascularise early if required

MRI useful to assess soft tissuesMRI useful to assess soft tissues

Diabetic Foot SepsisDiabetic Foot Sepsis

Severe ischaemia Severe ischaemia is present in 5 to is present in 5 to 15% of admitted 15% of admitted cases of foot cases of foot sepsissepsis

If ischemia present it must If ischemia present it must be corrected be corrected

OROR

measures to treat measures to treat infection/neuropathy infection/neuropathy

will failwill fail

Aetiology of the Diabetic FootAetiology of the Diabetic Foot

NeuropathyNeuropathy

Reduced response to infectionReduced response to infection

IschaemiaIschaemia

The concept of small vessel disease The concept of small vessel disease is erroneous and has no place in is erroneous and has no place in management of diabetic footmanagement of diabetic foot

Distribution similar to Distribution similar to atherosclerosisatherosclerosis

Foot arteries almost always sparedFoot arteries almost always spared

Diabetic Vascular DiseaseDiabetic Vascular Disease

Large vessel diseaseLarge vessel diseasecommoncommon

early age of onsetearly age of onset

rapid progressionrapid progression

Microvascular diseaseMicrovascular diseasepresence in limbs controversialpresence in limbs controversial

retinal and renal lesions commonretinal and renal lesions common

Assessment of Foot PerfusionAssessment of Foot Perfusion

SubjectiveSubjectivepalpation of pulsespalpation of pulses

ObjectiveObjectiveDoppler pressures (ankle/brachial index)Doppler pressures (ankle/brachial index)

toe pressurestoe pressures

NB:ABI unreliable in diabetes/renal failure/ NB:ABI unreliable in diabetes/renal failure/ rheumatoid arthritis/leg swellingrheumatoid arthritis/leg swelling

Doppler StudiesDoppler Studies

Low readingsLow readings (ABI <0.5) (ABI <0.5)confirm severe ischaemiaconfirm severe ischaemia

High readingsHigh readings (ABI >0.5) (ABI >0.5)difficult to interpret if no pulses palpabledifficult to interpret if no pulses palpable

Toe PressuresToe Pressures

Toe PressuresToe Pressures

Better predictors of wound healingBetter predictors of wound healing

DiabeticsDiabetics toe pressuretoe pressure <40mmHg <40mmHg skin perfusion pressureskin perfusion pressure healing very healing very

unlikelyunlikely

40 to 60mmHg 40 to 60mmHg healing likelyhealing likely

Management - MedicalManagement - Medical

↓ ↓ Progression of diseaseProgression of disease

Stop smokingStop smoking

Rx predisposing factorsRx predisposing factors

Foot careFoot care

Management - MedicalManagement - Medical ↓ ↓ progression of diseaseprogression of disease

↑ ↑ blood flowblood flowExercisesExercises

DrugsDrugs

-Antiplatelet :Aspirin / ticlopidine / -Antiplatelet :Aspirin / ticlopidine / clopidogrelclopidogrel

-Dipyridamole ( Persantin )-Dipyridamole ( Persantin )

-Pentoxiphylline ( Trental )-Pentoxiphylline ( Trental )

-Cilostazol ( Pletoz )-Cilostazol ( Pletoz )

Management - medicalManagement - medical↓ ↓ progression of diseaseprogression of disease

↑ ↑ blood flowblood flow

Relief of painRelief of pain-NSAIDS:-NSAIDS: check renal functionscheck renal functions

-Opiates:-Opiates: cause constipationcause constipation

-Epidural analgesia-Epidural analgesia

-Antibiotic-Antibiotic

-Drainage abscess-Drainage abscess

Management - Management - interventionintervention

Endovascular Endovascular Balloon angioplasty +/- StentBalloon angioplasty +/- Stent

SurgerySurgery BypassBypass

Anatomical Anatomical

Aorto-bifemoralAorto-bifemoral

Ileo-femoralIleo-femoral

Femoro-popliteal Femoro-popliteal

Extra-anatomicalExtra-anatomical

Axillo-bifemoralAxillo-bifemoral

Femoro-femoralFemoro-femoral

CaseCase

52 yrs male52 yrs maleSmoking ++Smoking ++DM X 5 yrsDM X 5 yrs

Rest pain & blackening of right foot x Rest pain & blackening of right foot x 3 months3 months

B\L lower limb pulses absentB\L lower limb pulses absentABI R - 0 , L – 0.2ABI R - 0 , L – 0.2

ManagementManagement

Underwent emergency Aorto-bifem Underwent emergency Aorto-bifem bypass and right trans-tarsal bypass and right trans-tarsal amputationamputation

Outcome Outcome

Post Op ABI left 1.1Post Op ABI left 1.1

Right stump healed wellRight stump healed well

CaseCase

55 yrs male 55 yrs male

DM x 6 yrs DM x 6 yrs

Smoking many yearsSmoking many years

Rest pain / nonhealing wound R foot x Rest pain / nonhealing wound R foot x 4 m4 m

Right lower limb pulses absentRight lower limb pulses absent

ABI R – 0.24 L – 1.03ABI R – 0.24 L – 1.03

ManagementManagement

Underwent left fem to right bypass Underwent left fem to right bypass usingusing

8mm ringed PTFE graft8mm ringed PTFE graft

Outcome Outcome

Post-operative recovery uneventfulPost-operative recovery uneventful

ABI R 1.07 L – 0.96ABI R 1.07 L – 0.96

Wounds healed wellWounds healed well

CaseCase

60 yrs male60 yrs male

DM x 12yrsDM x 12yrs

HT x 9 yrsHT x 9 yrs

Heavy smoker Heavy smoker

3 months H/O ulceration toes L foot & 3 months H/O ulceration toes L foot & rest painrest pain

ABI ABI RR 0.5 0.5 LL 0.32 0.32

ManagementManagement

Underwent left Femoro-popliteal Underwent left Femoro-popliteal bypass using reversed LSVbypass using reversed LSV

Outcome Outcome

Post op course uneventfulPost op course uneventful

Post-op ABI R – 0.54 L – 0.73Post-op ABI R – 0.54 L – 0.73

Wound healed within a monthWound healed within a month

CaseCase

64 yrs male 64 yrs male

DM x 16 yrsDM x 16 yrs

HT x 2yrsHT x 2yrs

Heavy smoker Heavy smoker

Painful nonhealing ulcer left footPainful nonhealing ulcer left foot

ABI ABI RR 0.7 0.7 LL 0.43 0.43

ManagementManagement

Underwent balloon angioplasty and Underwent balloon angioplasty and stenting of left common iliac arterystenting of left common iliac artery

ManagementManagement

Followed byFollowed by

Left Femoro-popliteal bypass using Left Femoro-popliteal bypass using reversed GSVreversed GSV

Patient did wellPatient did well

CaseCase

69 yrs male69 yrs male DM + 12 yrsDM + 12 yrsHT+ / Smoking +HT+ / Smoking +Rest pain left forefootRest pain left forefootLeft popleteal and pedal pulses absentLeft popleteal and pedal pulses absentABI ABI

R – 0.93R – 0.93L – 0.21L – 0.21

ManagementManagement

Underwent fem-anterior tibial bypass Underwent fem-anterior tibial bypass using reversed GSVusing reversed GSV

Required forefoot amputation Required forefoot amputation

assess perfusion, degree of neuropathy, mechanical abnormalities

pus/wet gangrene in foot present

dry gangrene/ ulceration ±cellulitis/

osteomyelitis

draindebride

Management Algorithm for Management Algorithm for the the

Diabetic Foot LesionDiabetic Foot Lesion

assess perfusion, degree of neuropathy, mechanical

abnormalities

ischaemic footABI <0.5 and/or

toe pressure <40mmHg

probably adequate perfusion

ABI >0.5 andtoe pressure 40-60mmHg

good perfusion, pulses present, ABI >0.8 and

toe pressure >60mmHg

vascular imaging no vascular interventionpodiatry/orthotic care

± local procedure

no vascular interventionpodiatry/orthotic care

± local procedure

revascularisation if possible- angioplasty

- bypassfailure success failure success

NB: less likely outcome

Management Algorithm for Management Algorithm for the the

Diabetic Foot LesionDiabetic Foot Lesion

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