APPROACH to DIABETIC FOOT

Dr. Faiez Alhmoud

Surgery Dpt.
Albashir Hospital
(MOH)
 Diabetic Foot (DF)

 It will be unwise if we restrict the

term (DF) to foot infection, ulcer or
gangrene in a diabetic patient
 Why?


 (advanced stage of the disease)
 Diabetic foot definition

 Diabetic foot is a disease complex that can develop in

the skin, muscles, or bones of the foot as a result of
the nerve damage, poor circulation and/or infection
that is associated with diabetes.

 The Diabetic Foot may be defined as a syndrome in

which neuropathy, angiopathy, and infection will
lead to tissue breakdown resulting in morbidity and
possible amputation ( WHO 1995 )

 Any foot pathology that result from diabetes or it’s

long – term results (Boulton 2002)
 Epidemiology and facts
 15% of the adult population in Jordan are diabetics
 15% of those with diabetes will, develop an ulcer
 15% of patients develop osteomyelitis & 15% amputation
 80% of foot ulcers are precipitated by external trauma
 20% of diabetics admitted to hospitals because of foot
problems
 Cellulitis occurs 10 times more frequently in diabetics
 Osteomyelitis of the foot 15 times more frequently in
diabetics than non-diabetics
 Diabetic patients are 15x at risk of BKA
 Nearly half of non-traumatic LLA caused by diabetes.
 70% of lower limb amputations begin with a foot ulcer
 ~50% of diabetics with LLA require 2nd LLA within 5 years
 5 year survival rate ~50% after BKA--Tragic “Rule of 50”
 The annual direct and indirect costs is high
 Up to 85% of amputations can be avoided.
 Diabetic foot…..facts
 Every 30 seconds a lower limb is lost somewhere
in the world as a consequence of diabetes
 Diabetic foot infection require attention to local
(foot) and systemic (metabolic) issues by
multidisciplinary foot care team
 Only in the last 20 years progress in the
understanding of pathogenesis and management
of diabetic foot had been made
 However …. there is still gap between
what’s known about diabetic foot and
what’s really done to them
 Natural history of diabetic
foot
 It’s unwise to consider that major
diabetic foot problem occur all of
sudden
 There is high risk foot which means
 There are
1 Predisposing factors (Neuro- and angiopathy) ‫ةئيهمال لماوعال‬
2 Precipitating factors (Trauma and tinea) ‫ةلجعمال لماوعال‬
3 Perpetuating factors (Pt’s factors & delay healing) ‫سيركتال لماوع‬
 What’s the high risk foot ?

Long duration and uncontrolled D.M …Plus

one or more:
 Peripheral neuropathy
 Peripheral vascular disease
 Trauma
 Previous ulcers
 Diabetic nephropathy or retinopathy
 Obesity
 Lack of education
 Male gender ??!!
FOOT AT RISK
 Pathophysiology

 The critical triad of :

1 Neuropathy
2Foot deformity &
3- Trauma ……………
will lead to ulcer

The presentation in the majority of pts

is an infected ulcer!!
 Neuropathy
 Sensory : lack of protective
sensation (unrecognized trauma)

 Motor : Change in foot anatomy

(Pressure points) & altered gait
and deformity

 Autonomic : Lack of sweat ( dry &

cracked skin )
 Neuropathy

The Gift of Pain

“Pain: The gift nobody wants “.

Paul Brand
 Classification and definition
of problem
The neuropathic foot – in which
neuropathy predominates but the major
arterial supply to the foot is intact.

The neuro-ischaemic foot – where

neuropathy, and ischaemia resulting from
a reduced arterial supply, contribute to
the clinical presentation.

Infection - is rarely the only factor

but often complicates neuropathy and or
ischaemia, and is responsible for
considerable tissue necrosis
Stages Of Ulcer Development
 Assessment

 History
 Physical examinations
 Investigations


 Patient
 Limb or foot
 Wound
 Who will take care ?

 G. Physicians
 General Surgeons
 Diabetologists (Endocrinologist)
 Orthopaedic surgeon
 Vascular surgeon
 Plastic surgeon
 Podiatrists
 Specialised nurse
 Assessment………..History

 Generally: fever, chills, sweats, vom…

 Condition : confused, depressed….
 Socially : neglected, lack of home sup
 Neuropathy : Numbness, loss of sens.
burning, tingling, numbness &
nocturnal leg pains.
 Others : duration, diabetic control,
previous ulceration, smoking, HTN....
 Assessment………Clinical Ex.

What to look for ?

 V.S : tachycardia, hypotension…
 Signs of volume depletion
 Cognitive state:delirium,stupor, coma
 Limb-Foot:
1 Biomechnics: deformities, change pressure points
2 Vascular status ( arterial, venous, ABI, ischemia, gangrene…
3 Neuropathy ( light touch, vibration, monofilament pressure
4 Examining the feet for structural abnormalities such as nails,
calluses, hammer toes, claw toes and flat foot
 Diabetic Foot Examination

 D deformity
 I infection
 A atrophic nails
 B breakdown of skin
 E oedema
 T temperature
 I ischemia
 C callosities
 S skin colour
Assessment………Clinical Ex.
Typical neuropathic foot
 Neurologic assessment

 Temperature
 Vibration Sense
 Pressure Sense
 Light Touch
 Proprioception (Romberg’s Sign)
 Superficial Pain
 Reflexes
Nylon monofilament test
 Neuropathy
 Charcot foot
“Acute or subacute inflammation of all or part
of the foot in people with diabetes
complicated by distal symmetrical
neuropathy, accompanying fracture or
dislocation that cannot be explained by
recent trauma, and with or without
preceding ulceration of the surrounding
skin”
(Jeffcoate 2004)
 Diagnosis of Acute Charcot
 Painless

 Redness, swelling, and more than 2°C skin

temperature difference when compared
with the contralateral foot.

 Dorsalis pedis pulses are often bounding.

 The patient is afebrile unless a systemic

infection is present.
 Ulcer assessment
1. Site, size and shape
2. Edges
3. Establish its depth and involvement of deep
structures
4. Examine it for purulent exudates, necrosis, sinus
tracts, and odor
5. Assess the surrounding tissue for signs of edema,
cellulitis, abscess, and fluctuation
6. Perform a vascular evaluation.
7. The ability to gently probe through the ulcer to
bone has been shown to be highly predictive of
osteomyelitis.
8. Establish the ulcer's etiology
9. Exclude systemic infection
Classification of diabetic foot
ulcer
Wagner Grading System
 Grade 0 skin intact but "foot at risk"
 Grade 1: Superficial Diabetic Ulcer & localised
 Grade 2: Deep ulcer & extension
 Involves ligament, tendon, joint capsule or
fascia
 No abscess or Osteomyelitis
 Grade 3: Deep ulcer with abscess or Osteomyelitis
 Grade 4: Gangrene to portion of forefoot
 Grade 5: Extensive gangrene of entire foot
Classification of diabetic foot
ulcer
 Neuropathic foot ulcer.

Khanolkar M et al. QJM 08;101:685-695

© The Author 2008. Published by Oxford University Press on behalf of the Association of
Physicians. All rights reserved. For Permissions, please email:
journals.permissions@oxfordjournals.org
 The Charcot foot.

nolkar M et al. QJM 2008;101:685-695

© The Author 2008. Published by Oxford University Press on behalf of the Association of
Physicians. All rights reserved. For Permissions, please email:
journals.permissions@oxfordjournals.org
Effects of Diabetic Peripheral
Neuropathy
Vascular assessment
 History
 Changes in skin
 Pulses
 Exercise Testing
 ABPI
 Duplex
 Angiography
 Assessment..........Ischemia

Peripheral Vascular Disease

Chronic limb ischaemia
Grade 0 = Mild claudication

Grade 1 = Moderate to severe claudication without

tissue loss or ischaemic rest pain

Critical ischaemia
Grade 2 = Ischaemic rest pain

Grade 3 = Tissue loss due to ischaemic ulceration or

gangrene
 Vascular assessment .........
...........Ankle Brachial Index
ABI value Indicates
 <0.9 Abnormal
 0.8- 0.9 Mild PAD
 0.5- 0.8 Moderate PAD
 <0.5 Severe PAD
 <0.25 Very Severe PAD
******The ABI has limited use in evaluating
calcified vessels that are not compressible
as in diabetics (gives reading above one)
 Ischaemic foot ulcer.

Khanolkar M et al. QJM 2008;101:685

© The Author 2008. Published by Oxford University Press on behalf of the Association of
Physicians. All rights reserved. For Permissions, please email:
journals.permissions@oxfordjournals.org
 Assessment…….Infection

Infection is diagnosed clinically by

The presence of purulent secretion
OR
 At least 2 of the cardinal local
manifestations of inflamation
 Hotness
 Redness
 Swelling
 Function loss or pain
 Clinical assessment of
infection
Non-Limb-threatening Infections:
 Superficial infection

 Lack systemic toxicity

 Minimal cellulitis (< 2 cm. Extension from

portal of entry)
 Ulcer-if present-doesnot penetrate fully thru
skin
 No bone or joint involvement

 No underlying ischemia
 Clinical assessment of
infection
Limb-threatening infections:
 Extensive cellulitis (> 2 cm.)
 Lymphangitis
 Full-thickness ulcers
 Frequent bone & joint infections
 Ischemia + gangrene
 Fever +
 Deep plantar abscesses
 Bacteremia + hematogenous spreading infections
Classification of diabetic foot
infection
 Minimal inflammation with no pus = 1
 2 or more signs or ~2cm erythema
around the ulcer or superficial path.
and no systemic manifistations = 2
 As above plus deeper infection,
lymphangitis ,abscess or gangrene =3
 As above with systemic or metabolic
instability = 4
 Classification of diabetic foot
infection
Non-Limb-threatening
Infections:
Classification of diabetic foot
infection
Limb-threatening Infection:
 Common Pathogens

 MILD infection = MONOMICROBIAL

 SEVERE infection = POLYMICROBIAL

 In acute wounds and cellulitis : S. aur. & B.Hem.

Strept. are commonly found (+)
 In chronic infected wounds : add entrobacter (-)
 Macerated soaked wound : Pseudomonas
 Long duration & nonhealing : all the above plus
fungi
 Deep infection & extensive necrosis with bad odor
: all the above plus obligate anaerobes
 Principles of diabetic
foot ulcer management
‫ربص اهدب‬
 Five cornerstones of management
of the diabetic foot

The situation can be changed & possibly

reduce amputation rates between 50% -
85% by:
1 Regular inspection and examination of the foot and
patient education
2 Identification of the foot at risk.
3 Education of patient, family and healthcare providers.
4 Appropriate footwear.
5 Multidisciplinary approach & treatment of ulcerative
and non-ulcer pathology
 Patient education

Decreases the chance of occurrence

 Foot hygiene
 Daily inspection
 Proper footwear
 Prompt treatment of new lesions
Must take an active role in their care
 Disease management
 Routine nail care
 Ulcer management
Elective surgery to correct structural
deformities before ulcerations occur
 A multidisciplinary approach

 Providing :
- Debridement,
- Meticulous wound care,
- Adequate vascular supply,
- Metabolic control,
- Antimicrobial treatment and
-Relief of pressure (offloading) are essential
in the treatment of foot ulcer.
 Investigations

 Bloodwork for high BS, DKA, hyperosmolar

state…..
 Gram staining and culture
 Imaging
- Plain X-ray
- MRI ?
- Doppler – Angiogram
- US? For deep abscess
- Doppler and ABI
 Approach to foot wound in
diabetics
 General Principles
1 Avoid antibiotics in uninfected foot
2 Determine the need for hospitalization
Severe infection or critical ischemia
3 Stabilize the patient and correct:
- Fluids and electrolytes
- Hyperglycemia, hyperosmolarity ,acidosis
-Treat other exacerbating factors
4- Choose antibiotic regimen:
Limited data support the use of topical antibiotics
Mild-moderate infection, give narrow spectrum antibiotics –no anaerob
Severe infection, give broad-spectrum with anaerobic coverage
 Principles of Foot ulcer
management
1.InfectionControl
2.Offloading
3.Vascular assessment
4.Wound care
 Infection Control
 Foot infections are the most common cause of
admission to hospital for patients with diabetes
 Infection is a precursor to amputation in many
cases
 Need to be treated aggressively
 Sampling by sterile swabs misses important
pathogens
 True bacteriological yield is obtained from deep
tissue samples
 IF INFECTION IS PRESENT, DO NOT WAIT FOR
SWAB RESULTS
 Approach to foot wound in
diabetics
 ……Principles of wound care
1 Determine the need for surgery
Ranges from debridement to revascularization
Determine life- or limb-threatening condition ( NF, GG, Ischemia…. )
2 Formulate wound care plan
- Daily inspection
- Dressing and debridement as needed
- Removal of pressure…..
3 Twice- weekly follow up for outpatients
4 WBC, ESR, C-RP, culture … are of limited value
 Debridement

 Sharp

 Larval

 Enzymatic
(Lytic)
 Approach to diabetic foot ulcer

According to ulcer stage

1 At-risk foot, no ulceration : Patient education,
accommodative footwear, regular clinical
examination
2 Superficial ulceration, not infected :Offloading with
total contact cast (TCC), walking brace, or special
footwear
3 Deep ulceration exposing tendons or joints :
Surgical debridement, wound care, offloading,
culture-specific antibiotics
4 Extensive ulceration or abscess : Debridement or
partial amputation, offloading, culture-specific
antibiotics
Approach to ischemic diabetic foot

Ischemia Classification
A Not ischemic : no treatment
B Ischemia without gangrene: Noninvasive
vascular testing, vascular consultation if
symptomatic
C Partial (forefoot) gangrene :Vascular
consultation and debridement
D Complete foot gangrene : Major extremity
amputation, vascular consultation
 Approach to diabetic foot infection

Antibiotics Empirical antibiotics

 Benzylpenicillin or ampicillin – Streptococcus sp.
 Oxacillin, nafcillin or 1 st generation cephalosporin (eg. cefazolin) –
Staphylococcus sp.
 Quinolone + aminoglycoside (gentamycin) – Pseudomonas sp.
 Methicillin-resistant Staphylococcus aureus – vancomycin or cotri-
moxazole
 Clostridial species are sensitive to a combination of penicillin G and
clindamycin
Duration of antibiotic treatment
* 1-2 weeks course for mild to moderate infections
* more than 2 weeks for more serious infections
* 6 - 8weeks for osteomyelitis
* If all infected bone is removed,a shorter course (1-2 weeks) of
antibiotics, as for soft tissue infection, may be adequate
 Offlaoding
Remove pressure from the affected site is
essential

 How ?
- Footwear
-Specialised
offloading
devices
 Offlaoding
 Footwear
Good shoes are integral to good foot health
Offloading
 Vascular assessment

Surgical revascularisation
 Follow up

 Osteomyelitis
Consider potential osteomyelitis in any
1- Deep or extensive chronic ulcer and over bony prominence
2- Unhealed ulcer after 6 weeks of Abx. And offloading ttt.
3 Ulcer in which bone is visible or easily felt
4 Sausage toe
 Osteomyelitis
Initial screening tool is the plain X-ray :
 Easily obtained, relatively inexpensive and
provides anatomical information
 Demineralization, periosteal reaction, bony
destruction: (the classic triad)
 Appear after 30 – 50% of bone is destroyed
and can take as much as 2 weeks to
appear
 Found in other conditions such as fracture
or deformity
 Sensitivity and specificity approximately
54% and 80%
Osteomyelitis
 Follow up……Osteomyelitis
Diagnosis
Serial X-rays with 2-4 weeks interval
- If typical, treat as ostemyelitis
- If not but clinically suspected
MRI or Bone scan or
Radionuclide or Scintigraphic imaging
 Triple Phase Bone Scan (TPBS)
 Gallium Scan
 Indium-111 Leukocyte Scan
- Probe to Bone
- Empirical antibiotics for 6-8 weeks and repeat Ro or
- Bone biopsy
MRI is the most accurate imaging modality
Three-phase bone scintigraphy is highly sensitive
 Outcome
 Good outcome to appropriate therapy
In 80–90% of mild-moderate infection
50-80% of severe or OM infection
 Poor outcome associated with
Signs of systemic infection
Inadequate limb ischemia
OM
Necrosis or gangrene
Proximal site of infection
Inexperienced surgeon
 Prevention

 Early detection of neuropathy

 Educate patient about
- Optimizing glycemic control
- Using appropriate footwear
- Avoid foot trauma
- Perform daily self examination
- Smoking cessation
 Refer patient with critical ischemia
 Key Message
 Of all late complications of diabetes, foot problems
are the most easily detectable and easily
preventable.
 Relatively simple interventions can reduce
amputations by 50 - 80%. (Bakker et al 1994).
 Strategies aimed at preventing foot ulcers are cost
effective and cost saving.
 “The pathway to amputation
Is littered with bandages and dressings which have
deceived both the doctor and patient into thinking
that by dressing an ulcer they were curing it”
 Diabetics should treat their Feet like their Face
Key Message
Mission:… HappyFeet

QUSTIONS?