2. 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)
3. 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)
4. 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.
5. 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
6. 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) العوامل المهيئة
2- Precipitating factors (Trauma and tinea) العوامل المعجلة
3- Perpetuating factors (Pt’s factors & delay healing) عوامل التكريس
7. 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 ??!!
9. Pathophysiology
The critical triad of :
1- Neuropathy
2- Foot deformity &
3- Trauma ……………
will lead to ulcer
The presentation in the majority of pts
is an infected ulcer!!
10. 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 )
12. 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
14. Assessment
History
Physical examinations
Investigations
Patient
Limb or foot
Wound
15. Who will take care ?
G. Physicians
General Surgeons
Diabetologists (Endocrinologist)
Orthopaedic surgeon
Vascular surgeon
Plastic surgeon
Podiatrists
Specialised nurse
16. 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....
17. 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
18. 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
22. 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)
23. 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.
24. 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
25. 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
30. Vascular assessment
History
Changes in skin
Pulses
Exercise Testing
ABPI
Duplex
Angiography
31. 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
32. 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)
34. 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
35. 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
37. 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
40. 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
42. 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
43. 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
44. 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.
45. 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
46. 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
47. Principles of Foot ulcer
management
1.Infection Control
2.Offloading
3.Vascular assessment
4.Wound care
48. 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
49. 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
51. Approach to diabetic foot ulcer
According to ulcer stage
0 At-risk foot, no ulceration : Patient education,
accommodative footwear, regular clinical
examination
1 Superficial ulceration, not infected :Offloading with
total contact cast (TCC), walking brace, or special
footwear
2 Deep ulceration exposing tendons or joints :
Surgical debridement, wound care, offloading,
culture-specific antibiotics
3 Extensive ulceration or abscess : Debridement or
partial amputation, offloading, culture-specific
antibiotics
52. 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
53. 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
54. Offlaoding
Remove pressure from the affected site is
essential
How ?
- Footwear
- Specialised
offloading
devices
58. 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
59. 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%
61. 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
62. 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
63. 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
64. 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
