Diabetic Foot - Review

8/3/2019 Diabetic Foot - Review

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An Overview

Dr. Amit Bhargava, MBBS, MD

Family Physician & Medical Content Specialist

DIABETIC FOOT



MAGNITUDE OF PROBLEM2

• 5-10% risk of developing DM

• 12-25% risk of Diabetics developing Diabetic Foot in their lifetime

• In USA, > 10,00,000 amputations per year for diabetic foot

• Foot Wound Incidence: 2-7% diabetics /yr .; 10-30% undergo amputation

• Foot Wound Recur rence: 20-80%

• Global Long-term Outcome of hospitalized patients is poor.

• In a 10 year survey (HUNT-2), History o f Foot Ulcer (HFU) increases ris k

of mortality.

• Thus, need to PREVENT & properly TREAT Diabetic Foot.

Iversen MM, Tell GS, Riise T, et al. Diabetes Care 32: 2193-9. 2009

Bloo mgarden ZT. Diabetes Care 31: 372-6. 2008

Ghanassia E, Villon L , et al. Diabetes Care 31: 1288-92. 2008

Farber DC, Farber JS. Pr Care Clin Office Pract 34: 837-85. 2007

Andersen C, Roukis TS. Surgical Clin N America 87: 1149-77. 2007

Prepared by Dr. Amit Bhargava, 3C Spectrum, Mumbai



Challenges In DFU Rx3

• DENIAL of disease by patient

• MAINTAINING TARGET glucose levels (FPG, PPG & HbA 1c)

• IMPLEMENTING LIFESTYLE CHANGES

• AVAILABILITY OF TREATMENT & FOLLOW-UP FACILITIESappropriate to diabetic foot management

• PATIENT EDUCATION about numerous aspects of disease,

management, prevention & complications

• PATIENT EMPOWERMENT for self-disease management




ETIOPATHOGENSIS:

Etiology, Pathogenesis & Recurrence

Section 2

4




RISK FACTORS5

• Poor Glycemic Control

• Peripheral Neuropathy

• Foot Deformity

• Peripheral Vascular Disease

• Past H/O Amputation

• Past H/O Ulcer

• Visual Impairment

• Diabetic Nephropathy

•Cigarette Smoking

Boul ton AJM, Arms tron g DG, Albert SF, et al. Diabetes Care 31: 1679-1685. 2008




ETIOPATHOGENESIS6

NEUROPATHY

REPETITIVE TRAUMA DEFORMITY

theCRUCIAL

TRIAD




ETIOPATHOGENESIS: 17

• Primary etiology: NEUROPATHY• Sensory

• Motor

• Autonomic

• Associated etiology:• Deformity• Infection

• Peripheral Ar terial Disease (PAD)

• Associated Pathogenic Mechanisms:

• Ulceration

•

Decrease in Neurokines including Substance P


Andersen C, Roukis TS. Surgical Clin N America 87: 1149-77. 2007




Etiopathogenesis: 2: Impact of Sensory Neuropathy8

Sensory Neuropathy

Loss of Protective Sensation

Unrecognized Foot Trauma

Ulceration

Infection & Impaired Healing




Etiopathogenesis: 3: Impact of Motor Neuropathy9

Motor Neuropathy

Foot Defo rmi ty A ltered Biomechan ics

Ulceration


Muscle Atrophy

Areas of High Pressure





Etiopathogenesis: 4: AN Neuropathy & PAD10

Autonomic Neuropathy

Dry Skin due to Hypohidrosis


Cracks & Fissures

Ulceration

Altered Cutaneous Blood Supply

PAD




Etiopathogenesis: 5: Summary11

Ulceration



Sensory Neuropathy

Autonomic NeuropathyMotor Neuropathy

PAD




Chron icity of DFU12

Greater & Persistent

Inflammatory ResponseMore Neutrophils

& Macrophages MigrationMore Cytokine Release

More Macrophage ActivationMore TNF-a & IL-1b releaseMore Inflammatory Cells& Fibroblasts recruited

Serine-Proteases MMPs TIMPs

Increased Release of …Degradation of …

• Matrix proteins,

• Growth Factors, &

•

Receptors for GF

CHRONICITY

OF

DFU

Repeated Traumatized DFU




RECURRENCE OF FOOT ULCERS13

• Indicators / Risk-factors for Recurrence:

• Peripheral Arterial Disease

• Location of Index Ulcer

•

Plantar hallux u lcers more likely to recur or develop moreulcers

• Ulcers on the bottom of the foot more likely to recur

• Ulcers of the lesser toes usually located dorsally; less likely

to recur

Peters EJG, Armst rong DG, Lavery LA. Diabetes Care 30: 2077-9. 2007




DIAGNOSIS:

Clinical Presentation & Investigations

Section 2

14




Early Indicators & Clinical Progression15

• NEUROPATHY:

SENSORY:

• Numbness, tingling, paresthesias, “stock and glove”, hyperalgesia …

progressing to insensitivity (loss of sensation)

MOTOR:

• Can result in deformities (Claw Toes, Achilles contracture, Hammer-toe) …

abnormally hig h pressure areas (plantar MT heads, dorsal proximal IP joints )

AUTONOMIC:

• Dry skin … cracks & fissures

• VASCULAR DISEASE:

LARGE VESSEL DISEASE:

• Diminished peripheral pulses, cool extremities, dry skin

MICROVASCULA R DISEASE:

• Affects peripheral neural fibers, aggravating neuropathy

• Retards access of antimicrobial agent to wou nd/ulcer




DIAGNOSIS: History: Special Focus on …16

• PAST H/O:Ulceration, Amputation, Charcot Joint, Vascul ar Surgery,

Angiopl asty, Cigarette Smoki ng

• Neurolog ical Symptoms:Positive Symp.: Burning, Shoot ing Pain, Sharp sensation,

Electrical sensation.

Negative Symp .: Numbness, Feet feel dead

• Other Diabetic Complications:Nephropathy, Retinopathy




DIAGNOSIS: Physical Examination: 117

INITIAL & FOLLOW-UP EXAMINATION• Visual Inspection

• Foot Examination

• Vascular assessment

•

Neurologic assessment

• Dermatologic assessment

• Deformity

• Mobility assessment of foot & ankle

See next 2 slides for details …




DIAGNOSIS: Physical Examination: 218

• VISUAL INSPECTION:

• INJURIES & BRUISING

• DEFORMITIES: Bunions, Achilles contracture, Rocker-bottom foot,

Hammertoes

• VASCULAR SKIN CHANGES: Stasis dermatitis, Skin atrophy, hair loss ,

nail changes, clear areas of d ecreased perfus ion

• SHOE’S FITTING

• VASCULAR ASSESSMENT:

• Dorsalis Pedis, Post. Tibial A.

• Temperature of Foot relative to leg, Capillary Refill, Pallor, Ankl e-

Brachial Index




DIAGNOSIS: Lab. Invest igations20

• CBC: Hb is specially important• Glucose profile: Fasting, PP, HbA1c

• Inflammatory Markers: ESR, CRP

• Nutritional Status: Serum Albumin

•

Hepatic & Renal Func.n

Test• Urinalysis

• Blood C/S

• Wound C/S

• X-Ray of both feet, MRI




DIAGNOSIS: Other Investigations21

If required …• Arterial Doppler

• Toe pressure measurement

• Oxygen tensiometry

•

Arteriogram




DIAGNOSIS: Osteomyelit is22

If chr. non-healing ul cer, HUNT for underlying Osteomyelitis• Probe-to-Bone Test

• Bone Biopsy (gold standard)

• Appropriate imaging technique:

• Plain radiographs of both feet, bone scin tigraphy, US, CT, MRI (most-

reliable)

• Radiographic Milestones:

• Radiolucency: 5-7 days

• Sequestrum & Involucrum: 10-14 days (first signs)

• Osseous demineralization, periosteal elevation, cortical irregu larity

usually detected after 35-50% reducti on in BMD

• Other Radiographic Features:

• Soft-tissue edema, Gas in soft -tissues, Foreign Bodies




DIAGNOSIS: Muscle Atrophy23

Estimation of muscle volume of small foot muscles

• MRI is gold standard (high spatial resolution permits identif ication of individual foot m s.)

• Limitations of MRI:

• Cannot be done at bed-side

• Time-consuming• Expensive

• Ultrasonography (USG) is good alternative for detecting atrophy

• Electromyography (EMG)

Severinsen K, Obel A, et al. Diabetes Care 2007; 30(12): 3053-57




RISK STRATIFICATION &

SCORING SYSTEMS

Section 3

24




RISK STRATIFICATION25

No H/O Ulceration

Pedal Pulses Present

No Deformity

No h/o Previous Amputation

No Sensory Loss

Category 0


No H/O Ulceration


Moderate Deformity (prelesion)

Single lesser ray Amputation

Sensory Loss

Category 2

No H/O Ulceration


No Deformity

No Previous Amputation

Sensory Loss

Category 1

No H/O Ulceration

Pedal Pulses Present or Absent

Moderate Deformity (prelesion)

Single lesser ray Amputation

Sensory Loss

Category 4




RISK STRATIFICATION: Algori thm26

Ulceration +ve

Pulses may be absentCategory 3

Y

Deformity +ve

H/O Previous AmputationCategory 2

Category 1Sensory Loss +ve

No H/O Ulceration

No Deformi ty

No H/O Previous Amputati on

Pedal Pulses PresentNo Sensory Loss

Category 0


Clayton W. Jr, Elasy TA.. Clinical Diabetes 27: 372-6. 2009

Y

Y

Y

N

N

N




Diabetic Foot Grading: 127

NUMEROUS GRADING SYSTEMS

• UT: University of Texas

• SINBAD: Site, Ischemia, Neuropathy, Bacterial infection , Ulcer Area, Depth

• S(AD)SAD: Size ( Area, Depth), Sepsis, Arthropathy, Denervation

• PEDIS: Perfusion, Extent, Depth, Infection, Sensation

• Wagner

• Duss




Diabetic Foot Grading: 2: TU28

GRADE DESCRIPTION INFECTION

0

1

2

3

Foot At Risk

Superficial Ulceration

Ulcer penetrating to tendon o r capsule

Ulcer penetrating to bone or joint

None

None

Superficial Infection

Deep Infection

ISCHEMIC GRADES:

A = No ischemia; B = Ischemia w/o gangrene; C = partial gangrene; D = complete gangr ene

Beckart S, Witte M, Wicke C, et al. Diabetes Care 29: 988-92, 2006




Diabetic Foot Grading: 3: DUSS29

• Palpable Pedal Pulses: Yes = 0, No = 1

• Probing-to-Bone: No = 0, Yes = 1

• Site of Location: Toe = 0, Foot = 1

• No. of Ulcers: Single = 0, Multiple = 1

• Maximum score of 4 possible

• High score correlate with healing, hospitalization, amputation .

Beckart S, Witte M, Wicke C, et al. Diabetes Care 29: 988-92, 2006




Diabetic Foot Grading: 4: SINBAD30

Site, Ischemia, Neuropathy, Bacterial infection , Ulcer A rea, Depth

• SITE: 0 = Forefoot 1 = Midfoot, Hindfoot

• ISCHEMIA: 0 = Pedal Flow Intact; at least one pedal pulse palpable,

1 = Clinical evidence of reduced pedal blood flo w

• NEUROPATHY: 0 = Protec tive sensation int act 1 = Protectiv e sensation lost

• BA. INFECTION: 0 = None 1 = Present

• ULCER AREA: 0 = Ulcer < 1cm2 1 = Ulcer < 1cm2

• DEPTH: 0 = Ulcer limit ed to skin & subcutaneous tissue,

1 = Ulcer reaching musc le, tendon or deeper

Ince P, Abbas ZG, Lutale JK, et al. Diabetes Care 31: 964-67, 2008




TREATMENT:Goals & Modalit ies

(Rx of PPG, Neuropathic Pain & DFU)

Section 4

31




DFU Rx: Therapeutic Objectives32

TREAT Diabetic Foot

PREVENTIVE

MEASURES

AgainstDiabetic Foot

PREVENT

Diabetes Mellitus

TREAT

Diabetes Mellitus

TREAT

Other

Complications




DIABETES Rx: Target PPG too …33

“ Wide glycemic variability, especially in the postprandial state…”

induces a high oxidative stress which is specially damaging to

the risk of long-term diabetic complications.

Farber DC., Farber JS. Prim Care Clin Office Pract 34: 873-85. 2007

Therefore, in light of above and other abundant data …

• PPG should not be neglected during follow-up.

• Normal FPG with untested PPG as an indicator of good diabetes control is a placebo.

• Control of PPG, in addition to FPG, is strongly recommended.




DIABETES Rx: Impact of PPG …34

PPG & Vascular Complications

Uncontrolled

PP Glucose Peaks

Activation of Protein Kinase C

MICROVASCULAR

COMPLICATIONS

Enhanced DetrimentalMetabolic Consequences

MACROVASCULAR

COMPLICATIONS

(See Next Sli de …)




DIABETES Rx: Modali ties of PPG Contro l36

• Diet Control

• Pharmacological:

• Meglitinides

• Nateglinide, Repaglinide

•Side effects of Wt. gain, Hypoglycemia

• a-Glucosidase Inhibitors

• More preferred

• Acarbose

• Voglibose (better tolerance … see next slide)




DIABETES Rx: Why Vogl ibose …37

A

V

Complex &Partially Digested CHO

delivery to Colon

Gas

Production

More

Less

More

Less

GI

Side-Effects

More

Less

A = Acarbose, V = Vogli bose




NEUROPATHIC PAIN Rx38

•Following are used for management of neuropathic pain:• Duloxetine (US-FDA approved)

• Pregabalin (US-FDA approved)

• Others that are used for management of neuropathic pain:

• Amitriptyline

• Carbamazepine

• Gabapentin

• No option exists for restoration of sensory loss

• Surgical Nerve Release is controversial and evolving




DFU Rx: Treatment Team39

Some specialist who can con tribu te to treatment of DF:• Primary Care Phys ician

• Certified Diabetes Educator

• Endocrinologist

• Orthopedic (foot & ankle specialist)

• Vascular sur geon

• Infectious Disease specialist

• Podiatrist

• Pedorthist

• Physical therapist

• Social worker

• Home Health Care Service




DFU Rx: Objectives40

• Off-Loading:Objective: Pressure normalization on affected areas

• Wound Care:

Objective: to maintain moist wound bed, absorb exudate, prevent infection

• Antibiotic Treatment:Objective: to treat polymicrobial infection

• Vascular interventions:

Objective: to restore vascular flow




DFU Rx: Modalities41

• Surgical Debridement

• Larval Debridement

• Off-loading

• Evidence-based Ant imicrobial therapyC/S based choice of d eep tissue cultures (supf. cultures can be misleading)

•

Growth Factors:rh-PDGF (recombinant hu man Platelet Derived Growth Factor),

VEGF (Vascular Endoth elial Growth Factor)

• Protease Inhibito rs:Doxycycline,

Gelatin dr essing (Promogram) ,

Metal ions & Citric acid dressing (Dermax)

• Cell Therapy

• Vascular Intervention:Surgical by-pass with upto 90% 10-yr survival rate have been reported

Lobmann R., Schuktz G., Lehnert H. Diabetes Care 28: 461-71. 2005


Clayton W. Jr, Elasy TA.. Clinical Diabetes 27: 372-6. 2009




DFU Rx: Off-Loading Devices (OLD)42

• Following are some of the OLD:

• Bed-rest, wheel chair, Crutch-assisted gait

• Total Con tact Cast (TCC) (Gold standard)

• Felted Foam

• Half-shoes

• Therapeutic Shoes

• Removable Cast walkers

• TCC, though a gold standard, were used by only 1.7% centers in USA … as

reported in a survey in 2008.

Wu SC, Jensenn JL, Weber AK. Diabetes Care 31: 2118-9. 2008




DFU Rx: Off Loading Devices43

TOTAL CONTACT CASTS

HALF-SHOES




DFU Rx: Larval Debridement44

Larval Debridement Therapy

• Sterile Green Blow Fly Larvae

• Secrete digestive enzymes

• Surface area of necroti c ti ssue reduced

•

Initiates granulation tiss ue formation• In one trial, 12 of 12 MRSA infected wounds recovered

• Other successful trials reported

Bowling FL, Salgami EV, Boulton AJ. Diabetes Care 30: 370-1. 2007





PREVENTION:Goals & Modalities

Section 5

45




DFU: Preventive Measures46

Some preventive steps to safeguard feet in diabetics:• Motivate patient to “ take-over”

• Patient-education about gravit y of disease & gluco se control

• Smoking-cessation

• Appropri ate diet & exercise

• Avoid excessi vely high temperatures to foot

• Avoid hot surfaces (sandy beaches, cement areas, etc.)

• Avoid chemicals for removal of corns

• Check sho es for foreign objects that might exert pressure

• Daily foo t hy giene inspection

• Care during n ail trimming

• Immediate treatment of fungal infecti on




DFU Management: SUMMARY47

• Patient empowerment for stric t compl iance & implementation of Life-style changes

• Multispecialty Team-work

• Off-load Ulcer

• Debride, if necessary

• Antimicrob ial choice based on Deep tissue C/S

• Vascular surgery, if necessary

• Contro l Plasma Glucose … FPG & PPG




Thank You for Your Attention… !!!

48


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