Classification and Management of

Diabetic Foot UlcersMedical and Surgical

Classification and Management of

Diabetic Foot UlcersMedical and Surgical

Karin Schara M.D.

University Medical Centre Ljubljana

Dept. of Orthopaedic Surgery

Slovenia

Karin Schara M.D.

University Medical Centre Ljubljana

Dept. of Orthopaedic Surgery

Slovenia

DiabeticDiabetic footfoot

AmputationAmputation:: one one ofof thethe most most fearedfeared complicationscomplications

DiabeticDiabetic footfoot -- late late complicationcomplication::•• affects up to 25% of all diabetic patientsaffects up to 25% of all diabetic patients•• affects up to 25% of all diabetic patientsaffects up to 25% of all diabetic patients

•• 20 % 20 % requirerequire hospitalisationhospitalisation

•• 20 to 70% of lower limb amputations 20 to 70% of lower limb amputations

•• patientpatient -- newnew set set ofof problemsproblems -- home, home, familyfamily andand occupationoccupation

Diabetic foot Diabetic foot

Look for wounds!Look for wounds!

Diabetic foot Diabetic foot

Look for wounds!Look for wounds!

Take the shoes off!Take the shoes off!

Diabetic foot Diabetic foot

Every nonEvery non--healing wound presents a threat for healing wound presents a threat for infection and inflammation. Amputation!infection and inflammation. Amputation!

Treatment ?Treatment ?

UlcerUlcer !!!!

Diabetic foot Diabetic foot

EEvaluationvaluation

1. Wound1. Wound

2. Blood supply2. Blood supply

3. Infection3. Infection

4. Deformity4. Deformity

MeggittMeggitt––Wagner classificationWagner classification

Deep ulcer penetrating below the dermis - fascia, muscle or

tendon2

Superficial full thickness ulcer1

Intact skin, no ulcer0

Gangrene of the entire foot5

Gangrene of a toe or part of the foot4

Deep ulcer with abscess or osteomyelitis3

tendon

1. 1. WoundWound

•• Meggit WagnerMeggit Wagner

•• University of TexasUniversity of Texas

0 1 2 3

A Pre or

postulcerative

lesion

Superficial, not

involving

tendon, capsule

Penetrates to

tendon or

capsule

Penetrates to

Bone A lesion

(epithelialized)

tendon, capsule

or bone

capsule

B INFECTION INFECTION INFECTION INFECTION

C ISCHEMIA ISCHEMIA ISCHEMIA ISCHEMIA

D INFECTION and

ISCHEMIA

INFECTION and

ISCHEMIA

INFECTION and

ISCHEMIA

INFECTION and

ISCHEMIA

2. 2. ArterialArterial bloodblood supplysupply

•• palpationpalpation ofof peripheralperipheral pulsespulses

•• perfusionperfusion pressurepressure measurmentmeasurment

•• TCPO2TCPO2

•• arteriographyarteriography (major (major surgicalsurgical proceduresprocedures

or or amputationamputation))

3. 3. InfectionInfection

•• inspectioninspection•• inspectioninspection

•• woundwound swabswab

•• XX--rayray

4. 4. PeripheralPeripheral neuropathyneuropathy

•• sensitivitysensitivity ((monofilamentmonofilament) )

5. 5. PlantarPlantar pressurepressure measurmentmeasurment ((electiveelective casescases))

OtherOther diseasesdiseases!!

DiagnosticDiagnostic evaluationevaluation shouldshould answeranswer::

1. 1. ischemicischemic

2. 2. neuroischemicneuroischemic

3. 3. neuropathicneuropathic

InfectionInfection !!

1&2 Ischemic, neuroischemic ulcer1&2 Ischemic, neuroischemic ulcer

•• pale, cyanotic skinpale, cyanotic skin

•• no callus formationno callus formation

•• no joint deformitiesno joint deformities

•• claudication (not painful claudication (not painful --neuropathy!)neuropathy!)

WhereWhere::

•• at the edges at the edges –– toes, toes,

•• lateral border, heellateral border, heel

AngiologyAngiology or or vascularvascular surgerysurgery!!

AmputationAmputation??

3. Neuropathic ulcer3. Neuropathic ulcer

•• insensateinsensate footfoot

•• skinskin is is warmwarm (no (no significantsignificant

bloodblood supplysupply impairmentimpairment) )

•• jointjoint deformitiesdeformities

•• calluscallus formationformation

WhereWhere -- under metatarsal headsunder metatarsal heads

CauseCause::

-- minimal traumaminimal trauma

-- shoe shoe

A diabetic foot ulcer should heal if:A diabetic foot ulcer should heal if:

•• adequate arterial inflowadequate arterial inflow

infection is appropriately managedinfection is appropriately managed•• infection is appropriately managedinfection is appropriately managed

•• pressure is removed from the wound pressure is removed from the wound

and its marginsand its margins

Gold standard:Gold standard:

•• wound debridementwound debridement

•• offoff--loadingloading•• offoff--loadingloading

•• dressingdressing

Regular wound debridementRegular wound debridement

Water and soap!Water and soap!

RegularRegular woundwound debridementdebridement, , offoff--loadingloading, , andand

dressingsdressings

1. 1. 3. 3.

2.2.

RegularRegular woundwound debridementdebridement,, offoff--loadingloading, , andand

dressingsdressings

RegularRegular woundwound debridementdebridement, , offoff--loadingloading, , andand

dressingsdressings

1. 3. 1. 3.

2.2.

Case presentation:Case presentation:

•• male, diabetic, 45 yearsmale, diabetic, 45 years

•• acute injuryacute injury

Case presentation.

• male, 67 years, diabetic patient

• non-healing wound - hindfoot

Osteomyelitis!!

DiabeticDiabetic footfoot & & SurgerySurgery

PrimaryPrimary goalgoal todaytoday -- Limb Limb salvagesalvage

Surgery

Curative: infection

blood supply

Elective:plastic surg methods

orthopaedic

methods

Preventative

Treatment Treatment of theof the neuropathic foot ulcer:neuropathic foot ulcer:

1. Off1. Off--loading loading -- debridement debridement –– infection controlinfection control

2. Surgery 2. Surgery -- correction of the deformitiescorrection of the deformities

Facts:Facts:

•• NeuropathicNeuropathic foot ulcers heal readily with appropriate plantar pressure relief. foot ulcers heal readily with appropriate plantar pressure relief.

•• Ulcer recurrence is frequent if the underlying cause of increased plantar Ulcer recurrence is frequent if the underlying cause of increased plantar

pressure is not eliminated.pressure is not eliminated.

•• Ulcer healing can be achieved Ulcer healing can be achieved surgicalsurgicalllyy -- metatarsal head resectionmetatarsal head resections ors or

osteotomosteotomies .ies .

Case presentation .Case presentation .

•• male, 55 years, type 1 diabetesmale, 55 years, type 1 diabetes

•• neuropathic plantar forefoot ulcer, 1 yearneuropathic plantar forefoot ulcer, 1 year•• offoff--loading, regular wound debridement and loading, regular wound debridement and

dressingsdressings

•• 8 weeks of conservative treatment: ulcer healing8 weeks of conservative treatment: ulcer healing

Case presentation.Case presentation.

•• male, 55 years, type 1 diabetesmale, 55 years, type 1 diabetes

•• the patient was fitted with customthe patient was fitted with custom--made shoesmade shoes

•• 3 weeks later 3 weeks later -- ulcer recurrenceulcer recurrence

•• XX--rays: minor 3rays: minor 3rdrd MTP jointMTP joint

deformitydeformity

•• oblique oblique distaldistal metatarsalmetatarsal osteotomyosteotomy

through dorsal approachthrough dorsal approach

•• no fixation usedno fixation used

Result 2 years after Result 2 years after

surgery.surgery.

OrthopaedicOrthopaedic surgsurgicalical methodsmethods forfor neuropathicneuropathic footfoot: :

•• osteotomiesosteotomies

•• arthrodesisarthrodesis

•• partialpartial bone bone resectionresection

•• removalremoval ofof sesessamoidamoid bonesbones

underunder locallocal or or regionalregional anesthesiaanesthesia..

Equinus deformity Equinus deformity

•• AT shortening AT shortening –– forefoot ulcer developmentforefoot ulcer development

•• after amputationafter amputation, Charcot foot..., Charcot foot...

Treatment: Treatment: AT lenghteningAT lenghtening•• pressure pressure returnreturnss to preoperatto preoperatiive level in 8 monthsve level in 8 months

•• selection of patients!selection of patients!

Chao W, Mizel M. What is new in foot and ankle surgery. JBJS 2006Chao W, Mizel M. What is new in foot and ankle surgery. JBJS 2006

Non-healing neuropathic diabetic foot ulcers present a major

threat for infection - amputation!!

Too late!

Treat before it is too late!

• wet dressing

• rest

• antibiotics• antibiotics

Infected wound Infected wound -- ischemic or neuropathicischemic or neuropathic

Characteristics:Characteristics:

•• acute acute -- postpost--traumatic infection (blister, puncture wounds ...)traumatic infection (blister, puncture wounds ...)

•• chronic chronic -- nonnon--healing woundhealing wound

Diabetic patients are at great risk:Diabetic patients are at great risk:

•• necrotising cellulitisnecrotising cellulitis

•• necrotising fasciitis necrotising fasciitis

LifeLife--threatening condition ! threatening condition !

•• early incision (longitudinal incisions) and drainageearly incision (longitudinal incisions) and drainage

•• serial debridementsserial debridements

•• amputationamputation

Fluid and blood replacement, antibiotics!Fluid and blood replacement, antibiotics!

Infected wound Infected wound -- ischemic or neuropathicischemic or neuropathic

Amputation technique:Amputation technique:

•• direct closure of the wounddirect closure of the wound

•• guilliotine amputationguilliotine amputation

Level:Level:

•• removal of all nonviable tissue (preoperative evaluation!)removal of all nonviable tissue (preoperative evaluation!)

•• try to preserve as much original tissue as possible!try to preserve as much original tissue as possible!

Skin graftingSkin grafting

Infected wound Infected wound -- ischemic or neuropathicischemic or neuropathic

Infected wound Infected wound -- ischemic or neuropathicischemic or neuropathic

Charcot neuroartropathy Charcot neuroartropathy

DefinitionDefinition

DespiteDespite a a historyhistory ofof 130 130 yearsyears in in

thethe medicalmedical literature, literature, thethe disorderdisorder

remainsremains unexplainedunexplained..

Non-infective, progressive condition associated with

peripheral neuropathy.

HypothesesHypotheses -- neurotraumaticneurotraumatic, ,

neurovascularneurovascular........

Charcot Charcot neuroneuroarthropathy arthropathy

CCaracterized by:

• joint dislocation

• pathological fractures

• cartilage destruction

• severe anatomical disruption

The result The result -- collapse of the foot.collapse of the foot.

EpidemiologEpidemiologyy

•• PrevalPrevalenceence: 0.15%: 0.15%

•• Affects both men and womenAffects both men and women

•• AgeAge: 5: 50 0 –– 60 years60 years

•• TTypeype 1 = T1 = Typeype 2 DM2 DM

Prolonged duration of DMProlonged duration of DM(~10(~10 yearsyears))•• Prolonged duration of DMProlonged duration of DM(~10(~10 yearsyears))

•• 16% 16% of those with history of neuropathic ulcers of those with history of neuropathic ulcers show Charcot changes on Xshow Charcot changes on X--RaysRays

•• 30% bilateral30% bilateral

CavanaghCavanagh et al, Diabetes Caret al, Diabetes Care e 1994;17:2011994;17:201

Charcot neuroarthropathy and ClassificationCharcot neuroarthropathy and Classification

Eichenholtz, 1966Eichenholtz, 1966•• clinical and radiographic caracteristicsclinical and radiographic caracteristics

1.1. Developmental (acute dissolution)Developmental (acute dissolution)

2.2. Coalescent (healing)Coalescent (healing)

3.3. Reconstructive stages (resolution)Reconstructive stages (resolution)

Caracteristic patterns: Caracteristic patterns:

•• Fractures (low bone mineral density)Fractures (low bone mineral density)

•• Dislocations (normal bone mineral density)Dislocations (normal bone mineral density)

Timming of surgical procedure !Timming of surgical procedure !

Acute Acute Charcot Charcot NeuroNeuroarthropathy arthropathy

Recognise acute findings: Recognise acute findings:

Infection!! Infection!!

•• swelling and joint effusionswelling and joint effusion

•• elevated skin temperatureelevated skin temperature

•• weakenedweakened ligamentsligaments

•• abnormal joint alignmentabnormal joint alignment

•• bone resorptionbone resorption•• bone resorptionbone resorption

•• erosion of cartilageerosion of cartilage

•• bone fragmentationbone fragmentation

Charcot or infection?Charcot or infection?

•• No ulcer No ulcer –– almost certainly Charcotalmost certainly Charcot

•• Ulcer Ulcer –– usually Charcotusually Charcot

•• General conditionGeneral condition –– CRP, WBCCRP, WBC

•• ImagingImaging

-- XX--raysrays-- XX--raysrays

-- MRIMRI

-- Labelled WCC/antibodiesLabelled WCC/antibodies

•• BiopsyBiopsy

Charcot Charcot NeuroNeuroarthropathy & arthropathy & PPatterns of destructionatterns of destruction

Charcot Charcot NeuroNeuroarthropathy & arthropathy & PPatterns of destructionatterns of destruction

1. To reduce disease activity1. To reduce disease activity

2. To achieve a stable joint2. To achieve a stable joint

3. To reduce deformity3. To reduce deformity

TreatmentTreatment

3. To reduce deformity3. To reduce deformity

Acute Charcot Acute Charcot NeuroNeuroarthropathy & treatmentarthropathy & treatment

ImmobilizationImmobilization ((castcast, , bracesbraces, , orthosesorthoses......crutchescrutches!) !)

to to preventprevent developmentdevelopment ofof severe severe footfoot deformitydeformity..

HowHow longlong? ? As As longlong as as clinicalclinical signssigns are are presentpresent –– temperature!temperature!

Average Average -- from 4 to 5 months. from 4 to 5 months.

Chronic Chronic Charcot Charcot NeuroNeuroarthropathy arthropathy

ChronicChronic (late) (late) findingsfindings: : UlcerUlcer developmentdevelopment !!!!

•• periostealperiosteal newnew bone bone formationformation

•• fusionfusion ofof largelarge fragmentsfragments

•• exuberantexuberant bonebone

•• decreaseddecreased jointjoint mobilitymobility

•• increasedincreased bone bone densitydensity

•• stabilizationstabilization

•• deformitydeformity•• deformitydeformity

Surgery:Surgery:

•• excisionexcision ofof bonybony prominencesprominences

•• stabilizationstabilization ofof neuropathicneuropathic jointsjoints

CharcotCharcot arthropathyarthropathy andand SurgerySurgery

Main goals of surgical treatment Main goals of surgical treatment areare to create:to create:

•• plantigradeplantigrade

•• stablestable footfoot•• stablestable footfoot

•• freefree fromfrom significantsignificant riskrisk forfor furtherfurther

breakdownbreakdown or or infectioninfection

•• footwearfootwear andand bracingbracing

•• preventionprevention ofof amputationamputation

Diabetic Diabetic FFoot & Preventative Surgeryoot & Preventative Surgery

Foot at risk!Foot at risk!

Severe foot deformities Severe foot deformities –– ulcers! ulcers! AArthrodesis, arthroplastyrthrodesis, arthroplasty,,

hallux valgus correctionhallux valgus correction

ConclusionConclusion..

PrimaryPrimary goalgoal throughthrough thethe last 20 last 20 yearsyears --

limb limb salvagesalvage

•• peripheralperipheral arterialarterial insufficiencyinsufficiency•• peripheralperipheral arterialarterial insufficiencyinsufficiency

•• acuteacute bone bone andand softsoft tissuetissue infectioninfection

LimitedLimited reconstructivereconstructive possibilitiespossibilities -- amputationamputation. .

ConclusionConclusion..

Primary goal through the last 20 years Primary goal through the last 20 years --

limb salvagelimb salvage

We can treat neuropathic foot ulcers.We can treat neuropathic foot ulcers.

Prevention of amputation in neuropathic ulcersPrevention of amputation in neuropathic ulcers! !