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

MeggittMeggittWagner 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:D