Classification and Management of Diabetic Foot...

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  • 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