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! !
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