ANATOMY & PATHOPHYSIOLOGY OF DISBETIC FOOT INFECTION

DR ARUN BALPRESIDENT

DIABETICV FOOT SOCIETY OF INDIA

PLANTAR ARCHES

ARCHES OF FOOT

LONGITUDINALTRANSVERSE

LONGITUDINAL ARCHES

MEDIAL: HIGHER MORE MOBILE RESILIENT

LATERAL:LOW LIMITED MOBILITY BUILT TO BEAR WT.

TRANSVERSE ARCHES

CONCEPT OF PLANTAR SPACES

PLANTAR SPACES

SURGICAL TREATMENT OF DIABETIC FOOT

MID FOOT ABCESS WITH TOE GANGRENE

Dr.bal

SURGICAL TREATMENT OF DIABETIC FOOT

DRAINAGE OF MID FOOT ABCESS-POST OPERATIVE

Dr.bal

CROWDING OF TOES CAUSING ARTERIAL THROMBOSIS

ANATOMY OF THE HEEL

MAJORITY OF DIABETIC FOOT ULCERS ARE IN THE REGION OF 1ST MTP JOINT

HAWAI(WEB & TOE STRAP) SLIPPERS ACCENTUATE TOE DEFORMITIES

HAWAI SLIPPERS /STANDING

HAWAI SLIPPERS /WALKING

TOE PRESSURE

PATHO- BIOMECHANICS OF DIABETIC FOOT ULCCEER

BIOMECHANICS OF FORE FOOT AMPUTATION

Dr.bal

PATH -BIOMECHANICS OF DIABETIC FOOT ULCER

BIOMECHANICS OF FOREFOOT AMPUTATION

Dr.bal

CAUSE OF 2ND MT ULCER

ANATOMICAL BASIS OF SPREADING FOOT INFECTION

HEMOSTASIS 1 hour

WOUNDING

PlateletsFibrin

INFLAMMATION days 1 through 7Proteoglycans

NeutrophilsMacrophages]

LymphocytesPROLIFERATION days 2 through 20

Normal wound healing

Fibroblasts[produce growth factors]

CollagenEpithelial Cells

Endothelial Cells

REMODELING 1 week to 6 months

Collagen Fibril Cross linking

Scar Maturation

Time from injury

WOUND BED PREPARATION

DYNAMIC & RAPIDLY EVOLVING CONCEPTREDUCES THE WOUND HEALING TIMEREDUCES HE COST OF THE TREATMENTDEFINATION:GLOBAL MANAGEMENTTO ACCELERATE ENDOGENOUS HEALING AND TO FACILITATE OTHER THERAPEUTIC MEASURESIT IS THIRD STAGE OF WOUND CARE REVOLUTION

EVOLUTION OF TIME FRAMEWORK

T = TISSUE MANAGEMENTI = INFECTION/INFLAMMATION

CONTROL M = MOISTURE CONTROLE = EDGE/EPIDERMAL

CONTROL

TISSUE MANAGEMENTDEBRIDEMENT

REMOVAL OF NECROTIC, DEVITALIZED, CONTAMINATED TISSUESHARP AND/OR SURGICAL DEBRIDEMENTNECROTIC TISSUE MASKES THE INFECTIONCREATES PHYSICAL BARRIER TO HEALINGINHIBITS CONSTITUENTS OF EXTRACELLULAR MATRIXPREVNETS GRANULATION TISSUE FORMATION

SELECTION OF TYPE OF DEBRIDEMENT

SIZE,POSITION,TYPE OF THE WOUNDMOISTURE LEVELPAIN MANAGEMENTTIME AVAILABLEFACILITIES AVAILABLELEVEL OF HEALTHCARE TRAINING

SURGICAL OR SHARP DEBRIDEMENT

FASTEST WAY TO REMOVE DEBRIS AND NECROTIC TISSUEMINIMAL DAMAGE TO THE SURROUNDING TISSUERELEASES CYTOKINES THAT HELPS WOUND REPAIRNEEDS TRAININGNEEDS INFRASTRUCTURE

SHARP DEBRIDEMENT

A

B

C

SURGICAL DEBRIDEMENTA B

ENZYMATIC DEBRIDEMENT

MOST SELECTIVEEXOGENOUS PROTEPLYTIC ENZYMES ARE USED TO RMOVE NECROTIC TISSUEWORK WITH ENDOGENOUS ENZYMES TO DEGRADE THE NECROTIC TISSUEMAY CAUSE MINOR TRASIENT PAIN AND DISCOMFORT

Papain-Ures CollagenaseDebridement +++ +++Speed ++ +Selectivity

- +++

Pain

++ -

Mt.Debridement

- ++

Reduce Bact.Burden

++

+++

Reduce Exudate ++ ++More Gran.Tissue ++ Epithelization - ++

ENZYME DEBRIDEMENT

AUTOLYTIC DEBRIDEMENT

NATURAL DEBRIDEMENTPHAGOCYTIC CELLS AND PROTEOLYTIC EZYMES LIQUIFY AND SEPARATE NECROTIC TISSUEMOIST ENVIRONMENT NECESSARY FOR AUTOLYTIC DEBRIDEMENTCAN RESULT IN TO SIGNIFICANT WOUND EXUDATEDOES NOT DAMAGE HEALTHY TISSUEREQUIRES MINIMAL TECHNOLOGY AND TRAININGMINIMAL PAIN

BIOLOGICAL DEBRIDEMENT

USE OF LARVAE /MAGGOTSGREEN BOTTLE FLY LARVAEUSEFUL IN PATIENTS WITH THICK SLOGHLIMITED AVAILABILITYNOT ACCEPTED BY MANY PATIENTSERADICATES INFECTION AND SMELL

MECHANICASL DEBRIDEMENT

NON SELECTIVE METHODWOUND IRRIGATION,WHIRPOOL THERAPY,WET TO DRY DRESSINGSIGNIFICANT DISCOMFORT AND PAINWOUND IRRIGATION IS UNSUITABLE FOR GRANULATING WOUNDS

MAINTENANCE DEBRIDEMENT

AN EXTENDED PHASE OF DEBRIDEMENTREQUIRED DUE TO CO MORBIDITIESSIGLE EPISODE OF DEBRIDEMENT MAY NOT BE SUFFECIENTOFFERS DISTINCT ADVANTAGE IN WOUND MANAGEMENTENZYMATIC AND AUTOLYTIC DEBRIDEMENT IS VERY USEFUL

Vacuum-Assisted Wound Closure

Topical negative pressure therapy which can be used to achieve closure of diabetic foot woundsThe pump applies subatmospheric pressure through a tube and foam sponge applied to the ulcer over a dressing and sealed in place with a plastic filmThe dressing is replaced every two to three daysSmall portable pumps are now available

Vacuum-Assisted Wound Closure

Negative pressure improves the dermal blood supply, and stimulates granulation which can form over bone and tendon. It reduces bacterial colonisation and diminishes oedema and interstitial fluidCourse of treatment is usually 7-10 daysThe effect may wear off after 3 days but if the pump is removed and then replaced after 1 day this restores the effectExcessive pain may prohibit the use of this technique (even in neuropathic feet)

VAC pump

VAC pump dressing

VAC pump sponge

Healing wound after VAC pump

Healed wound after VAC pump

Larva therapy (maggots)

The larvae of the green bottle fly Lucilia sericata are used to debride ulcers, especially in the neuroischaemic footThis results in relatively rapid atraumatic physical removal of necrotic materialLarvae also produce secretions that have antimicrobial activity against Gram-positive cocci including MRSARandomized clinical trials are awaitedExpensive (unless you grow your own)

THANK YOU