Diabetic Foot Diabetic Foot UlcersUlcers

Sonja Lichtenstein, MD, FACS, UHMSonja Lichtenstein, MD, FACS, UHMZone Medical Director, National Healing Zone Medical Director, National Healing

CorporationCorporation

ObjectivesObjectivesReview the risk factors for development Review the risk factors for development of diabetic foot ulcersof diabetic foot ulcers

Methods to use to help prevent diabetic Methods to use to help prevent diabetic foot ulcersfoot ulcers

Basic management of diabetic foot Basic management of diabetic foot ulcersulcers

Diabetes Diabetes epidemicepidemic

Incidence of diabetes in the world in Incidence of diabetes in the world in 2000 was 171,000,0002000 was 171,000,000

Projected incidence in 2030 is Projected incidence in 2030 is 366,000,000366,000,000

In 2010, 12.3% of adults in the United In 2010, 12.3% of adults in the United States had diabetesStates had diabetes

Incidence by Incidence by CountryCountry

Society in Society in TransitionTransition

Cost in Developed Cost in Developed CountriesCountries

25% of diabetic patients develop a foot problem 25% of diabetic patients develop a foot problem in their lifetimein their lifetime

2008: estimated 20.8 million with DM in USA 2008: estimated 20.8 million with DM in USA

Total of $19bn spent on diabetic foot ulcersTotal of $19bn spent on diabetic foot ulcers

$11bn spent on amputation$11bn spent on amputation

Up to $21bn could be saved annually with Up to $21bn could be saved annually with practical and effective preventative foot-care practical and effective preventative foot-care educationeducation

Rogers et al, JAPMA, Rogers et al, JAPMA, 2008;98:1662008;98:166

Cost in Cost in Undeveloped Undeveloped

CountriesCountries2010: estimated 51 million with DM in India 2010: estimated 51 million with DM in India

Population-based study from ChennaiPopulation-based study from Chennai

Cost of illness study: 4677 subjects screened: 1050 Cost of illness study: 4677 subjects screened: 1050 with DM, 718 agreed to take partwith DM, 718 agreed to take part

Median direct cost for DM $526, indirect $103Median direct cost for DM $526, indirect $103

Costs increased according to complicationsCosts increased according to complications

Extrapolated to all India – annual cost of Diabetes in Extrapolated to all India – annual cost of Diabetes in India – US$32bn.India – US$32bn.

Tharkar et al, DRCP 2010;89:334Tharkar et al, DRCP 2010;89:334

Who is at Risk for Who is at Risk for Ulceration?Ulceration?

NeuropathyNeuropathy

Peripheral Vascular Disease Peripheral Vascular Disease

Past history of foot ulcerationPast history of foot ulceration

Foot deformityFoot deformity

AmputationAmputation

SmokingSmoking

Poor glycemic controlPoor glycemic control

CallousesCallouses

Diabetic Foot Diabetic Foot UlcersUlcers

63% of all diabetic ulcers are due to a 63% of all diabetic ulcers are due to a combination of:combination of:

Neuropathy Neuropathy

TraumaTrauma

DeformityDeformity

Many are further complicated by Many are further complicated by Peripheral Arterial Disease (PAD) and Peripheral Arterial Disease (PAD) and infectininfectin

How do we screen How do we screen patients?patients?

Comprehensive foot examComprehensive foot exam

HgA1CHgA1C

History reviewing risk factorHistory reviewing risk factor

NeuropathyNeuropathyIncorporates metabolic and vascular Incorporates metabolic and vascular defectsdefects

Results in neuronal demyelination and Results in neuronal demyelination and atrophyatrophy

Motor – muscle atrophyMotor – muscle atrophy

Autonomic – decrease in perspirationAutonomic – decrease in perspiration

Sensory – loss of protective sensationSensory – loss of protective sensation

Trauma Resulting from Trauma Resulting from Neuropathic ChangesNeuropathic Changes

Motor neuropathy Motor neuropathy

Altered gait and foot Altered gait and foot deformitiesdeformities

Autonomic Autonomic neuropathyneuropathy

Dry skin and fissuresDry skin and fissures

Sensory neuropathySensory neuropathyUnrecognized trauma Unrecognized trauma

Ill fitting shoesIll fitting shoes

Stepping on pins, Stepping on pins, pebbles, etcpebbles, etc

Deformity Resulting Deformity Resulting from Neuropathic from Neuropathic

ChangesChangesIncludes:Includes:

BunionsBunions

Hammer-toesHammer-toes

Prominent metatarsal headsProminent metatarsal heads

Charcot jointCharcot joint

Deformity Resulting from Deformity Resulting from Neuropathic ChangesNeuropathic Changes

Cause high compressive & Cause high compressive &

frictional forces around frictional forces around

area of deformity = skin area of deformity = skin

breakdownbreakdown

Directly related to ill Directly related to ill

fitting footwearfitting footwear

Prevention in Prevention in Patients with Patients with NeuropathyNeuropathyNeed to screen patient for Need to screen patient for

neuropathyneuropathy

Test with Test with Semmes-Weinstein Semmes-Weinstein MonofilamentMonofilament

Uses touch pressure sensation by Uses touch pressure sensation by utilizing a 10 gram monofilamentutilizing a 10 gram monofilament

Defines level of loss-of-protective Defines level of loss-of-protective sensationsensation

Failed monofilament test defined as Failed monofilament test defined as inability to sense 4 of 10 locations inability to sense 4 of 10 locations per plantar aspect of the footper plantar aspect of the foot

Peripheral Peripheral Arterial DiseaseArterial Disease

• Diabetes Mellitus increases the risk of lower Diabetes Mellitus increases the risk of lower extremity PADextremity PAD

• PAD leads to additional healing complications PAD leads to additional healing complications and increased risk for infectionand increased risk for infection

• One in three patients with diabetes over the age One in three patients with diabetes over the age of 50 has PADof 50 has PAD

• The American Diabetes Association recommends The American Diabetes Association recommends screening for PAD in all diabetic patients older screening for PAD in all diabetic patients older than 50 yearsthan 50 years

Screening for PADScreening for PADFeeling for pulses at all levels in the Feeling for pulses at all levels in the lower extremitylower extremity

ADA/ACC recommend that all those patients ADA/ACC recommend that all those patients >50 years old should have an annual ABI>50 years old should have an annual ABI

Ankle-brachial indexAnkle-brachial indexLess than 0.80: abnormalLess than 0.80: abnormalLess than 0.45: severe, limb-threateningLess than 0.45: severe, limb-threatening

Absolute toe systolic pressure - less Absolute toe systolic pressure - less than 45 mmHg is abnormalthan 45 mmHg is abnormal

Handheld DopplerHandheld Doppler

Every patient with a Every patient with a lower extremity ulcer lower extremity ulcer receives Hand Held receives Hand Held Doppler assessmentsDoppler assessments

Assesses macro-Assesses macro-circulationcirculation

Used to auscultate Used to auscultate flow velocityflow velocity

T.K. Carlson

Structural Structural DeformityDeformity

Leads for focal area of high pressureLeads for focal area of high pressure

Due to atrophy of the intrinsic Due to atrophy of the intrinsic musculature responsible for stabilizing musculature responsible for stabilizing the toesthe toes

Other FactorsOther FactorsGlycemic controlGlycemic control

ObesityObesity

Impaired visionImpaired vision

SmokingSmoking

CallousCallous

Physician Physician Responsibilities Responsibilities Inspect patient’s shoes for areas of Inspect patient’s shoes for areas of inadequate support or improperinadequate support or improper

Most patients are okay with athletic Most patients are okay with athletic shoes and thick absorbent socksshoes and thick absorbent socks

Patients with deformities or special Patients with deformities or special support needs benefit from custom shoessupport needs benefit from custom shoes

Provide education about proper care and Provide education about proper care and follow upfollow up

Control blood sugarsControl blood sugars

Patient EducationPatient EducationDaily foot inspection by the patient or Daily foot inspection by the patient or caregivercaregiver

Gentle cleansing with soap and water, Gentle cleansing with soap and water, followed by topical moisturizersfollowed by topical moisturizers

Minor foot injuries and infections can be Minor foot injuries and infections can be unintentionally exacerbated by home unintentionally exacerbated by home remedies that impede healingremedies that impede healing

Avoid hot soaks, heating pads, hydrogen Avoid hot soaks, heating pads, hydrogen peroxide, betadineperoxide, betadine

Cleanse minor wound and apply topical Cleanse minor wound and apply topical antibiotic to maintain a moist wound antibiotic to maintain a moist wound environmentenvironment

Development of Development of UlcersUlcers

Typically painless, even with severe Typically painless, even with severe infectioninfection

Often just report soiled socksOften just report soiled socks

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

There is adequate arterial inflowThere is adequate arterial inflow

Any infection is appropriately managedAny infection is appropriately managed

Pressure is removed from the wound and its Pressure is removed from the wound and its marginsmargins

Diabetic Lower Extremity Diabetic Lower Extremity UlcersUlcers

Cascade of Events:Cascade of Events:

• NeuropathyNeuropathy

• Ischemic changesIschemic changes

• InjuryInjury

• Massive tissue disruptionMassive tissue disruption

(tunneling, undermining, cavity formation)(tunneling, undermining, cavity formation)

• Cellular dysfunction leukocytes / Cellular dysfunction leukocytes / macrophagesmacrophages

• InfectionInfection

How Should Diabetic How Should Diabetic Foot Ulcers Be Foot Ulcers Be

Treated?Treated?Multidisciplinary Approach to TreatmentMultidisciplinary Approach to Treatment

May involve a number of the following:May involve a number of the following:PodiatryPodiatryVascular surgeryVascular surgeryDieticiansDieticiansInfectious diseaseInfectious diseaseEndocrinologyEndocrinologyDiabetes EducatorsDiabetes EducatorsRadiologyRadiologyPhysical TherapyPhysical TherapyOrthotistOrthotistNursingNursing

Care Plan ObjectivesCare Plan ObjectivesDetermine and Manage EtiologiesDetermine and Manage Etiologies

Comprehensive History and Physical Comprehensive History and Physical AssessmentAssessmentNon-invasive studiesNon-invasive studiesManagement of etiologiesManagement of etiologies

Laboratory EvaluationLaboratory EvaluationNutrition statusNutrition statusGlucose controlGlucose controlCo-morbid disease managementCo-morbid disease management

Ulcer managementUlcer management

Off-loadingOff-loading

Patient EducationPatient Education

Determine and Manage Determine and Manage EtiologiesEtiologies

History and PhysicalHistory and PhysicalPatient and their family medical historyPatient and their family medical historyHistory of the ulcerHistory of the ulcerThorough assessment of the patientThorough assessment of the patient

Lower Extremity AssessmentLower Extremity AssessmentSemmes Weinstein and Tuning Fork - Semmes Weinstein and Tuning Fork - Assesses for neuropathyAssesses for neuropathyHand-held Doppler - Dorsalis pedis and Hand-held Doppler - Dorsalis pedis and posterior tibial pulse signalsposterior tibial pulse signals

Non-invasive studiesNon-invasive studiesVascular studiesVascular studiesRadiographic studiesRadiographic studies

Transcutaneous Oximetry (TcPOTranscutaneous Oximetry (TcPO22) – ) – measures the measures the oxygenation of the tissues around the ulceroxygenation of the tissues around the ulcer

Skin Perfusion Pressure (SPP) Skin Perfusion Pressure (SPP) - measures the - measures the pressure at which blood flow first returns to the pressure at which blood flow first returns to the capillaries following a controlled release of capillaries following a controlled release of occlusion from a blood pressure cuff. occlusion from a blood pressure cuff.

Arterial Duplex Ultrasound Arterial Duplex Ultrasound - Duplex - Duplex ultrasonography of the arteriesultrasonography of the arteries

Ankle-Brachial Index (ABI)/Segmental Ankle-Brachial Index (ABI)/Segmental Pressures/Toe Pressures Pressures/Toe Pressures - Assess pressure at - Assess pressure at multiple levels on the limb or digitmultiple levels on the limb or digit

AngiographyAngiography – invasive study providing detailed – invasive study providing detailed imaging of the arteries imaging of the arteries

Vascular StudiesVascular Studies

Radiographic Radiographic StudiesStudies

X-ray – X-ray – should be performed on all diabetic should be performed on all diabetic foot ulcerations to rule out foreign body foot ulcerations to rule out foreign body presencepresence

MRI – MRI – recommended by ADA as best non-recommended by ADA as best non-invasive diagnostic imaging for osteomyelitisinvasive diagnostic imaging for osteomyelitis

Bone Biopsy - Bone Biopsy - the definitive diagnostic study the definitive diagnostic study for osteomyelitis allowing for culture and for osteomyelitis allowing for culture and sensitivity of the specimensensitivity of the specimen

Management of Management of EtiologiesEtiologies

PAD and Osteomyelitis are two common PAD and Osteomyelitis are two common secondary etiologies affecting healing of the secondary etiologies affecting healing of the diabetic ulcerdiabetic ulcer

Both must be identified and Both must be identified and corrected/optimized for successful ulcer corrected/optimized for successful ulcer healing to occurhealing to occur

Other etiologies also need to be identified and Other etiologies also need to be identified and corrected/optimized for successful ulcer corrected/optimized for successful ulcer healinghealing

Ulcer ManagementUlcer Management

Diagnose and treat underlying Diagnose and treat underlying etiologiesetiologies

Adequate debridement Adequate debridement

Dressing choice based on ulcer needsDressing choice based on ulcer needs

Treatments that stimulate healingTreatments that stimulate healingNegative Pressure Wound Therapy (NPWT)Negative Pressure Wound Therapy (NPWT)Biologic productsBiologic products

Bioengineered tissuesBioengineered tissuesGrowth factorsGrowth factors

Hyperbaric Oxygen Therapy (HBOT)Hyperbaric Oxygen Therapy (HBOT)

Offload!!!!Offload!!!!

Adequate DebridementAdequate Debridement

Serial sharp ulcer bed Serial sharp ulcer bed preparationpreparation

Removes senescent Removes senescent cells, necrotic tissue, cells, necrotic tissue, converts a chronic ulcer converts a chronic ulcer to an acute wound, to an acute wound, re-initiates healing re-initiates healing cascadecascade

Centers that utilize Centers that utilize sharp debridement sharp debridement exhibit the highest exhibit the highest degree of healing. degree of healing.

T.K. Carlson

Approaches to ulcer Approaches to ulcer Care For the Diabetic Care For the Diabetic

PatientPatientSimple dressings that meet the needs of the ulcerSimple dressings that meet the needs of the ulcer

Antimicrobial therapy – topically and systemicallyAntimicrobial therapy – topically and systemically

Advanced Treatment ModalitiesAdvanced Treatment ModalitiesGrowth FactorsGrowth FactorsBio-engineered TissueBio-engineered TissueNegative Pressure Wound TherapyNegative Pressure Wound TherapyHyperbaric Oxygen TherapyHyperbaric Oxygen Therapy

Plastic surgery – skin grafts/flapsPlastic surgery – skin grafts/flaps

Advanced dressings can reduce costs up to Advanced dressings can reduce costs up to 50% particularly when you consider the 50% particularly when you consider the cost of an infectioncost of an infection

Utilizing the wrong dressing can increase Utilizing the wrong dressing can increase the cost of treating ulcers and cause the cost of treating ulcers and cause further complications for the patientfurther complications for the patient

Thoroughly assess the Thoroughly assess the ““state of the ulcer state of the ulcer bedbed”” before prescribing treatment before prescribing treatment plan/dressingsplan/dressings

Nothing works well on the DFU without Nothing works well on the DFU without proper offloadingproper offloading

Advanced Treatment Advanced Treatment ModalitiesModalities

Off-Loading: A Off-Loading: A Standard of CareStandard of Care

Proper off-loading:Proper off-loading:

Reduces pressureReduces pressure

Reduces shearReduces shear

Reduces shockReduces shock

Transfers weigh from sensitive or painful areasTransfers weigh from sensitive or painful areas

Corrects or supports flexible deformitiesCorrects or supports flexible deformities

Accommodates fixed deformitiesAccommodates fixed deformities

Off-Loading: A Off-Loading: A Standard of CareStandard of Care

Off-loading includes:Off-loading includes:Rest/elevationRest/elevationFelt/foamFelt/foamMulti- podus splint/bootMulti- podus splint/bootRemovable cast walker/walking bootRemovable cast walker/walking bootTotal contact casting (TCC)Total contact casting (TCC)Wedge shoeWedge shoeSurgical shoe with pressure relief insoleSurgical shoe with pressure relief insole

Other assistive devices used in additionOther assistive devices used in additionCrutchesCrutchesWheelchairsWheelchairsWalkersWalkers

Orthotic For Ulcers Orthotic For Ulcers That That DonDon’’tt Heal Heal

Orthotics For Ulcers That Orthotics For Ulcers That DoDo Heal Heal

Therapeutic Therapeutic footwear should be footwear should be placed upon healingplaced upon healing

Prevents recurrencePrevents recurrence

Accommodates Accommodates deformitiesdeformities

Distributes the Distributes the pressure equally pressure equally throughout the footthroughout the foot

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Patient EducationPatient EducationMust take an active role in their careMust take an active role in their care

Ulcer managementUlcer managementRoutine nail careRoutine nail careDisease managementDisease management

Decreases the chance of reoccurrenceDecreases the chance of reoccurrenceFoot hygieneFoot hygieneDaily inspectionDaily inspectionProper footwearProper footwearPrompt treatment of new lesionsPrompt treatment of new lesions

Elective surgery to correct structural Elective surgery to correct structural deformities before ulcerations occurdeformities before ulcerations occur

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Summarizing the Summarizing the InformationInformation

With the increase in diabetes in both the With the increase in diabetes in both the younger and aging population, we are at risk for younger and aging population, we are at risk for greater complicationsgreater complications

Total National Annual Cost: $174 billion Total National Annual Cost: $174 billion dollars.5dollars.5

Common causes of Diabetic Foot Ulcers include: Common causes of Diabetic Foot Ulcers include: neuropathy, trauma, deformity, high plantar neuropathy, trauma, deformity, high plantar pressurespressures

Common secondary etiologies include: Common secondary etiologies include: peripheral arterial disease (PAD) and peripheral arterial disease (PAD) and osteomyelitisosteomyelitis

Summarizing the Summarizing the InformationInformation

Treatment Objectives of Diabetic foot Treatment Objectives of Diabetic foot ulcersulcers

Determine and manage the etiologiesDetermine and manage the etiologies

Establish blood supplyEstablish blood supply

Off-loading followed by therapeutic footwear Off-loading followed by therapeutic footwear upon healingupon healing

Patient educationPatient education

Off-loading the pressure at the site of the Off-loading the pressure at the site of the ulcer is a ulcer is a standard of carestandard of care

Summarizing the Summarizing the InformationInformation

Treating the diabetic foot often includes:Treating the diabetic foot often includes:

Debridement (clinical and/or surgical) Debridement (clinical and/or surgical)

Advanced treatment options Advanced treatment options

HBOHBO

NPWTNPWT

Biologic products:Biologic products:

Growth factorsGrowth factors

Bio-engineered tissuesBio-engineered tissues

Diabetic patients must be active Diabetic patients must be active participants in their care to decrease the participants in their care to decrease the chance of reoccurrencechance of reoccurrence

Thank You For Thank You For Your AttentionYour Attention

Any Questions?