Download - Dr Harikrishna - Management of Diabetic Foot
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
1/89
1
MANAGEMENT OFDIABETIC FOOT
DR. HARIKRISHNA .R .
MD(UKM) OSH(NIOSH) OHD(DOSH) CMIA(MAL)Post Grad in Wound Healing & Tissue Repair (Cardiff, UK)
Cert in Hyperbaric Medicine (USA)
ESWT (Austria, Germany) , FMSWCP
DIABETIC FOOTCARE UNIT ,
KUALA LUMPUR HOSPITAL
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
2/89
2
Nerveslet you feel sensations suchas pain, vibration, pressure, heat &
cold.
Blood vesselscarrynutrients and oxygen to your feet
to nourish them and help them
heal them heal from injuries.
Bonesgive your foot shape andhelp distribute the pressure from your
weight.
Jointsare the connectionbetween your bones. They help
absorb pressure and enable the
parts of your foot to move. Your
arch is a group of joints thatprovides stability for your entire
foot.
Bone
Blood Vessel
Nerve
Fat
SkinTHE FOOT
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
3/89
3
Leonardo daVinci describedthe foot as
A masterpiece
of engineering
and a work ofart
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
4/89
4
What is the definition
of a wound ?A wound is an injury to the
integument or to the underlying
structures that may or may notresult in a loss of skin integrity.
Physiological function of thetissue is impaired .
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
5/89
5
Wounds are the visible resultof individual cell death ordamage and can be classified
by site,size,depth and causation- DAVID 1986
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
6/89
6
ULCER
Definition:
An interruption of continuity of anepithelial surface with an inflamedbase.
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
7/897
DIABETIC FOOT
ULCERS25%pt.s develop foot ulcers in their life
time
40-80% of ulcers eventually get infected25-50% of infections require minor foot
amputation
And 10-40% require major amputation85% amputations are preceded by foot
ulcerations
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
8/898
Altered skin integrity
Wound healing failure
Infection or gangrene
Amputation
Peripheral Vascular
DiseaseAltered Response
to Infection
Diabetes Mellitus
Triopathy of
Neuropathy
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
9/899
Risk Factors for Foot Ulcers
Duration of diabetes
Previous history of ulcer or amputation
Peripheral neuropathy & angiopathy
Structural deformity
Poor glycaemic control Impaired functional ability
Smoking
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
10/8910
Common Sites for DiabeticFoot Ulcers
Dorsum toes claw toes
Plantar aspect Metatarsal head
Inter-digital space
Heel
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
11/8911
TYPES OF FOOT LESIONS
Neuropathic Foot 90 %
Extrinsic 70 %
Intrinsic 30 %
Neuroischaemic Foot 10 %
The scenario would change withlongevity & longstanding DM
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
12/8912
NEUROPATHIC ULCERS - CAUSES
Extrinsic factorsIll fitting footwear
Falls / accidents
Objects inside shoes
Thermal trauma
Injury due to sharp objectsHome surgery
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
13/89
13
ILL FITTINGFOOTWEAR
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
14/89
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
15/89
15
THERMAL TRAUMA
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
16/89
16
INJURY DUE TO SHARP OBJECTS
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
17/89
17
HOME SURGERY
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
18/89
18
NEUROPATHIC ULCERS-CAUSES
Intrinsic factorsLimited joint mobility
Bony prominences
Foot deformities
Plantar callus
Neuroarthropathy (Charcot Foot)Scar tissue
Fissures (Cracks)
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
19/89
19
WOUNDASSESSMENT
Wound edges
Assess forundermining &
condition of
margin
Size
Measure
and/or trace
wound area.
Measure
depth
Surrounding Skin
Assess for: color,moisture, suppleness
Wound bed
Assess for:
necrotic and
granulation
tissue,
fibrin slough,
epithelium,exudate,odor
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
20/89
20
CLINICAL APPEARANCE
SiteSize
Edges & walls - 4 types
inflammed indurated
covered with slough
healthy in colorTypes of exudate
State of the surrounding tissue
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
21/89
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
22/89
22
VISITRAK
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
23/89
23
3 STAGES OF ULCER
Spreading / extending / active
Stagnant / chronic
Healing
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
24/89
24
DRY HEALING
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
25/89
25
MOIST HEALING
a moist environment as created beneath a
semi permeable membrane allows optimalconditions for the re-epithelization of
surface wounds
(Winter, 1971)
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
26/89
26
CLASSIFICATIONS
Wagners Classification
University of Texas Diabetic Woundclassification
Kings College Classification
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
27/89
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
28/89
28
WAGNERS CLASSIFICATION OFDIABETIC FOOT ULCERS
Grade 1
Superficial ulcers through full skin
thickness but without subcutaneoustissue involvement
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
29/89
29
WAGNERS CLASSIFICATION OFDIABETIC FOOT ULCERS
Grade 2
Deep ulcers penetrating superficialadipose tissue to tendon, capsule/ bone
without deep infection (involvement of thesubcutaneous tissue)
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
30/89
30
WAGNERS CLASSIFICATION OFDIABETIC FOOT ULCERS
Grade 3
Deep penetrating ulcers
- complicated
- need surgical debridement
with I/V antibiotic
- patient need to be admitted
to hospital(osteitis , abscess , osteomyelitis)
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
31/89
31
WAGNERS CLASSIFICATION OFDIABETIC FOOT ULCERS
Grade 4
Areas of Gangrene associated with
ulceration- common site - toes, forefoot/ heel
- surgical excision of dead tissue
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
32/89
32
WAGNERS CLASSIFICATION OFDIABETIC FOOT ULCERS
Grade 5
Extensive gangrene of the foot -
major amputation / disarticulationrequired
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
33/89
33
A Comparison of Two Diabetic Foot UlcerClassification Systems
The Wagner and the University of Texas wound classificationsystems
Samson O. Oyibo, MRCP, Edward B. Jude, MD, IbrahimTarawneh, MD, Hienvu C. Nguyen, DPM, Lawrence B. Harkless,DPM and Andrew J.M. Boulton, MD
From the Department of Medicine and Diabetes (S.O.O., E.B.J., I.T.,A.J.M.B.), Manchester Royal Infirmary, Manchester, U.K.; and theDepartment of Orthopedics (H.C.N., L.B.H.), University of TexasHealth Science Center, San Antonio, Texas.
Address correspondence and reprint requests to Dr. Samson Oyibo,Department of Medicine, Manchester Royal Infirmary, Oxford Road,Manchester, M13 9WL, U.K. E-mail: [email protected].
OBJECTIVE In this study, the following two ulcer classification
systems were applied to new foot ulcers to compare them aspredictorsof outcome: the Wagner (grade) and the University ofTexas (UT) (gradeand stage) wound classification systems.
mailto:[email protected]:[email protected] -
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
34/89
34
RESEARCH DESIGN AND METHODSUlcer size, appearance, clinicalevidenceof infection, ischemia, and neuropathy at presentation were
recorded, and patients were followed up until healing or for6 months.
RESULTSOf 194 patients with new foot ulcers, 67.0% were neuropathic,
26.3% were neuroischemic, 1.0% were ischemic, and 5.7% had no identified
underlying factors. Median (interquartile range [IQR]) ulcersize atpresentation was 1.5 cm2 (0.6-4.0). Lower-limb amputationswere performedfor 15% of ulcers, whereas 65% healed [median(IQR) healing time 5 (3-10)weeks] and 16% were not healed atstudy termination; 4% of patients died.Wagner grade (P
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
35/89
35
University of Texas Diabetic WoundClassification
Classification System
Stages
Stage A: No infection or ischemiaStage B: Infection present
Stage C: Ischemia present
Stage D: Infection and ischemiapresent
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
36/89
36
Grading
Grade 0: Epithelialized wound
Grade 1: Superficial wound
Grade 2: Wound penetrates totendon or capsule
Grade 3: Wound penetrates to bone
or joint
http://www.fpnotebook.com/SUR10.htmhttp://www.fpnotebook.com/SUR10.htm -
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
37/89
37
KINGS SIMPLE STAGING
Stage 1Normal Foot
Not presenting any risk factors,
neuropathy, ischaemia, deformity, callus orswelling
Stage 2 High Risk Foot
Patients feet present with 1 or more of the
risk factors Stage 3 Ulcerated Foot
The foot has a skin breakdown, no matterhow minor, that lasts for a week or more
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
38/89
38
Treatment & Management
Strategy TIGHT Glycaemic Control Investigations
FBC/ESR/C-REACTIVE PROTEIN X RAY
C&S Cleansing Dressing
Wound hydration Moisture retentive dressings ( moist wound healing)
Exudate management Bacterial burden
Mechanical Therapy padding , Off Loading Surgery I&D, debridement, amputation
Advice
TEAMWORK
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
39/89
Wound Bed Preparation
Debridement Bacterial Balance
Exudate Management
Dr. Gary Sibbald, et al
Preparing the wound bed for healing debridement, bacterialbalance & moisture balanceOstomy/ wound management 2000, 46(1)
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
40/89
WOUND BED PREPARATION
IDENTIFY& REMOVE
BARRIERS TO WOUND
HEALING
Wound bed preparation is the management of the wound to
accelerate endogenous healing or to facilitate the effectiveness of
other therapeutic measuresParis International Advisory board in June 2002
PROMOTEWOUND
HEALING
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
41/89
41
ENVIRONMENTAL DRESSING
Expensive
Can be left in situ for several days
Reducing cost of both materials and time
Many types:
-Semipermeable polymeric films eg. Opsite
-Hydrocolloids eg. Duoderm CGF
-Hydrogels eg. Intrasite Gel & DuodermHydroactive Gel
-Alginates eg. Kaltostat & Sorbsan-Polyurethane foams eg. Lyofoam
- Hydrofibre eg Aquacel
-Charcoal dressings eg Carboflex
-Silver dressings eg Acticoat , Silverlon , Silversorb
MANAGEMENT OF
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
42/89
42
MANAGEMENT OFDIABETIC FOOT ULCERS
ENVIRONMENTAL DRESSING
G O
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
43/89
43
MANAGEMENT OFDIABETIC FOOT ULCERS
DEBRIDEMENT :- the removal of foreign matter or devitalised ,
injured and infected tissue from a woundWHITESIDE M.C.R.& MOOREHEAD R.J. (1998)
- to remove devitalised tissue when appropriatefor the patients condition and when consistent
with the patients goals
EPUAP REVIEW (1999)
- Surgical debridement is the gold standard ofcare , once ischaemia is excluded. Wagner 1984 ,
Knowles 1997 , Laing 1994 , Steed 1996 , Levin 1996
METHODS OF
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
44/89
44
METHODS OFDEBRIDEMENT
SURGICAL
MECHANICAL
AUTOLYTIC
ENZYMATIC
BIOLOGICAL
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
45/89
45
CENTRAL
PLANTAR SPACE
ABSCESS
CENTRAL PLANTAR SURGERY TOTAL
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
46/89
46
CENTRAL PLANTAR
SPACE ABSCESSSURGERYTOTAL
DEROOFING
FOOT EXPLORATION
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
47/89
47
CHARCOT`S FOOT
EARLIEST
RADIOLOGICALSIGN
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
48/89
48
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
49/89
49
METHODS OF OFF LOADING
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
50/89
50
METHODS OF OFF LOADING
BED REST
CRUTCH/WALKER WALK
TOTAL CONTACT CAST
MODIFIED FOOT WEAR
ROCKER OUTSOLE
OUTSOLE WEDGE/FLARE
INSOLE STRESS RELIEF(WING)PADMETATARSAL BARS
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
51/89
51
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
52/89
52
Total Contact Cast
Optimizes protection for diabeticulcerations
Reduces pressure at the site of the ulcer
while allowing ambulationMinimally padded and carefully molded to
the shape of the foot and the leg and hasthe heel for walking
Reduces oedema Effective for ulceration of the sole
Not indicated for the use in deep infections
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
53/89
53
TOTAL
CONTACTCAST
AT RISK FOOT
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
54/89
54
AT RISK FOOT Ischaemia
Numbness Structural Deformities
Callus and / or Corn
Absence of Pedal Pulses A capillary refill time in excess of 3 secs
Limb pain and / or parasthesia
Intermittent Claudication History of Foot Ulcer
Loss of sensation of light touch,sharp andblunt touch
ADVANCES IN MANAGEMENT OF
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
55/89
55
ADVANCES IN MANAGEMENT OFDIABETIC FOOT
HYPERBARIC OXYGEN
GRANULOCYTE COLONY STIMULATING
FACTOR & GROWTH FACTORSPAMIDRONATE TO HASTEN STAGE OF
REFORMATION IN ACUTE CHARCOT
FOOTPEDOGRAPH TO DETECT HIGH
PRESSURE AREAS IN FOOT
MAGGOT THERAPY
O OC O C
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
56/89
MONOCHROMATIC INFRARED THERAPY (MIRE)
56
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
57/89
3.7.2009
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
58/89
17092009
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
59/89
17092009
Prep Before 1st MDT
Sloughy halluxbefore MDT
3.7.09
After 48 hoursst Post MDT
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
60/89
1st Post MDT20.7.2009
20072009
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
61/89
20072009 Post First MDT
20072009
Post First MDTAft l i
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
62/89
After clearingmaggots
20072009
3rd MDT 27.7.09
Outcome of 3rd MDT on 29.7.09
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
63/89
Hallux after 3rd MDT on 29.7.09
Hallux after 3rd MDT
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
64/89
Medial and dorsal view after 3rd MDT29.7.09
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
65/89
19.8.2009
5.10.2009
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
66/89
22.12.2009
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
67/89
19.2.2010
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
68/89
9
20.5.2010
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
69/89
19.7.2010
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
70/89
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
71/89
NADI 2010 LUCILIA THE SAGA
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
72/89
NADI 2010 LUCILIA THE SAGA
Preparation process Maggot therapy
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
73/89
NADI 2010 LUCILIA THE SAGA
Shake containerPour water to release maggots
Use stick to stir
Approx. 200 + maggots
Loosening with water
Preparation process Maggot therapy
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
74/89
NADI 2010 LUCILIA THE SAGA
Preparation process Maggot therapy
Maggot dispense on gauze before dressing
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
75/89
NADI 2010 LUCILIA THE SAGA Shortcut to MVI_2145.lnk
R 6/11/09
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
76/89
NADI 2010 LUCILIA THE SAGA
R-6/11/09
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
77/89
NADI 2010 LUCILIA THE SAGA
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
78/89
NADI 2010 LUCILIA THE SAGA
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
79/89
NADI 2010 LUCILIA THE SAGA
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
80/89
NADI 2010 LUCILIA THE SAGA
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
81/89
NADI 2010 LUCILIA THE SAGA
C C
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
82/89
82
Clinical Case 1
28/7/013/9/01
25/2/02 5/9/02
Cli i l C 2
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
83/89
83
Clinical Case 2
Cli i l C 3
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
84/89
84
Clinical Case 3
Cli i l C 4
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
85/89
85
Clinical Case 4
Clinical Case 5
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
86/89
86
Clinical Case 5
Clinical Case 6
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
87/89
87
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
88/89
88
August 2008 HKL
CME MDT The Malaysian Scenario
THANK YOU
-
7/31/2019 Dr Harikrishna - Management of Diabetic Foot
89/89
THANK YOU