MANAGEMENT OF DIABETIC FOOT SYNDROME

BY

DR AKPOJEVWE E.O.

CONSULTANT ORTHOPAEDIC/TRAUMA SURGEON

DELSUTH

OGHARA

NIGERIAN MEDICAL ASSOCIATION, DELTA STATE

CME SERIES MAY 2014

OUTLINE• OVERVIEW

• PATHOPHYSIOLOGY

• CLINICAL PRESENTATION

• GRADING

• INVESTIGATION

• TREATMENT OPTIONS

• LOCAL/ REGIONAL CHALLENGES

• RECENT ADVANCES

• PREVENTION

• CONCLUSION

OVERVIEW• GROUP OF METABOLIC DISEASES CHARACTERISED BY

HYPERGLYCAEMIA

• DEFECTS IN INSULIN SECRETION, INSULIN ACTION OR BOTH

• LONG TERM DAMAGE AND DYSFUNCTION OF MULTIPLE ORGAN SYSTEMS

• TYPE 1 DIABETES MELLITUS AND TYPE 2 DIABETES MELLITUS

• OTHER TYPES- GESTATIONAL, ENDOCRINOPATHIES, DRUG/CHEMICAL INDUCED, IMMUNE-MEDIATED, DISEASES OF THE EXOCRINE PANCREAS

• IMPAIRED GLUCOSE TOLERANCE

• IMPAIRED FASTIG GLUCOSE

• FASTING BLOOD SUGAR

<100MG/DL NORMAL

100-125MG/DL IMPAIRED FASTING GLUCOSE

≥126MG/DL PROVISIONAL DIAGNOSIS OF DM

• 2- HOURS POST PRANDIAL GLUCOSE

<140MG/DL NORMAL GLUCOSE TOLERANCE

140-199MG/DL IMPAIRED GLUCOSE TOLERANCE

≥200MG/DL PROVISIONAL DIAGNOSIS OF DM

• DIAGNOSIS OF DIABETES MELLITUS

FBS ≥ 126MG/DL OR

SYMPTOMS OF HYPERGLYCAEMIA + RBS >200MG/DL OR

2-HOURS POST PRANDIAL GLUCOSE ≥ 200MG/DL

HbA1c ≥ 6.5%

• WORLD WIDE EPIDEMIC• 171 MILLION CASES OF DM WORLDWIDE IN 2000 (2.8%

PREVALENCE)• 366 MILLION CASES PROJECTED FOR 2030 (4.4% PREVALENCE)• 15% OF DIABETICS DEVELOP DFU THEIR LIFETIME• 11.7- 19.1% PREVALENCE OF DFU AMONG DIABETICS IN NIGERIA• AMPUTATION RATES UP TO 53%• MORTALITY RATES UP TO 29%• MEAN COST OF TREATMENT N180,581.60K• $28,000.00 SPENT PER PATIENT OVER 2 YEARS FOR EACH EPISODE

OF DFU• LEADING CAUSE OF NON-TRAUMATIC LOWER EXTREMITY

AMPUTATIONS IN USA• LEADING CAUSE OF LOWER EXTREMITY AMPUTATIONS IN NIGERIA

• MALE PREPONDERANCE UP TO 85%• TYPE 2 DM IN UP TO 88% OF CASES• MEAN AGE IS THE 6TH DECADE OF LIFE• 50% NEUROISCHAEMIC, 35% NEUROPATHIC, 15%

ISCHAEMIC• POLYMICROBIAL CULTURES COMMONEST IN CHRONIC

ULCERS• STAPHYLOCCOCUS AUREUS AS SINGLE ISOLATE IN 38%

ON NON-GANGRENOUS LIMBS• ANAEROBES; 16% GAS GANGRENE• 60% RESISTANCE TO PENICILLINS

HIGHLIGHT

ONE LIMB IS AMPUTATED EVERY

20 SECONDS DUE TO DIABETIC

COMPLICATIONS

PATHOPHYSIOLOGY• MULTIFACTORIAL

• TETRAD OF NEUROPATHY, VASCULOPATHY, DEFORMITY AND INFECTION

• IMPAIRED IMMUNITY

• ATHEROSCLEROSIS AND NEUROPATHY OCCUR WITH INCREASED FREQUENCY IN DM

• NON-ENZYMATIC GLYCOSYLATION OF LIGAMENTS CAUSING STIFFNESS

• STIFFNESS + NEUROPATHY INCREASES MECHANICAL STRESSES ON FOOT

DIABETIC ATHEROSCLEROSIS• THICKENED CAPILLARY BASEMENT MEMBRANE

• ARTERIOLAR HYALINOSIS

• ENDOTHELIAL PROLIFERATION

• MONCKEBERG’S SCLEROSIS

• HIGH AFFECTATION OF INFRAPOPLITEAL AND DIGITAL ARTERIES

• HIGH LDL, VLDL,

• ELEVATED PLASMA VON WILLEBRAND FACTOR

• INHIBITION OF PROSTACYCLIN SYNTHESIS

• ELEVATED PLASMA FIBRINOGEN

• INCREASED PLATELET ADHESIVENESS

DIABETIC PERIPHERAL NEUROPATHY

• OCCLUDED VASA NERVORUM

• ENDONEURAL DYSFUNCTION

• DIMINISHED Na-K ATPase ACTIVITY

• CHRONIC HYPEROSMOLARITY CAUSING NERVE TRUNK OEDEMA

• EFFECTS OF INCREASED SORBITOL AND FRUCTOSE

• LOSS OF SENSATION – REPETITIVE STRESS, UNNOTICED INJURIES AND FRACTURES

• STRUCTURAL FOOT ABNORMALITIES

• UNNOTICED EXCESSIVE HEAT/COLD

• PRESSURE FROM ILL FITTING SHOES

COMMON PRECIPITATING FACTORS• TRAUMA• BLISTERING• ILL FITTING/NEW SHOES• NAIL CUTTING• BURNS• TINEA PEDIS• FURUNCLES

RISK FACTORS FOR FOOT ULCERATION• PREVIOUS HISTORY OF FOOT ULCERATION OR

AMPUTATION• VISUAL IMPAIRMENT• DIABETIC NEPHROPATHY• POOR GLYCAEMIC CONTROL• CIGARETTE SMOKING• MALESEX• LOW SOCOECONOMIC STATUS• POOR EDUCATION• POOR ACCESS TO HEALTH CARE

CLINICAL PRESENTATION• PRESENT AS INFECTION, ULCER, ABSCESS OR GANGRENE

• 4% -13.1% NEWLY DIAGNOSED AS DIABETIC AT PRESENTATION

• 11.7% - 21.1% OF DIABETIC ADMISSIONS IN NIGERIA

• MEAN DURATION OF DM 7-12 YEARS

• ONSET OF SYMPTOMS TO PRESENTATION AVERAGELY 6 WEEKS

SYMPTOMS• SYMPTOMS OF DM

POLYURIA

POLYDIPSIA

POLYPHAGIA

WEIGHTLOSS

• SYMPTOMS OF PERIPHERAL NEUROPATHY

HYPERESTHESIA

HYPOESTHESIA

PARAESTHESIA

DYSESTHESIA

ANHYDROSIS

RADICULAR PAIN

• SYMPTOMS OF PERIPHERAL ARTERIAL INSUFFICIENCY

INTERMITTENT CLAUDICATION

REST PAIN

NON-HEALING ULCERATION OF FOOT

FRANK ISCHAEMIA

• SYMPTOMS OF INFECTION

GANGRENE

SEPSIS: LOCAL, GENERALISED

• SYMPTOMS REFERRABLE TO OTHER ORGAN SYSTEMS

RETINOPATHY, NEPHROPATHY, HYPERTENSION

PHYSICAL EXAMINATION• GENERAL EXAMINATION – FEVER, PALLOR, JAUNDICE, DEHYDRATION,

REGIONAL LYMPH NODES, LEG SWELLING, WEIGHT LOSS

• FULL SYSTEMIC EXAMINATION

• MANDATORY EYE EXAMINATION

• MUSCULOSKELETAL SYSTEM EXAMINATION

FOOT/ULCER

POWER

SENSATION

REFLEXES

PULSES

EXAMINATION OF THE ULCER• LOCATION, SIZE, DEPTH

• DETERMINE TYPE- NEUROPATHIC, ISCHAEMIC OR NEUROISCHAEMIC

• MUSCULOSKELETAL SYSTEM ABNORMALITIES

• COLOUR AND STATE OF WOUND

• EXPOSED BONE

• NECROSIS OR GANGRENE

• INFECTION: LOCAL AND SYSTEMIC

• MALODOROUS

• LOCAL PAIN

• EXUDATE

• WOUND EDGE : CALLUS, MACERATION, OEDEMA

• CLINICAL PHOTOGRAPHS

DFU FEATURES ACCORDING TO AETIOLOGY

FEATURE NEUROPATHIC ISCHAEMIC NEUROISCHAEMIC

SENSATION SENSORY LOSS PAINFUL DEG OF SENSORY LOSS

CALLUS/ NECROSIS

OFTEN THICK CALLUS NECROSIS COMMON MINIMALCALLUSPRONE TO NECROSIS

WOUND BED PINK, GRANULATING, SURROUNDING CALLUS

PALE, SLOUGHY, POOR GRANULATION

POOR GRANULATION

FOOT TEMP/ PULSES

WARM, BOUNDING PULSES

COOL, ABSENT PULSES COOL, ABSENT PULSES

OTHER DRY SKIN, FISSURING DELAYED HEALING HIGH RISK OF INFECTION

TYPICAL LOCATION

WEIGHT BEARING AREAS OF FOOT

TIPS OF TOES, NAIL BEDS, B/W TOES, LATERAL BORDER OF FOOT

MARGIN OF FOOT AND TOES

PREVALENCE 35% 15% 50%

GRADING SYSTEMS• SEVERAL SYSTEMS IN USE

• OLDER CLASSIFICATIONS

WAGNER-MEGGIT

UNIVERSITY OF TEXAS CLASSIFICATION

GIBBONS

FORREST

FRYKBERG AND COLEMAN’S

• NEWER CLASSIFICATIONS

PEDIS

KINGS

KOBE’S

AMIT JAIN’S

SAD

WAGNER-MEGGIT CLASSIFICATION OF DIABETIC FOOT

• DEVELOPED IN 1977

• WIDELY ACCEPTED, UNIVERSALLY USED,SIMPLE

• DOES NOT ADDRESS DIABETIC ULCERATIONS AND INFECTION ADEQUATELY

• LIMITED IN IDENTIFYING/DESCRIBING VASCULAR DISEASE

• GRADE 0 FOOT AT RISK

• GRADE 1 SUPERFICIAL ULCER

• GRADE 2 DEEP ULCER

• GRADE 3 ULCER WITH BONE INVOLVEMENT

• GRADE 4 FOREFOOT GANGRENE

• GRADE 5 FULL FOOT GANGRENE

UNIVERSITY OF TEXAS CLASSIFICATION• VALIDATED, GENERALLY PREDICTIVE OF OUTCOME

• INCREASING USE IN CLINICAL TRIALS AND DIABETIC FOOT CENTERS

GRADE 0 GRADE 1 GRADE 2 GRADE 3

STAGE A PRE- OR POST ULCERATIVE LESION,FULLY EPITHELISED

SUPERFICIAL WOUND, NIL TENDON, CAPSULE OR BONE INVOLVED

WOUND PENETRATING TO CAPSULE OR TENDON

WOUND PENETRATING TO BONE OR JOINT

STAGE B INFECTION INFECTION INFECTION INFECTION

STAGE C ISCHAEMIA ISCHAEMIA ISCHAEMIA ISCHAEMIA

STAGE D INFECTION AND ISCHAEMIA

INFECTION AND ISCHAEMIA

INFECTION AND ISCHAEMIA

INFECTION AND ISCHAEMIA

DIABETIC FOOT SEVERITY SCORE(DFSS)- UMEBESE AND OGBEMUDIA

• BEING VALIDATED• GRADES ULCER, PULSES, SENSATION, COLOUR, AGE

AND RADIOGRAPHS OF THE FOOT• PREDICTS LIMB SALVAGEABILITY• ≤ 11 UNSALVAGEABLE• 21 BEST PROGNOSTIC INDEX• 6 WORST PROGNOSTIC INDEX• COMPLEX• DIFFICULT TO MEMORISE

• COLOUR OF FOOT

NORMAL 3

DARKER DISCOLOURATION 2

BLACK 1

• PERIPHERAL PULSES

DORSALIS PEDIS AND POSTERIOR TIBIAL PALPABLE 4

POSTERIOR TIBIAL ONLY 3

DORSALIS PEDIS ONLY 2

NONE1

• SENSATION

NORMAL LIGHT TOUCH AND PIN PRICK 3

DIMINISHED HYPOESTHESIA 2

INSENSIBILITY TO INSENSATE 1

• ULCER GRADING

GANGRENE LIMITED TO 1 OR 2 TOES 5

FULL THICKNESS ULCERATION OF DORSALSKIN 4

ULCER INVOLVEMENT OF >2 TOES OR BALL OF FOOT 3

OPEN PENETRATING ULCER >50% OF SOLE 2

WHOLE FOOT GANGRENE + SUPRAMALLEOLAR 1

NECROTISING CELLULITIS

• AGE

40 YEARS3

41- 60 YEARS2

> 61 YEARS1

• RADIOGRAPH OF FOOT

NORMAL 3

COM OR CALCIFIED PERIPHERAL VESSELS 2

COM + CPV1

DIFFERENTIAL DIAGNOSES

• DIABETIC DERMOPATHY

• ERUPTIVE XANTHOMAS

• NECROBIOSIS LIPOIDICA

• ARTHRITIS

• MUSCLE PAIN

• THROMBOPHLEBITIS

• RADICULAR PAIN

• MYEXDEMA

• VASCULITIC NEUROPATHIES

• METABOLIC NEUROPATHIES

• AUTONOMIC NEUROPATHY

INVESTIGATIONS

• ESTABLISH DIAGNOSIS/ GLYCAEMIC CONTROL

FASTING BLOOD SUGAR

2-HOUR POST PRANDIAL GLUCOSE

HbA1c ASSAY

• BASELINE

FULL BLOOD COUNT

ERYTHROCYTE SEDIMENTATION RATE

C-REACTIVE PROTEIN ASSAY

ELECTROLYTE/UREA/CREATININE

URINALYSIS

24-HOUR URINE FOR PROTEIN ESTIMATION

• DIABETIC FOOT

DEEP TISSUE CULTURE/HISTOLOGY

ASPIRATE M/C/S

PULSE VOLUME RECORDING(PVR)

ANKLE-BRACHIAL INDEX

PLAIN RADIOGRAPHS

DOPPLER/DUPLEX ULTRASOUND SCANS

MONOFILAMENT TESTING

BIOTHESIOMETER

CONTACT THERMOGRAPHY

• CT SCAN/MRI

• BONE SCANS

• ANGIOGRAPHY

• TRANSCUTANEOUS TISSUE OXYGEN STUDIES

• INVESTIGATE FOR RETINOPATHY, NEPHROPATHY, CARDIAC DISEASE ETC

TREATMENT

• NON-SURGICAL

• SURGICAL

APPROACH CONSIDERATIONS FOR TREATMENT

• OFFLOAD THE WOUND WITH APPROPRIATE FOOT WEAR

• DEBRIDEMENT

• DAILY WOUND DRESSING

• ANTIBIOTICS

• OPTIMAL CONTROL OF GLUCOSE, HYPERTENSION AND HYPERLIPIDAEMIA

• EVALUATE/ CORRECT PERIPHERAL VASCULAR INSUFFICIENCY

• MULTIDISCIPLINARY

ENDOCRINOLOGIST INFECTIOUS DISEASE SPECIALIST

CARDIOLOGIST PLASTIC SURGEON

NEPHROLOGIST PROSTHETIST/ ORTHOTIST

PODIATRIST NUTRITIONIST

ORTHOPAEDIC SURGEON WOUND CARE SPECIALIST

VASCULAR SURGEON

NON-SURGICAL TREATMENT

• WOUND DRESSING• AUTOLYTIC DEBRIDEMENT• ENZYMATIC DEBRIDEMENT• LARVAL THERAPY• VACUUM ASSISTED CLOSURE• HYDROTHERAPY• HYPERBARIC OXYGEN THERAPY• OFFLOADING THE FOOT: TCC, RCW, ITCC, CRUTCHES,

WHEEL CHAIR

• ANTIBIOTICS

• HEMORRHEOLOGIC AGENTS: PENTOXIFYLLINE, CILOSTAZOL

• ANTIPLATELET AGENTS: CLOPIDOGREL, SOLUBLE ASPIRIN

• WOUND HEALLING AGENTS: BECAPLERMIN

GEL(REGRANEX)

• SUPPORTIVE THERAPY: ANALGESIA, FLUID AND ELECTROLYTE CORRECTION, BLOOD TRANSFUSION, GLYCAEMIC CONTROL

DRESSING AGENTS• WET TO DAMP DRESSINGS

• ABILITY TO ABSORB EXUDATE AND PROTECT HEALTHY SKIN

• OPSITE; TEGADERM

• NORMAL SALINE

• ISOTONIC SALINE GEL(NORMGEL)

• HYDROCOLLOIDS: DUODERM, INTRASITE – DRY WOUNDS

• CALCIUM ALGINATES: KALTOSTAT, CURASORB – EXUDATIVE WOUNDS

• IMPREGNATED GAUZE (MESALT) – VERY EXUDATIVE WOUNDS

• HYDROFIBRES (AQUACEL) – VERY EXUDATIVE WOUNDS

• DERMAZINE, BACITRACIN, NEOSPORIN – INFECTED WOUNDS

• DRY DRESSING + BETADINE – ESCHAR

• HONEY – INFECTED WOUNDS

• CYTOTOXIC AGENTS: NOT ADVISED EXCEPT IN INFECTED WOUNDS

HYDROGEN PEROXIDE

POVIDONE IODINE

SODIUM HYPOCHLORITE

ACETIC ACID

EUSOL

SURGICAL TREATMENT• SHARP DEBRIDEMENT

• REVISION SURGERIES

• VASCULAR RECONSTRUCTION

• SOFT TISSUE COVERAGE

• AMPUTATION

SHARP DEBRIDEMENT

• MUST PRECEDE NON-SURGICAL TREATMENT

• REMOVE INFECTED AND NON-VIABLE TISSUES

• REMOVE EXCESS CALLUS

• CURETTAGE OF UNDELYING OSTEOMYELITIC BONES

• REDUCES PRESSURE

• ALLOWS FULL INSPECTION OF UNDERLYING TISSUES

• HELPS DRAINAGE OF SECRETIONS AND PUS

• HELPS OPTIMSE EFFECTIVENESS OF TOPICAL PREPARATONS

• STIMULATES HEALING

VASCULAR RECONSTRUCTION

• EARLY REFERRAL TO THE VASCULAR SURGEON

• INTRACTABLE REST OR NOGHTPAIN

• INTRACTABLE FOOT ULCERS

• IMPENDING GANGRENE

• FEMORO-POPLITEAL BYPASS

REVISION SURGERIES

• FOR BONY ARCHITECTURE

• REMOVE PRESSURE POINTS

• RESECTION OF METATARSAL HEADS, OSTECTOMY

SOFT TISSUE COVERAGE

• SKIN GRAFTING

AUTOGRAFT

CADAVERIC

• TISSUE CULTURED SKIN SUBSTITUTES

DERMAGRAF

APLIGRAF

• XENOGRAFT

AMPUTATION• 85% OF AMPUTATIONS ARE PRECEDED BY ULCERS

• AMPUTATION RATES AVERAGELYBETWEEN 5-24%

• 53% AMPUTATION RATES HAVE BEEN QUOTED

• 26% RE-AMPUTATION RATE

• PREDICTORS FOR MAJOR AMPUTATION

SMOKINGLIMB ISCHAEMIA

OSTEOMYELITIS ULCER SIZE

ELEVATED WBC,ESR,CRP REDUCED Hb, ALBUMIN

LOCAL OR DIFFUSE GANGRENE

INDICATONS FOR AMPUTATION

• ISCHAEMIC REST PAIN THAT CANNOT BE MANAGED BY ANALGESIA OR REVASCULARISATION

• LIFE THREATENING FOOT INFECTION THAT CANNOTBE MANAGED BY OTHER MEASURES

• NON-HEALING ULCER ACCOMPANIED BY HIGHER BURDEN OF DISEASE THAN WOULD RESULT FROM AMPUTATION

TYPES OF AMPUTATION• RAY AMPUTATION

• FOOT CONSERVING AMPUTATIONS: TRANSMETATARSAL, LISFRANC’S

• BELOW KNEE AMPUTATION

• ABOVE KNEE AMPUTATIONS

• DISARTICULATIONS

STEPS TO AVOID AMPUTATION: GLOBAL WOUND CARE PLAN

• DIAGNOSIS OF DM +/- PERIPHERAL SENSORY NEUROPATHY

DFU PREVENTION CARE PLAN

TREAT COMORBIDITIES

GOOD GLYCAEMIC CONTROL

OFFLOAD FOOT

ANNUAL PROFESSIONAL FOOT EXAMINATION

REGULAR REVIEW AND PATIENT EDUCATION

• DEVELOPMENT OF DFU

DETERMINE CAUSE OF ULCER

AGREE TREATMENT WITH PATIENT AND IMPLEMENT WOUND CARE PLAN

INITIATE ANTIBIOTIC TREATMENT

REVIEW OFFLOADING DEVICE

OPTIMISE GLYCAEMIC CONTROL

VASCULAR ASSESSMENT

PATIENT EDUCATION

• DEVELOPMENT OF VASCULAR DISEASE

EARLY REFERRAL TO VASCULAR SURGEON

OPTIMSE DM CONTROL

• INFECTED ULCER

ANTIMICROBIALS

OFFLOAD PRESSURE

THERAPY DIRECTED AT BIOFILM

REASONS FOR POOR TREATMENT OUTCOMES• POOR HEALTH LITERACY

• LOW ACCESS TO QUALITY MEDICAL CARE

• NON-COMPLIANCE TO MEDICATION

• LACK OF ACCESS TO DIABETES INFORMATION AND SERVICES

• WEAK REFERRAL SYSTEMS

• ABSENCE OF ROUTINE SCREENING FOR DM

• POVERTY

• LACK OF CAPACITY FOR MANAGEMENT OF DM IN LOWER LEVELS OF HEALTH CARE

• BELIEF IN ALTERNATIVE REMEDIES

LOCAL AND REGIONAL CHALLENGES• LATE PRESENTATION

• ALTERNATIVE UNORTHODOX CARE

• THE MIRACLE PHENOMENON

• POOR PERIPHERAL HEALTH CARE SERVICES

• DEARTH OF SKILLED MANPOWER

• LACKED OF DEDICATED FOOT SERVICE

• DELAYED REFERRALS

• POOR PATIENT COMPLIANCE

• POOR FOLLOW UP

• REFUSAL TO GIVE CONSENT FOR SURGERY

• LOW LEVELS OF COMMUNITY/ PATIENT AWARENESS AND PRACTICES

• LACK OF POLITICAL WILL

PREVENTION• DAILY FOOT INSPECTION

• GENTLE SOAP AND WATER CLEANSING

• APPLICATION OF SKIN MOISTURISERS

• INSPECTIONS OF SHOES FOR SUPPORT AND FIT

• PROMPT TREATMENT OF MINOR WOUNDS

• AVOID HOT SOAKS,HEATING PADS,IRRITATING TOPICAL AGENTS

• STOP CIGARETTE SMOKING

• CONTROL OF BLOOD SUGAR, BLOOD PRESSURE AND SERUM LIPIDS

• PROPHYLACTICPODIATRIC SURGERY

• AVOID USE OF SHARPS TO PARE NAILS

• WEAR CLEAN SOCKS

• NEVER WALK BARE FOOT

• CHECK INSIDE SHOES BEFORE WEARING THEM

RECENT ADVANCES

• BIOENGINEERED SKIN SUBSTITUTES: DERMAGRAF

• EXTRACELLULAR MATRIX PROTEINS: HYAFF,PROMOGRAN

• MMP MODULATOR(MATRIX METALLOPROTENASES): DERMAX

• AUTOLOGOUS PLATELET-RICH PLASMA

CONCLUSION

• INCREASING PREVALENCE OF DM AND ITS ATTENDANT COMPLCATIONS

• POOR KNOWLEGDE, ATTITUDE AND PRACTICES

• LOCAL CHALLENGES RESULT IN HIGH AMPUTATION RATES

• PARADIGM SHIFT TO PREVENTIVE CARE NEEDED

THANK YOU!

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