MANAGEMENT OF DIABETIC 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

Nerves let you feel sensations such

as pain, vibration, pressure, heat & cold.

Blood vessels

carry nutrients and oxygen to your feet to nourish them and help them heal them heal from injuries. Bones give your foot shape and help distribute the pressure from your weight. Joints are the connection between your bones. They help absorb pressure and enable the parts of your foot to move. Your arch is a group of joints that provides stability for your entire foot.

Bone Blood Vessel

THE FOOT

Nerve
Fat Skin

Leonardo da Vinci described the foot as A masterpiece of engineering and a work of art
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What is the definition of a wound ?

A wound

is an injury to the integument or to the underlying structures that may or may not result in a loss of skin integrity. Physiological function of the tissue is impaired .
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Wounds are the visible result of individual cell death or damage and can be classified by site,size,depth and causation - DAVID 1986

ULCER
Definition: An interruption of continuity of an epithelial surface with an inflamed base.

DIABETIC FOOT ULCERS

25%pt.s develop foot ulcers in their life time 40-80% of ulcers eventually get infected 25-50% of infections require minor foot amputation And 10-40% require major amputation 85% amputations are preceded by foot ulcerations
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Diabetes Mellitus
Triopathy of

Neuropathy

Peripheral Vascular Disease

Altered Response to Infection

Altered skin integrity Wound healing failure Infection or gangrene Amputation

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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
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Common Sites for Diabetic Foot Ulcers

Dorsum toes claw toes Plantar aspect Metatarsal head Inter-digital space Heel
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TYPES OF FOOT LESIONS

Neuropathic Foot
90 %

Extrinsic 70 % Intrinsic 30 % Neuroischaemic Foot 10 % The scenario would change with longevity & longstanding DM
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NEUROPATHIC ULCERS - CAUSES

Extrinsic factors Ill fitting footwear Falls / accidents Objects inside shoes Thermal trauma Injury due to sharp objects Home surgery

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ILL FITTING FOOTWEAR

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OBJECTS INSIDE SHOES

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THERMAL TRAUMA
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INJURY DUE TO SHARP OBJECTS

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HOME SURGERY

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NEUROPATHIC ULCERS-CAUSES
Intrinsic factors Limited joint mobility Bony prominences Foot deformities Plantar callus Neuroarthropathy (Charcot Foot) Scar tissue Fissures (Cracks)
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Surrounding Skin
Assess for: color, moisture, suppleness Size
Measure and/or trace wound area.

Wound bed

Measure depth

WOUND ASSESSMENT
Wound edges
Assess for undermining & condition of margin

Assess for: necrotic and granulation tissue, fibrin slough, epithelium, exudate,odor

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CLINICAL APPEARANCE
Site Size Edges

& walls - 4 types

inflammed indurated covered

with slough healthy in color

Types

of exudate State of the surrounding tissue

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Necrosis Depth

Infection
Slough Maladour

Granulation
Epitheliazation

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VISITRAK

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3 STAGES OF ULCER
Spreading

/ extending / active

Stagnant

/ chronic

Healing
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DRY HEALING

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MOIST HEALING
a moist environment as created beneath a semi permeable membrane allows optimal conditions for the re-epithelization of surface wounds (Winter, 1971)

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CLASSIFICATIONS
Wagners
University

Classification

of Texas Diabetic Wound classification College Classification

Kings

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WAGNERS CLASSIFICATION OF DIABETIC FOOT ULCERS

Grade

No open lesion - highly potential sites of ulceration (preulcerative / healed ulcers) especially at areas of bony deformity e.g. Hammer toes, hallux abducto valgus, prominent metartasal head /charcots joint

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WAGNERS CLASSIFICATION OF DIABETIC FOOT ULCERS

Grade

1 Superficial ulcers through full skin thickness but without subcutaneous tissue involvement

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WAGNERS CLASSIFICATION OF DIABETIC FOOT ULCERS

Grade 2 Deep ulcers penetrating superficial adipose tissue to tendon, capsule/ bone without deep infection (involvement of the subcutaneous tissue)

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WAGNERS CLASSIFICATION OF DIABETIC FOOT ULCERS

Grade

Deep penetrating ulcers - complicated - need surgical debridement with I/V antibiotic - patient need to be admitted to hospital (osteitis , abscess , osteomyelitis)

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WAGNERS CLASSIFICATION OF DIABETIC FOOT ULCERS

Grade

4 Areas of Gangrene associated with ulceration - common site - toes, forefoot/ heel - surgical excision of dead tissue

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WAGNERS CLASSIFICATION OF DIABETIC FOOT ULCERS

Grade

5 Extensive gangrene of the foot major amputation / disarticulation required

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A Comparison of Two Diabetic Foot Ulcer Classification Systems

The Wagner and the University of Texas wound classification systems Samson O. Oyibo, MRCP, Edward B. Jude, MD, Ibrahim Tarawneh, 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 the Department of Orthopedics (H.C.N., L.B.H.), University of Texas Health 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: samson@dc.cmht.nwest.nhs.uk . OBJECTIVE In this study, the following two ulcer classification systems were applied to new foot ulcers to compare them as predictors of outcome: the Wagner (grade) and the University of 33 Texas (UT) (grade and stage) wound classification systems.

RESEARCH DESIGN AND METHODS Ulcer size, appearance, clinical evidence of infection, ischemia, and neuropathy at presentation were recorded, and patients were followed up until healing or for 6 months. RESULTS Of 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]) ulcer size at presentation was 1.5 cm2 (0.6-4.0). Lower-limb amputations were performed for 15% of ulcers, whereas 65% healed [median (IQR) healing time 5 (3-10) weeks] and 16% were not healed at study termination; 4% of patients died. Wagner grade (P < 0.0001), and UT grade (P < 0.0001) and stage (P < 0.001) showed positive trends with increased number of amputations. For UT stage, the risk of amputation increased with infection both alone (odds ratio [OR] = 11.1, P < 0.0001) and in combination with ischemia (OR = 14.7, P < 0.0001), but not significantly with ischemia alone (OR = 4.6, P = 0.09). Healing times were not significantly different for each grade of the Wagner (P = 0.1) or the UT system (P = 0.07), but there was a significant stepwise increase in healing time with each stage of the UT system (P < 0.05), and stage predicted healing (P < 0.05). CONCLUSIONS Increasing stage, regardless of grade, is associated with increased risk of amputation and prolonged ulcer healing time. The UT system's inclusion of stage makes it a better predictor of outcome.

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University of Texas Diabetic Wound Classification Classification System Stages Stage A: No infection or ischemia Stage B: Infection present Stage C: Ischemia present Stage D: Infection and ischemia present
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Grading Grade 0: Epithelialized wound Grade 1: Superficial wound Grade 2: Wound penetrates to tendon or capsule Grade 3: Wound penetrates to bone or joint

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KINGS SIMPLE STAGING

Stage 1Normal Foot Not presenting any risk factors, neuropathy, ischaemia, deformity, callus or swelling 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 matter how minor, that lasts for a week or more
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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

TEAM WORK

Mechanical Therapy padding , Off Loading Surgery I&D, debridement, amputation Advice
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Wound Bed Preparation

Debridement

Bacterial Balance

Exudate Management
Dr. Gary Sibbald, et al

Preparing the wound bed for healing debridement, bacterial balance & moisture balance
Ostomy/ wound management 2000, 46(1)

WOUND BED PREPARATION

IDENTIFY & REMOVE BARRIERS TO WOUND HEALING

PROMOTE WOUND HEALING

Wound bed preparation is the management of the wound to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures
Paris International Advisory board in June 2002

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 & Duoderm Hydroactive Gel -Alginates eg. Kaltostat & Sorbsan -Polyurethane foams eg. Lyofoam - Hydrofibre eg Aquacel -Charcoal dressings eg Carboflex -Silver dressings eg Acticoat , Silverlon , Silversorb

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MANAGEMENT OF DIABETIC FOOT ULCERS

ENVIRONMENTAL

DRESSING

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MANAGEMENT OF DIABETIC FOOT ULCERS

DEBRIDEMENT :
WHITESIDE M.C.R.& MOOREHEAD R.J. (1998)

- the removal of foreign matter or devitalised , injured and infected tissue from a wound to remove devitalised tissue when appropriate for the patients condition and when consistent with the patients goals EPUAP REVIEW (1999)
Surgical debridement is the gold standard of care , once ischaemia is excluded. Wagner 1984 ,
Knowles 1997 , Laing 1994 , Steed 1996 , Levin 1996
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METHODS OF DEBRIDEMENT

SURGICAL MECHANICAL AUTOLYTIC ENZYMATIC BIOLOGICAL

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CENTRAL PLANTAR SPACE ABSCESS

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CENTRAL PLANTAR SPACE ABSCESS

SURGERY TOTAL DEROOFING

FOOT EXPLORATION

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CHARCOT`S FOOT

EARLIEST RADIOLOGICAL SIGN

LISFRANC`S JOINT
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METHODS OF OFF LOADING

BED REST CRUTCH/WALKER WALK TOTAL CONTACT CAST MODIFIED FOOT WEAR ROCKER OUTSOLE OUTSOLE WEDGE/FLARE INSOLE STRESS RELIEF(WING)PAD METATARSAL BARS

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Total Contact Cast

Optimizes protection for diabetic ulcerations Reduces pressure at the site of the ulcer while allowing ambulation Minimally padded and carefully molded to the shape of the foot and the leg and has the heel for walking Reduces oedema Effective for ulceration of the sole Not indicated for the use in deep infections
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TOTAL CONTACT CAST

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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 and blunt touch
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ADVANCES IN MANAGEMENT OF DIABETIC FOOT

HYPERBARIC

OXYGEN GRANULOCYTE COLONY STIMULATING FACTOR & GROWTH FACTORS PAMIDRONATE TO HASTEN STAGE OF REFORMATION IN ACUTE CHARCOT FOOT PEDOGRAPH TO DETECT HIGH PRESSURE AREAS IN FOOT MAGGOT THERAPY
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MONOCHROMATIC INFRA RED THERAPY (MIRE)

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3.7.2009

17092009

Prep Before 1st MDT

Sloughy hallux before MDT 3.7.09

After 48 hours 1st Post MDT 20.7.2009

20072009

20072009 Post First MDT

20072009

Post First MDT After clearing maggots

20072009
3rd MDT 27.7.09 Outcome of 3rd MDT on 29.7.09

Hallux after 3rd MDT on 29.7.09

Hallux after 3rd MDT

Medial and dorsal view after 3rd MDT 29.7.09

19.8.2009

5.10.2009

22.12.2009

19.2.2010

20.5.2010

19.7.2010

NADI 2010

LUCILIA THE SAGA

NADI 2010

LUCILIA THE SAGA

Preparation process Maggot therapy

Pour water to release maggots

Shake container

Use stick to stir

NADI 2010

Loosening with water

LUCILIA THE SAGA

Approx. 200 + maggots

Preparation process Maggot therapy

Maggot dispense on gauze before dressing

NADI 2010

LUCILIA THE SAGA

NADI 2010

LUCILIA THE SAGA

Shortcut to MVI_2145.lnk

R-6/11/09

NADI 2010

LUCILIA THE SAGA

NADI 2010

LUCILIA THE SAGA

NADI 2010

LUCILIA THE SAGA

NADI 2010

LUCILIA THE SAGA

NADI 2010

LUCILIA THE SAGA

NADI 2010

LUCILIA THE SAGA

Clinical Case 1

28/7/01

3/9/01

25/2/02

5/9/02
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Clinical Case 2

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Clinical Case 3

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Clinical Case 4

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Clinical Case 5

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Clinical Case 6

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August 2008 HKL CME

MDT The Malaysian Scenario

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THANK YOU

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