Download THE DIABETIC FOOT

THE DIABETIC
FOOT
DR.SEIF I M ELMAHI
MD, FRCSI
University of Khartoum, Sudan
CONTENT
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Definition
Epidemiology
Social & Economic factors
Pathophysiology of foot ulceration
Diabetic Neuropathy
Peripheral Vascular Disease & Diabetes
Biomechanics of Foot Wear
The Diabetic Foot Ulcer Outcome & Management
Neuro-osteoarthropathy
Amputation in Diabetic Patient
Prevention of Foot Problem
Diabetic Foot
Definition:
Infection, ulceration or
destruction of deep tissues associated
with neurological abnormalities &
various degrees of peripheral vascular
diseases in the lower limb
(based on WHO definition)
Epidemiology
 40%
- 60% of all non traumatic lower
limb amputation
 85% of diabetic related foot
amputation are preceded by foot ulcer
 4 out of 5 ulcer in diabetics are
precipitated by trauma
 4% -10% is the prevalence of foot ulcer
in diabetics
Epidemiology
In Sudan:
 Prevalence of DM ? 6 – 12 %
 DSF inpatient KTH :
30% - 40% risk of major amputation
8% - 20% mortality
Social & Economic Factors
 Diabetic
foot complications are
expensive : (cost of healing 7000-10000 USD)
(healing with amp. 43000-63000USD)
In Khartoum :
 Intervention
(4 weeks dressing cost 110000SD)
of foot care is cost
effective in most societies
 Scarce information regarding long
term prognosis
Pathophsiology of Foot Ulceration
Neuropathic
Ischemic
Neuro -ischemic
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STAGES OF ULCER DEVELOPMENT
STAGES OF ULCER DEVELOPMENT
Diabetic Neuropathy
 Sensorimotor
& peripheral sympathatic
neuropathy are major risk factors for ulcer
 History & careful foot examination are
mandatory to diagnose neuropathy
 Up to 50%of type2 diabetic patient have
significant neuropathy & at risk of foot
ulcer
Periphral vascular disease&
diabetic PVD
PVD is the most important factors related to
outcome of diabetic foot ulcer
 PVD is diagnosed by simple clinical examination
 non invasive vascular test determines probability of
healing
 Symptoms of ischemia may be masked by
neuropathy
 Microangiopathy shouldn't be accepted as primary
cause of ulcer
 Conservative approach for treatment
 Outcome of revascularization is similar to that in
non-diabetic
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Biomechanics of foot wear
Biomechanical abnormalities are
consequence of neuropathy, they lead to
abnormal foot pressure
 Foot deformity & neuropathy increase the
risk of ulcer
 Pressure relief is essential for ulcer healing
and/or prevention
 Frequent inspection of shoes & insoles is
mandatory
 Appropriate foot wear significantly reduce
ulcer recurrence
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Diabetic Foot Infection
Infection in diabetic foot is limb threatening
 Signs of infection may be absent in diabetic
pt. with foot ulcer
 Superficial infection is usually caused by
gram +ve cocci, deep infection is poly
microbial
 Surgical debridment is essential in acute
deep infection
 Osteomylitis( diagnoses & treatment)
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Neuro-osteoarthropathy
 Non-
infective pathology
 Should be suspected in any swollen
hot erythematous foot
 Differentiation from infection is
important to prevent misdiagnosis &
possible amputation
 Treatment should aim at preventing
severe deformity
Diabetic Foot Ulcer Treatment
 Multidisciplenary
approach
 Staging dictate the treatment
option
 Continuity of care & life long
observation
Amputation in Diabetic Patient
 Increased minor\major
amputation
increased the no. of deformed feet
 Minor amputation is needed :
*Gangrene
*As part of debriment
*for correction of foot deformities
 Minor
amputation doesn’t significantly
compromise walking ability
Major Amputation
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Risk of loss walking ability
Mortality
Risk of contra-lateral amputation
Strict indication
Careful choice of the level
How To Prevent Foot Problems
5 corner stones
 Regular
inspection & examination of
foot & foot wear
 Identification of high risk patient
 Education of patient, family & health
care providers
 Appropriate foot wear
 Treatment of non ulcerative pathology
SENSORY NEUROPATHY
Diabetic Neuropathy
PERIPHRAL VASCULAR DISEASE
Biomechanics of foot wearAREAS AT
RISK OF ULCERATION
FOOT WEAR
FOOT WEAR
OSTEOMYLITIS
Diabetic Foot Ulcer Treatment
Modalities
 Microbiological
 Wound
control
control
 Vascular control
 Mechanical control
 Metabolic control
 Educational control
Staging of Diabetic Foot
Stage
1
2
3
4
5
6
Clinical condition
Normal
High risk
Ulcerated
cellulitic
Necrotic
Major amputation
Assessment of Diabetic Foot
 Neuropathy
 Ischemia
 Deformity
 Callus
 Swelling
 Skin
breakdown
 Infection
 Necrosis
NEURO-OSTEOARTHROPATHY(CHARCOT
FOOT)
NEURO-OSTEOARTHROPATHY(CHARCOT
FOOT)Neuro-osteoarthropathy
PODIATRY