diabetic foot disease is very important topic

1. By:
Dr. Ismail Naameh
General Surgeon
DIABETIC
FOOT
DISEASE

2. CONTENTS
❶DEFINITION.
❷EPIDEMIOLOGY.
❸ETIOLOGY.
❹FOOT EXAMINATION.
❺DIABETIC FOOT ULCER MANAGEMENT.
❻DIABETIC FOOT CARE DUIDELINES.

3. ❶DEFINITION
●diabetic foot disease (DFD) can be
defined as a group of syndromes in which
neuropathy, ischemia, and infection lead to
tissue breakdown or ulceration possibly
resulting in amputation.
●Diabetic foot lesions frequently result
when 2 or more risk factors are present.

4. ❷EPIDEMIOLOGY
• 15% of diabetics will develop a foot ulcer.
• 4 out of 5 ulcers in diabetic are precipitated by trauma.
• 85% of diabetic foot amputations are preceded by foot
ulcer.
• 50% of all non-traumatic lower limb amputation are 2 ͦDFD.
• Every 20 seconds a lower limb is amputated due to DFD.
• Mortality following amputation increases with level of
amputation and ranges from 50% to 68% at 5 years.

5. ❸ETIOLOGY
Why diabetics are different?
The cause of foot problems and faulty wound healing in
diabetes can be attributed to three predisposing factors:
1-Peripheral neuropathy,
2-Peripheral vascular (arterial) disease and tissue hypoxia,
3- and abnormal cellular and inflammatory pathways.
As well as;
Hyperglycemia,
Foot edema,
And foot deformity.

6. :Diabetic neuropathy
• More than 50% of diabetic patients have some form of neuropathy.
• Neuropathy may predispose the foot to ulceration through its effects
on the sensory, motor, and autonomic nerves.
• The loss of protective sensation ( pressure, pain and temp.) renders
the patient vulnerable to physical, chemical, and thermal
trauma.(sensory neuropathy is the major component of nearly all
DFD. It is asso. with a 7- folds increase in risk of ulceration).
• Motor neuropathy → weakness and atrophy of foot muscles →
altering foot structure →deformity and altered biomechanics.
• Autonomic neuropathy is asso. with dry skin → fissures, cracking,
and callus.

7. PAD):)PERIPHERAL ARTERY DISEASE
• The incidence of PAD in diabetic patients is at
least 4 times that of nondiabetics.
• 20% of diabetic patients > 40 years.
• 30% of diabetic patients >50 years.
• Hypertension, smoking, and dyslipidemia ↑
the risk of atherosclerosis in diabetes.
• PAD →circulation reduction (macro and micro
vessels→ Claudication, rest pain and vascular
ulceration.

8. Abnormal cellular and inflammatory
pathways:
 the diabetics have abnormalities in
cellular function ( neutrophils and
fibroblasts).
 humoral responses to wound healing
(cytokine production,…) are affected.
 the inflammatory proliferative phase
frequently gets “stuck”.
All are allowing for repeated injury,
infection, and further inflammation.

9. ❹FOOT EXAMINATION
Who is at risk of developing foot
ulcer?

10. steps of examination
• Full history & examination.
• Foot examination:
- inspection.
- loss of sensation.
- vascular status.
- identifying infection.
- Ulcer examination.

11. FOOT EXAMINATION
VISUAL INSPECTION
• Color: red, pale, matted, ……
• Foot shape and toe nails.
• deformity: hammer or claw toes, bunion, ….
• Callus, corns, blisters,……
• Ulceration :( current or previous).
• Infection : swelling, skin breakdown,…

12. FOOT EXAMINATION
VISUAL INSPECTION
Ingrowing nail Hammer toe

13. FOOT EXAMINATION
VISUAL INSPECTION
bunion Corn & callus

14. FOOT EXAMINATION
VISUAL INSPECTION
Dry skin: Marceration:

15. FOOT EXAMINATION
(VISUAL INSPECTION)
Charcot’s foot Clawed toes

16. FOOT EXAMINATION
NEUROPATHY ASSESSMENT
Testing touch pressure sensation
with a monofilament

17. FOOT EXAMINATION
NEUROPATHY ASSESSMENT
Testing vibration sensation with
a biothesiometer:
Testing vibration sensation by
tuning fork ( standard: 128 cs):

18. FOOT EXAMINATION
NEUROPATHY ASSESSMENT
• Pressure- specified
sensory device:
measures the
cutaneous sensibility of
hallax pulp. ( the most
accurate).

19. FOOT EXAMINATION
PAD. ASSESSMENT
Taking temp. of the foot.
Palpation of arterial pulses (Fem. Pop. DP.
And PT).
Ankle brachial index (ABI).
Toes pressure (TP).
Transcutaneous oximetry (TCpo2).
Asking about : claudication and rest pain.

20. FOOT EXAMINATION
PAD. ASSESSMENT
Tem. Taking: Arterial palpation:

21. FOOT EXAMINATION
PAD. ASSESSMENT
Taking Brachial pressure: Taking Ankle pressure;

23. FOOT EXAMINATION
PAD. ASSESSMENT
Taking toe pressure:
• Cost-effective
• Convenient and efficient
• Used when arteries are
caLcified.

24. FOOT EXAMINATION
PAD. ASSESSMENT
Duplex scan:
• In significant vascular
disease.

25. FOOT RISK CATEGORIES
Clinic follow-upRisk profilecategory
Every yearnormal0
3-6 monthsSensory neuropathy1
1-3 monthsSensory neuropathy , deformity
&Or
Peripheral arterial disease
2
1-4 weeksSensory neuropathy & previous DFU or amputation3

26. DIABETIC FOOT INFECTION
• Diabetic patient have poor defense against infection.
• Minor cut and abrasion can turn into infection.
• It is essential to distinguish between localized and
generalized foot infection

27. DIABETIC FOOT INFECTION
● Diabetic foot infection typically take one of
the following forms:
- Cellulitis
- Deep-skin and soft-tissue infection
- Acute osteomyelitis
- Chronic osteomyelitis.
● cultures should be taken only from clinically
infected wounds.

28. DIABETIC OSTEOMYELITIS
● Suspected on;
- Prolonged or recurrent ulcer.
- Deep ulcer
- Difficult ulcer to heal( <2mothes) despite optimal treatment.
- X-Ray is not diagnosed in early phase.( bone scan or MRI).

29. DIABETIC FOOT ULCER
EXAMINATION OF THE ULCER
• Classification
• Ischemia, deformity
• Size, depth, location,
• Ulcer bed color
• Exposed bone, necrosis. Gangrene
• Infection
• Local pain
• Exudate
• Ulcer edge
Digitally photographing at the 1st consultation and
periodically thereafter to document progress.

31. USUAL LOCATIONS OF DFU.

32. Typical neuropathy ulcer
• Painless.
• Surrounded by callus.
• asso. with good foot
pulses.
• At the soles or tips of
toes.

33. Typical vascular ulcer
• Painful.
• Not Surrounded by
callus.
• Asso. with absent or
poor foot pulses.
• At the edge of the foot
or toes.

34. ❺MANAGEMENT OF DIABETIC FOOT ULCER
VIPS
V= Vascular supply is adequate
I= Infection control is achieved
P= Pressure offloading
S= Sharpsurgical debridement

35. MANAGEMENT OF DIABETIC FOOT
ULCER
V= Vascular supply is adequate
○ A patient with acute limb ischemia is a clinical
emergency.
○ Revasculrization is to be considered in case of
decreased perfusion or impaired circulation.

36. MANAGEMENT OF DIABETIC FOOT ULCER
I = Infection control and local wound care
)Antibiotics & wound dressing)

37. General principles of bacterial management
 At initial presentation of infection it is important to assess its severity, take appropriate
cultures and consider need for surgical procedures.
 Optimal specimens for culture should be taken after initial cleansing and debridement
of necrotic material.
 Patients with severe infection require empiric broad-spectrum antibiotic therapy,
pending culture results. Those with mild (and many with moderate) infection can be
treated with a more focused and narrow-spectrum antibiotic.
 Patients with diabetes have immunological disturbances; therefore even bacteria regarded
as skin commensals can cause severe tissue damage and should be regarded as pathogens when
isolated from correctly obtained tissue specimens.
 Gram-negative bacteria, especially when isolated from an ulcer swab, are often
colonizing organisms that do not require targeted therapy unless the person is at risk
for infection with those organisms.
 Blood cultures should be sent if fever and systemic toxicity are present.
 Even with appropriate treatment, the wound should be inspected regularly for early
signs of infection or spreading infection.
 Clinical microbiologists/infectious diseases specialists have a crucial role; laboratory
results should be used in combination with the clinical presentation and history to
guide antibiotic selection.
 Timely surgical intervention is crucial for deep abscesses, necrotic tissue and for
some bone infections.

38. MANAGEMENT OF DIABETIC FOOT ULCER
• All dressings are not a substitute for sharp
debridement, managing systemic infection,
offloading devices, and diabetic control.
• The optimal dressing is the one can maintain a
balanced wound environment (not too moist or
too dry).
• There is no single dressing to suit all scenarios.
local wound care

39. percautionsindicationactionType of dressing
Sensitivity
Osmotic effect
(drawing pain)
Sloughy low to moderate
exuding wound, critically
colonized wound or clinical
signs of infection
Rehydrate wound bed
Antimicrobial
Autolytic debridement
honey
Sensitivity
Short-term use
Do not use on dry
necrotic tissue.
critically colonized wound
or clinical signs of infection.
Low to high exuding wound
AntimicrobialIodine
Sensitivity
Discolouration
DC after 2 weeks.
critically colonized wound
or clinical signs of infection.
Low to high exuding wound.
Antimicrobialsilver
Do not use on highly
exuding wounds
or where anaerobic
infection is suspected
May cause maceration
Dry/low to moderate
exuding wounds
Combined presentation
with silver for
antimicrobial activity
Rehydrate wound bed
Moisture control
autolytic debridement
Cooling
Hydrogels
May dry out if left in
place for too long.
sensitivity
Low to high exuding
wounds
Protect new tissue
growth
Atraumatic to
periwound skin
Low-adherent
wound contact
layer (silicone)

40. MANAGEMENT OF DIABETIC FOOT ULCER
P = Pressure offloading
 In patient with peripheral neuropathy, it is
important to offload at – risk areas of the foot in
order to redistribute pressure.
*Total contact cast: the gold standard
* Removable cast walkers
* Scotch cast boots
* Healing sandals
* Crutches, walkers and wheel chairs.

41. MANAGEMENT OF DIABETIC FOOT ULCER
• Contraindications of total contact cast:
 Ischemia
 Infected DFUs
 osteomyelitis
P = Pressure offloading

42. MANAGEMENT OF DIABETIC FOOT ULCER
P = Pressure offloading
Removable cast walker Scotchcast boot

43. MANAGEMENT OF DIABETIC FOOT ULCER
P = Pressure offloading
crutches wheelchair

44. MANAGEMENT OF DIABETIC FOOT ULCER
Healing sandal walker
P = Pressure offloading

45. FOOT ULCER MANAGEMENT
(DEBRIDEMENT)
● TYPES:
• SURGICALSHARP
• LARVAL
• AUTOLYTIC
• HYDROSURGERY
• ULTRASONIC

46. FOOT ULCER MANAGEMENT
(SURGICAL DEBRIDEMENT)
• Regular & local sharp debridement is the gold
standard technique.
• Tools: scalpel, scissors, andor forceps.
• The benefits are:
 removal of necroticsloughy tissue and callus,
 drainage of secretions and pus,
 stimulating healing,
 and reducing pressure.

47. FOOT ULCER MANAGEMENT
(OTHER DEBRIDEMENT METHODS)
 Larval therapy:
• Using the greenbottle fly larvae; they can
achieve rapid, atraumatic removal of moist,
slimy slough, and can ingest pathogenic
organisms present in the wound.
• Needs only for minimal training.
• Not indicated in neuropathic ulcers.

48. FOOT ULCER MANAGEMENT
(LARVAL DEBRIDEMENT)
Green bottle fly Larvae in the wound

49. FOOT ULCER MANAGEMENT
(LARVAL DEBRIDEMENT)

50. FOOT ULCER MANAGEMENT
(OTHER DEBRIDEMENT METHODS)
• Hydrosurgical debridement: is alternative to
surgical method, by creating of high-energy
cutting beam by forcing water or saline into a
nozzle.
• Autolytic debridement: is a natural process
that uses a moist wound dressing to soften
and remove devitalized tissues.
• Ultrasonic debridement.

51. ADVANCED THERAPIES
Adjunctive treatments such as negative pressure wound therapy (NPWT), biological
dressings, bioengineered skin equivalents, hyperbaric oxygen therapy, platelet
rich plasma and growth factors may be considered, if appropriate and where
available.
for DFUs that are not progressing. These techniques require advanced clinical
decision making and should be carried out only by practitioners with appropriate
skills and anatomical knowledge.
However, such therapies represent considerable greater product cost than
standard therapy.
. These costs may be justified if they result in improved ulcer healing,
reduced morbidity, fewer lower-extremity amputations and improved patient
functional status. There is a good level of evidence for some biological skin
equivalents as well as for the use of NPWT in DFU patients without significant
infection. More recently, NPWT with instillation therapy (NPWTi) using antiseptic
agents (eg PHMB) has become available. Although there are limited data
on its benefits, it could be considered when there is a need for wound cleansing or
treatment with tropical antimicrobial.

52. ❻DIABETIC FOOT CARE GUIDELINES

53. DIABETIC FOOT CARE
(PATIENT EDUCATION)
DO NOT WALK BAREFOOT

54. DIABETIC FOOT CARE
(PATIENT EDUCATION)
Use a magnifying hand mirror Inspect your feet daily

55. DIABETIC FOOT CARE
(PATIENT EDUCATION)
Moisturize your foot Cut nails carefully

56. DIABETIC FOOT CARE
(PATIENT EDUCATION)
Wear clean, dry, and right
type of socks
After washing, make feet dry
with soft towel

57. DIABETIC FOOT CARE
(PATIENT EDUCATION)
Look at your feet before
walking
Clean your shoes before you
put them on

59. Thank you