Diabetic foot and its complications -final.pptx

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Diabetic foot ulcer
and its complications
S u b t i t l e

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Definition
Diabetic foot ulcer
• A non healing or poorly healing, break in the skin, below the ankle in an individual with
diabetes, critical in the natural history of the diabetic foot.
Edmonds ME, Foster AV. Diabetic foot ulcers. BMJ. 2006 Feb 18;332(7538):407-10. doi: 10.1136/bmj.332.7538.407. PMID: 16484268; PMCID: PMC1370976.

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Risk factors
Neuropathy
Peripheral
Vascular
Disease
Abnormal Foot
Pressures
Hyperglycaemia
Trauma Foot Deformity
Limited Joint
Mobility
Previous
Ulceration
/Amputation
Poor Vision Old Age
Duration of
Diabetes

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Etiology
The three pathogenetic mechanisms involved in diabetic foot
complications are
Neuropathy Angiopathy/ischaemia Infection

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Pathophysiology
Mishra SC, Chhatbar KC, Kashikar A, Mehndiratta A. Diabetic foot. Bmj. 2017 Nov 16;359.

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Clinical presentation
• Onset and progression of ulcer
• Constitutional symptoms- fever
History
• Ulcer
• Neuropathic foot
• The neuropathic foot is warm and well perfused with palpable pulses; sweating is
diminished, and the skin may be dry and prone to fissuring.
• Neuroischemic foot
• The neuroischaemic foot is a cool, pulseless foot; the skin is thin, shiny, and without hair.
There is also atrophy of the subcutaneous tissue, and intermittent claudication and rest
pain may be absent because of neuropathy
• Infected
Physical examination

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Left: Neuropathic foot with plantar ulcer surrounded by callus. Right:
Ulcer over medial aspect of first metatarsophalangeal joint of
neuroischaemic foot
Neuropathic foot ulcer
Neuropathic ulcers usually occur
on the plantar aspect of the foot
under the metatarsal heads or on
the plantar aspects of the toes.
BMJ. 2006 Feb 18; 332(7538): 407–410.

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Hammer toe deformity with callus and ulcer
• Hammer toe is caused by weakened muscles in the
foot.
• The joint connecting the foot with the toe bends
upwards and the joint in middle of the toe bends
downwards towards the floor.
• This results in the toe curling under the foot and being
subjected to excessive ground reaction forces during
walkin

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Ulcer examination
Location, size, depth, margins, colour, odour, base, floor
Type of discharge
Attempts made to express pus
Type of ulcer (neuropathic, ischemic or neuro-ischemic) needs to be determined.
Probed to look for extension into bone, sinus tract, joint and tendon sheath. Probe hitting bone signifies
possible underlying osteomyelitis. When bone is exposed, the patient is assumed to have osteomyelitis until
proven otherwise.

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Vascular
Pulses (dorsalis pedis, posterior tibial, popliteal, femoral)
Capillary return (normal < 2 seconds)
Colour changes: Cyanosis, erythema
Changes of ischemia: Skin atrophy; nail atrophy, abnormal wrinkling, diminished pedal hair

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Neurological
Vibration perception: Tuning fork 128 Hz
Pressure & Touch: Cotton wool (light), Monofilament (5.07) 10gm (Semmes Weinstein)
Pain: Pinprick, using sharp and blunt tool ( e.g. Neurotip)
Temperature perception: hot and cold

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Monofilament test: testing sites and
application. The nine plantar sites are
the distal great toe; third toe; fifth toe;
first, third, and fifth metatarsal heads;
medial foot, lateral foot, and heel; and
one dorsal site

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Musculoskeletal deformities
Attitude and posture of lower extremities and foot
Orthopedic deformities – Hammertoes / Bunions / Charcot deformities / amputations / prominent
metatarsal heads
Limited joint mobility – active and passive movements
Tendo - Achilles contractures
Mishra SC, Chhatbar KC, Kashikar A, Mehndiratta A. Diabetic foot. Bmj.
2017 Nov 16;359.

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Evaluation of the skin and nails of the foot
Skin appearance: color, texture, turgor, quality, and dry skin
Calluses, heel fissures, cracking of skin due to reduced sweating inautonomic neuropathy
Nail appearance: Onychomycosis, dystrophic, atrophy, hypertrophy,paronychia
Presence of hair
Ulceration, gangrene, infection
Interdigital lesions
Tinea pedis
2017 Nov 16;359.

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Classification
University of texas
Wagner’s

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2017 Nov 16;359.

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Stages
Stage A: No infection or ischemia
Stage B: Infection present
Stage C: Ischemia present
Stage D: Infection and ischemia
present
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
2017 Nov 16;359.

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Workup
• Fasting or random blood sugar (FBS, RBS)
• Glycohemoglobin (HbA1C)
• Full blood count (FBC)
• Erythrocyte sedimentation rates (ESR)
• CRP
• Wound and blood cultures(C&S)
Biochemical
Imaging
Vascular investigations Neurological investigations
Assessment of plantar foot pressure
2017 Nov 16;359.

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Imaging
• AP, lateral, and oblique of foot and ankle
Plain radiograph of the foot
• Best for differentiating abscess from soft tissue swelling
MRI
Bone scan
• Soft tissue infection
• Osteomyelitis
• Charcot arthropathy
Useful to differentiate between
2017 Nov 16;359.

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Vascular
• Doppler segmental artery pressures
• Ankle-brachial indices (ABI)
• Normal value 1.1, <0.9 abnormal
• Toe pressure measurements
• In general, 85%-100% of foot lesions will heal when toe pressures are >40mmHg and less than 10%
will heal if<20mmHg
• Transcutaneous oxygen tension (TcPO2)
• <10mmHg correlates with non-healing, >30mmHg correlates with healing
To evaluate the extent of occlusive vascular disease and in the assessment of healing potential
especially when clinical examination suggests lower extremity ischaemia
Any abnormal results of the above investigations in the presence of a non-healing foot ulcer warrant a vascular
assessment. Determination of distal run-off and perfusion can be assessed by arteriography, digital subtraction
angiography (DSA)or magnetic resonance angiography (MRA)
2017 Nov 16;359.

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Left: Hand held Doppler used withsphygmomanometer to measure ankle systolic pressure. Right: Doppler
waveform from normal foot showing normal triphasic pattern (top) and from neuroischaemic foot showing
damped pattern (bottom)
BMJ. 2006 Feb 18; 332(7538): 407–410.

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BMJ. 2006 Feb 18; 332(7538): 407–410.

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Assessment of plantar foot pressure
• High plantar foot pressures have been identified as a significant risk factor for
ulceration
• Measurements are to be done regularly as important changes in the distribution and
level of pressures under diabetic neuropathic feet occur during a relatively short
period
• Harris mat and computer techniques allow qualitative and quantitative measurements
of plantar foot pressures respectively. They are able to identify potential areas of
ulceration
BMJ. 2006 Feb 18; 332(7538): 407–410.

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Management
• Debridement
• Surgical management to reduce or remove bony prominences and/or improve soft
• tissue cover
Operative
• Wound care
• Reduction of plantar pressure
Non-operative
• Infection
• Vascular management of ischemia
• Medical management of comorbids
• Reduce risk of recurrence
Others
BMJ. 2006 Feb 18; 332(7538): 407–410.

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Debridement
• Indications : grade 3 or greater ulcers
• Infected wound
Surgical debridement
BMJ. 2006 Feb 18; 332(7538): 407–410.

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Wound care
• Provide moist environment
• Absorb exudate
• Act as a barrier
• Off-load pressure at ulcer
Goals of wound care and dressings
BMJ. 2006 Feb 18; 332(7538): 407–410.

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BMJ. 2006 Feb 18; 332(7538): 407–410.

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Reduction of plantar pressure (offloading)
Involves reducing the pressure to the diabetic
Foot ulcer, thus reducing the trauma to the ulcer and allowing it to heal.
• Total non-weight bearing.
• Total contact cast (GOLD STANDARD)
• Foot cast or boots
• Removable walking braces with rocker bottom soles
• Total contact orthoses – custom walking braces
• Patellar tendon bearing braces
• Half shoe or wedge shoes
• Healing sandal – surgical shoe with molded plastizote
• insole
• Accommodative dressing: felt, foam, felted-foam, etc
• Shoe cutouts (toe box, medial, lateral or dorsal pressure points).
• Assistive devices: crutches, walker, cane, etc.
Methods: (pics please)
BMJ. 2006 Feb 18; 332(7538): 407–410.

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BMJ. 2006 Feb 18; 332(7538): 407–410.
Vascular management of ischemia
Vascular supply to the affected limb should be assessed early
and if impaired, vascular reconstruction surgery (if feasible)
should be performed prior to definitive surgical management

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Surgical management to reduce or remove
bony prominences
BMJ. 2006 Feb 18; 332(7538): 407–410.
A structurally deformed foot may give rise to high-pressure areas causing ulcers that do not heal with off
loading treatment or therapeutic footwear.
Such deformities are treated surgically to effect healing and to prevent recurrence.
Examples are correction of hammertoes, excision of exostoses, bunions and tendo-achilles lengthening

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Diabetic foot
infection

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Local signs of wound infection
• Granulation tissue becomes increasingly
friable
• Base of the ulcer becomes moist and changes
from healthy pink granulations to yellowish or
grey tissue
• Discharge changes from clear to purulent
• Unpleasant odour is present
BMJ. 2006 Feb 18; 332(7538): 407–410.

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Non limb threatening
These patients are initially managed as outpatients and hospitalized only
when no improvement is noted after 48-72 hours or the condition deteriorates.
Antibiotic therapy is commenced and if ulcer is present. The ulcer is cleansed and debrided.
Ulcer management is then followed as previously outlined.
Correction of hyperglycemia and stabilization of other co-morbidities are carried out simultaneously.
The response to treatment is then re-evaluated after 48-72 hoursand necessary action may need to be
taken.
Aspects of prevention, patient education, podiatric care and orthotic treatment are also carried out.
BMJ. 2006 Feb 18; 332(7538): 407–410.

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Limb threatening
BMJ. 2006 Feb 18; 332(7538): 407–410.
• debridement of wounds, incision & drainage of abscesses, necrotising fascitis and amputations of
gangrenous tissues
• tissues taken deep from the wound are sent for aerobic and anaerobic cultures
• osteomyelitic bones are removed and sent for microbiological culture and histology
Surgical treatment
Wound care
Antibiotics
Medical management of comorbidities

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BMJ. 2006 Feb 18; 332(7538): 407–410.
Antibiotic
• That covers important and common pathogens, taking into account infection severity, while awaiting
culture results
Start with an empiric regime
• Broad-spectrum and given intravenously whereas minor infections can be treated with narrower
spectrum antibiotics.
The empiric therapy for severe infections should be

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BMJ. 2006 Feb 18; 332(7538): 407–410.
• Mild and moderate non-limb threatening
infections are usually monomicrobial, with Staph.
Aureus, Staph. Epidermidis and Streptococci
being the most common infecting organisms.
• These patients are given gram- positive coverage but
keeping in mind gram- negative organisms may also
be involved.

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BMJ. 2006 Feb 18; 332(7538): 407–410.
• Pseudomonas species are often isolated from wounds that have been soaked or
• treated with wet dressings.
• Enterococci are commonly cultured from patients who have previously received cephalosporin therapy.
• Anaerobes are found in wounds with necrosis, deep tissue involvement or a feculent odour.
• MRSA are often acquired during a previous hospitalization.
Severe limb and life threatening infections are poly-microbial in nature,
which includes gram-positive and negative organisms, anaerobic organisms
and enterococci.

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BMJ. 2006 Feb 18; 332(7538): 407–410.
Empiric intravenous broad- spectrum antibiotics therapy in these patients
should cover common isolates of the above organisms and then adjusted
according to culture and sensitivity results. Recurrent infections, despite
ongoing antibiotic therapy, should have repeated deep tissue cultures done to
exclude super infection. If MRSA is isolated, this should be treated early and
appropriately.

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BMJ. 2006 Feb 18; 332(7538): 407–410.
• 1-2 weeks course for mild to moderate infections
• more than 2 weeks for more serious infections
• For osteomyelitis, if infected bone is not removed, antibiotics are given for 6 -
8weeks, depending on culture results
• If all infected bone is removed, a shorter course (1-2 weeks) of antibiotics, as for
soft tissue infection, maybe adequate.
Duration of antibiotic treatment –

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BMJ. 2006 Feb 18; 332(7538): 407–410.
• clinical response,
• temperature,
• WBC count,
• ESR
• other inflammatory markers,
• blood sugar control
• other metabolic parameters,
• signs of wound healing and inflammation.
Maintaining effectiveness of therapy through parameters including, the
patient’s
If there is vascular impairment, the antibiotics may not be able to reach the
infected site. Hence, vascular reconstructive procedures may have to be
undertaken to improve blood flow to infected tissues.

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BMJ. 2006 Feb 18; 332(7538): 407–410.

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Prevention
Education
Foot care
Therapeutic shoes
Reduction of plantar pressure
Surgery
Multidisciplinary Team Approach
BMJ. 2006 Feb 18; 332(7538): 407–410.

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