3. Introduction: DM
Diabetes mellitus (DM) is a group of metabolic diseases
characterized by hyperglycemia resulting from defects in
insulin secretion, insulin action, or both
Chronic hyperglycemia is associated with long-term
damage, dysfunction &failure of various organs & tissues
such as eyes, kidneys, heart, nerves & blood vessels
3Basil Tumaini, May Shoo
4. Introduction: Diabetic foot
Diabetic foot is defined as any foot pathology
that results directly from diabetes or its long
term complications
4Basil Tumaini, May Shoo
6. Epidemiology: DM
• 1 in 11 adults have diabetes (415 million)
• By 2040, 1 adult in 10 (642 million) will have
diabetes
• 1 in 7 births is affected by gestational
diabetes
• Every 6 seconds a person dies from diabetes
(5.0 million deaths)
6Basil Tumaini, May Shoo
7. Epidemiology: DM foot
• The lifetime risk of a foot ulcer for diabetic
patients (type 1 or 2) may be as high as 25%1
• Foot ulcerations are the commonest cause of
hospital admission in diabetics
• Atherosclerosis rarely seen in type I diabetics
< 40 yrs while it may be present even before
diagnosis in type II
7Basil Tumaini, May Shoo
9. Epidemiology: amputations
• Half of all limb amputations are caused by
diabetes
• Risk is 40 times increased in diabetes
• 70% of people die five years following an
amputation
• Foot problems account for 40% of healthcare
resources in developing countries; 15% in
developed countries
9Basil Tumaini, May Shoo
10. • 85% of all amputations begin with an
ulcer
• Foot problems cost USD 6 billion/year in
the USA
• 49-85% of amputations can be prevented
10
Epidemiology: amputations …
Basil Tumaini, May Shoo
11. Epidemiology: DM foot in Tanzania
• In a study done between 2004 -2007, it was
pointed out that foot complications cause
substantial morbidity in Tanzania where 70%
of leg amputations occur in diabetic patients2
• In a study done among 404 DM patients in Dar
es Salaam in 2008, 15% had foot ulcers, 44%
had peripheral neuropathy and 15% had PVD3
11Basil Tumaini, May Shoo
12. Epidemiology – risk factors
• Peripheral neuropathy (loss of protective
sensation – LOPS)
• Foot deformity
• Peripheral arterial disease (PAD)
• H/o previous ulceration / amputation1
• DM > 10 years duration
• Smoking
• Poor glycemic control (HbA1c > 7%)
• Male sex
12Basil Tumaini, May Shoo
13. Risk category Definition
Treatment
recommendations
Suggested follow-
up
0 No LOPS, no PAD,
no deformity
Patient education
including advice on
appropriate footwear.
Annually (by
generalist and/or
specialist)
1 Loss of protective
sensation (LOPS)
± deformity
Consider prescriptive
or accommodative
footwear.
Every three to six
months (by
generalist or
specialist)Consider prophylactic
surgery if deformity is
not able to be safely
accommodated in
shoes. Continue
patient education.
2 Peripheral arterial
disease (PAD) ±
LOPS
Consider prescriptive
or accommodative
footwear.
Every two to
three months (by
specialist)
Consider vascular
consultation for
combined follow-up.
3 History of ulcer or
amputation
Same as category 1. Every one
to two months (by
specialist)
Consider vascular
consultation for
combined follow-up if
PAD present.
RISK CLASSIFICATION AND RECOMMENDATIONS1
13Basil Tumaini, May Shoo
14. Pathophysiology
• Factors leading to development of diabetic foot:
– Diabetic macroangiopathy – peripheral arterial
occlusive disease
– Diabetic microangiopathy – thickening of basement
membranes
– Diabetic polyneuropathy
– Diabetic osteoathropathy – abnormal foot
biomechanics
– Reduced resistance to infection
– Delayed wound healing
– Reduced rate of collateral vessel formation
14Basil Tumaini, May Shoo
17. DIABETIC FOOT INFECTIONS
• Compromise of the blood supply from
microvascular disease, often in association with
lack of sensation because of neuropathy,
predisposes persons with diabetes mellitus to
foot infections.
• These infections span the spectrum from
simple, superficial cellulitis to chronic
osteomyelitis.
17Basil Tumaini, May Shoo
18. Increased infection rate
• Skin fissurations predisposes to penetration of
infectious microbes
• Polymorphonuclear granulocyte chemotaxis and
phagocytosis is impaired
• Polyneuropathy predisposes to deep seated infections
due to impaired pain sensation
• Both anaerobe and aerobe infections are implicated in
diabetic foot infections
• Decreased immunity
18Basil Tumaini, May Shoo
20. Signs and symptoms
• Diabetic foot infections typically take one of the
following forms:
• Cellulitis
• Deep-skin and soft-tissue infections
• Acute osteomyelitis
• Chronic osteomyelitis
20Basil Tumaini, May Shoo
21. Cellulitis
• Tender, erythematous, non raised skin lesions
are present, sometimes with lymphangitis
• Lymphangitis suggests group A streptococcal
infection
• Bullae are typical of Staphylococcus aureus
infection, but occasionally occur with group A
streptococci
• No ulcer or wound exudate is present
21Basil Tumaini, May Shoo
23. • The WBC and ESR are slightly or moderately
elevated, but these elevations are not diagnostic
• Blood culture results are usually negative; if
positive, they usually indicate the presence of
group A or group B streptococci
• Cultures of skin via aspiration or biopsy are
generally unrewarding;
– aspiration of a sample from the leading edge of the
erythematous border has a low yield (likely < 5%) but
may be used if the likely organism must be identified
on initial presentation
23
Diagnosis
Basil Tumaini, May Shoo
24. Deep-skin and soft-tissue infections
• The patient may be acutely ill, with painful
induration of the soft tissues in the extremity
• Wound discharge is usually not present
• In mixed infections that may involve anaerobes,
crepitation may be noted over the afflicted area
• Extreme pain and tenderness may indicate
compartment syndrome or clostridial infection
(ie, gas gangrene)
• The tissues are not tense, and bullae may be
present
• Discharge, if present, is often foul
24Basil Tumaini, May Shoo
25. • The WBC and ESR are mildly or moderately elevated
• If bullae are present,
– Gram stain and culture results from aspirated exudate from a bullous lesion
may help identify the pathogen
• Blood culture results may be positive
• In suspected deep soft-tissue infection,
– plain radiography, CT, or MRI may be performed to evaluate for
compartment syndrome or for gas or a foreign body in the deep tissues
– excessive gas signifies a mixed aerobic-anaerobic infection, in contrast to
gas gangrene (clostridial myonecrosis)
• Gram stains and/or cultures of samples aspirated from deep-skin
and soft-tissue infections may be used to identify the organism
25
Diagnosis – skin & soft tissue infections
Basil Tumaini, May Shoo
26. • The patient's temperature is usually less than 102°F
• Discharge is commonly foul
• No lymphangitis is observed
• Pain may or may not be present, depending on the degree
of peripheral neuropathy
• Deep, penetrating ulcers and deep sinus tracts (diagnostic of
chronic osteomyelitis) are usually located between the toes or on
the plantar surface of the foot
• The medial malleoli, shins, or heels are not usually sites of
involvement
26
Chronic osteomyelitis
Basil Tumaini, May Shoo
27. Diagnosis - Osteomyelitis
• Acute osteomyelitis
• The WBC usually reveals leukocytosis, and the ESR is
moderately or highly elevated[4]
• Blood culture results are usually negative; when positive, the
findings most frequently indicate the presence of S aureus
• For affected long bones, plain radiographic findings generally
become abnormal after 10-14 days; soft-tissue swelling and
periosteal elevation are the earliest signs
• Bone scans are preferred to gallium or indium scans; bone-
scan findings are positive within 24 hours
• Bone biopsy is not necessary
27Basil Tumaini, May Shoo
28. Diagnosis - Osteomyelitis
Chronic osteomyelitis
• The WBC is often within the reference range; the ESR is usually
very highly elevated and may exceed 100 mm/hr[4] ; the platelet
count is also often elevated
• Blood culture results are usually negative
• Plain X-ray findings are invariably abnormal
• Bone scans -usually unnecessary unless diagnostic confusion
exists with another disorder (eg, bone tumor); an MRI scan would
also be helpful in such a situation
• Bone biopsy under aseptic conditions -preferred way to identify
the causative pathogen
• Important pathogens- Bacteroides fragilis, E coli, Proteus
mirabilis, and Klebsiella pneumoniae; Pseudomonas aeruginosa is
usually not the causative organism
28Basil Tumaini, May Shoo
29. Management
• Treatment of diabetic foot infections varies by type, as follows:
• Cellulitis – Most responsive to antibiotics
• Deep skin and soft-tissue infections – Usually curable, but
additional debridement is usually indicated
• Acute osteomyelitis – Infecting microorganisms and the likelihood
of successful treatment with antimicrobial therapy are essentially
the same as in patients without diabetes
• Chronic osteomyelitis – Surgical debridement is essential, in
addition to antibiotics; amputation may be necessary
29Basil Tumaini, May Shoo
30. Fungal nail infection
• Nails infected with a fungus become discolored (yellowish-
brown or opaque), thick and brittle, and may separate from
the rest of the nail.
– In some cases, the nail may crumble.
– The dark, moist, and warm environment of shoes
can promote fungal growth.
– In addition, an injury to the nail put the patient at
an increased risk for a fungal infection.
– Fungal nail infections are difficult to treat.
– Drugs applied directly to the nail only help a small
number of fungal nail problems.
• Pills may be used, and periodic removal of the damaged nail
tissue."
30Basil Tumaini, May Shoo
32. Athlete's foot
• "Athlete's foot is a fungus that causes
itching, redness, and cracking. Germs can
enter through the cracks in your skin and
cause an infection.
• Antifungal are used to treat athlete's foot-be
pills and/or creams applied directly *
32Basil Tumaini, May Shoo
34. Calluses
• "A callus is a build-up of hard skin, usually on
the underside of the foot.
• Calluses are caused by an uneven distribution
of weight, generally on the bottom of the
forefoot or heel.
• Calluses also can be caused by improperly
fitting shoes or by a skin abnormality.
• Keep in mind that some degree of callus
formation on the sole of the foot is normal.
34Basil Tumaini, May Shoo
36. Calluses
• After bath, use a pumice stone to gently
remove the build-up of tissue.
• Use cushioned pads and insoles in your shoes.
• Medication also may be used to soften
calluses.
• DO NOT try to cut the callus or remove it with
a sharp object.“
36Basil Tumaini, May Shoo
37. Localized callus
• When an increase in pressure and discomfort occurs,
people with normal sensation change their gait.
• People with neuropathy do not feel pain and continue
to walk in the same way.
• This leads to a build up of callus at the site of most
pressure.
• Ultimately this hard, localized callus can cause the
tissue underneath to breakdown forming ulceration.
• As a preventive measure, all callus should be removed.
• It is particularly important to note that bleeding callus is
indicative of possible ulceration and should be removed
immediately.
37Basil Tumaini, May Shoo
40. Corns
• "A corn is a build-up of hard skin near a bony
area of a toe or between toes.
• Corns may be the result of pressure from shoes
that rub against the toes or cause friction
between the toes.
• Use a pumice stone to gently remove the build-
up of tissue.
• Do not use over-the-counter remedies to
dissolve corns. Or cut the corns with a sharp
object.
40Basil Tumaini, May Shoo
42. Bunions
• "A bunion forms when the big toe angles in toward the
second toe. Often, the spot where big toe joins the rest of
the foot becomes red and callused.
• The area may begin to stick out and become hard.
Bunions can form on one or both feet.
• Bunion may run in the family, but most often are caused
by wearing high-heeled shoes with narrow toes. The shoes
put pressure on the big toe, pushing it toward the second
toe.
• The use of felt or foam padding on the foot may help
protect the bunion from irritation.
• A device also may be used to separate the big and second
toes. If the bunion causes severe pain and/or deformity,
surgery to realign the toes may be necessary
42Basil Tumaini, May Shoo
43. Blisters
• Wearing shoes that do not fit properly or
wearing shoes without socks can cause blisters,
which can become infected.
• When treating blisters, it's important not to
"pop" them.
• The skin covering the blister helps protect it from
infection.
• Use an antibacterial cream and clean, soft
bandages to help protect the skin and prevent
infection.
43Basil Tumaini, May Shoo
44. Plantar warts
• "Plantar warts look like calluses on the ball of
the foot or on the heel.
• They may appear to have small pinholes or tiny
black spots in the centre.
• The warts are usually painful and may develop
singly or in clusters.
• Plantar warts are caused by a virus that infects
the outer layer of skin on the soles of the feet.
• Over-the-counter medications to dissolve the
wart should not used.
44Basil Tumaini, May Shoo
48. Ingrown toenail
• "Ingrown toenails occur when the edges of the
nail grow into the skin.
• They cause pressure and pain along the nail
edges.
• The edge of the nail may cut into the skin, causing
redness, swelling, pain, drainage, and infection.
• The most common cause of ingrown toenails is
pressure from shoes.
• Other causes include improperly trimmed nails,
crowding of the toes, and repeated trauma to the
feet from activities such as running, walking, or
doing aerobics. 48Basil Tumaini, May Shoo
49. Ingrown toenail
• Keeping your toenails properly trimmed is the
best way to prevent ingrown toenails.
• Surgery to remove part of the toenail and
growth plate may be needed.
49Basil Tumaini, May Shoo
52. Peripheral neuropathy–Sensory motor
• Most common form of neuropathy
• The prevalence of peripheral neuropathy is very
dependent on the sensitivity of the test used.
• However, it is generally accepted that with standard
clinical examination and objective testing,
approximately 50% of people will have neuropathy
after 15 years of diabetes
• The long nerves of the feet and hands are affected
in what is commonly known as a ‘glove and
stocking distribution’. When the neuropathy has
reached the knees, usually the hands become
involved.
52Basil Tumaini, May Shoo
53. Causes/risk factors of DN
1. Metabolic factors, such as high blood glucose, long duration of
diabetes, abnormal blood fat levels, and/or low levels of
insulin
2. Neurovascular factors, leading to damage to the BV that carry
oxygen and nutrients to nerves
3. Autoimmune factors that cause inflammation in nerves
4. Mechanical injury to nerves, such as carpal tunnel syndrome
5. Inherited traits that increase susceptibility to nerve disease
6. Lifestyle factors, such as smoking or alcohol use
53Basil Tumaini, May Shoo
54. Pathophysiology
• Among the metabolic factors that contribute to dev. of
neuropathy , Polyol pathway activity has been most important
• The polyol pathway is comprised of two steps:
– (1) the conversion of glucose to sorbitol by aldose reductase
(localized to paranodal Schwann cells and endoneurial
microvessels )
– (2) the conversion of sorbitol to fructose by sorbitol
dehydrogenase.
• Glucose is converted to the sugar-alcohol (polyol)
sorbitol using NADPH as a coenzyme, which has a close
affinity to aldose reductase
54Basil Tumaini, May Shoo
55. Pathophysiology …
• Accumulation of sorbitol, perturbation of phosphoinositide
metabolism, as well as alterations of coenzymes, leads to
neural lesions
• Increased non enzymatic glycation of structural proteins is
also considered to be another factor in pathogenesis of DN.
• Advanced glycation end products resulting from
hyperglycemia act on specific receptors, inducing
monocytes and endothelial cells to increase the production
of cytokines and adhesion molecules which also, have an
effect on matrix metalloproteinases, which might damage
nerve fibers.
55Basil Tumaini, May Shoo
56. Peripheral neuropathy–Sensory motor
• Bilateral- Unlike peripheral vascular disease,
which can involve only one limb, peripheral
neuropathy affects both feet, with
approximately equal symptoms in each limb.
• Unlike peripheral vascular disease, which can
involve only one limb, peripheral neuropathy
affects both feet, with approximately equal
symptoms in each limb.
56Basil Tumaini, May Shoo
57. Diabetic peripheral neuropathy – risk
factors
• The poorer the glycaemic control, and
• the longer the duration of diabetes, the higher the risk of
developing foot problems.
• These are the two most important risk factors.
• The older the person, the higher the risk.
• Interestingly, the taller the person, the higher their chance of
developing neuropathy. This appears to be explained by the fact
that the most distal part of the nerve is damaged first. Diabetic
neuropathy is also known as the ‘dying back’ disease.
• Excessive alcohol
57Basil Tumaini, May Shoo
58. Sensory neuropathy
Deep sensory perception is reduced resulting
in loss of protective reflexes against physical
injury.
Overshooting due to loss of joint position
Joint injuries
Typically, manifests in a sock - like distribution.
58Basil Tumaini, May Shoo
59. Manifestations of sensory neuropathy
• Painful with these symptoms:
–burning
–pins and needles
–pain
• Painless (or insensate) - No symptoms
59Basil Tumaini, May Shoo
60. Nerve damage – neuropathy
• Symptoms of painful neuropathy include
– numbness,
– burning,
– pins and needles, and
– pain that can be excruciating,
– distressing and difficult to treat satisfactorily.
– These symptoms occur bilaterally and tend to be worse at night.
• The majority of people with neuropathy, however, experience no
symptoms, despite having significant disease. These people are more
likely to develop problems as they are not aware of their feet, having
lost their sensation of pain.
60Basil Tumaini, May Shoo
61. Most of us experience pain when we injure our foot.
This alerts us to examine the foot and treat it as necessary
61Basil Tumaini, May Shoo
62. Painless nature of diabetic foot
disease • However, in the insensate foot, pain
sensation is absent.
• A significant amount of damage can
occur; people are completely oblivious
to this until they notice blood or
swelling.
• For this reason it is often said that
people with insensate neuropathy can
have quite major surgical procedures
performed without the need for
anaesthetic.
Basil Tumaini, May Shoo
63. Sensory nerve damage
• This slide shows a person who
attended a foot clinic for
treatment of ulceration,
completely unaware that they
were walking with a thumb-
tack stuck into their foot.
• Had the tack not been found,
this injury could quite easily
have become infected, leading
to serious consequences
63Basil Tumaini, May Shoo
65. Motor nerve damage
• As well as affecting the sensory nerves, peripheral
neuropathy affects the motor nerves of the feet.
• This causes weakness in the intrinsic muscles of the feet,
leading to contraction of the muscles and clawed toes.
• As the toes claw back, the fat pads are pulled forward from
under the metatarsal heads, increasing the pressure under
these metatarsal heads and on the tips of the toes
(common places for neuropathic ulceration).
65Basil Tumaini, May Shoo
67. Motor neuropathy
Denervation and atrophy of small foot muscles
leading to malum perforans, transverse foot
arch instability with clawing and splay foot
Hammer toe
Claw toe
Hallux valgus, hammer toes, erythema over
pressure points 67Basil Tumaini, May Shoo
70. Charcot’s arthropathy
• Charcot’s arthropathy is a condition that is associated with end stage peripheral
neuropathy.
• While the pathogenesis of this condition is still under debate, one reasonable
explanation is that with the onset of autonomic neuropathy, a ‘shunting’
between the arteries and veins occurs.
• This leads to an increase in blood flow to the foot – hence the term ‘warm
neuropathic foot’.
• This increase in blood flow provokes the demineralization of the bones, making
them soft and weak.
70Basil Tumaini, May Shoo
71. Charcot’s arthropathy
• Insensate people can easily damage these weak bones, leading to
dislocation and/or fracture.
• People do not feel pain and continue walking on the damaged foot,
causing the bony architecture of the foot to collapse.
• This condition is often misdiagnosed as gout, septic arthritis or
osteomyelitis.
• A good rule of thumb is that if a person has a unilateral hot, swollen
foot, with no obvious portal for infection, consider Charcot’s
arthropathy.
71Basil Tumaini, May Shoo
73. Acute vs chronic Charcot’s arthropathy
• It is very important to understand that there are two phases in Charcot’s. The acute
phase, and the burnt out or chronic phase.
• If a patient comes to you with a
– unilateral warm swollen foot that is
– relatively pain free,
– with bounding pulses and
– with or without some deformity,
– and if there is no obvious portal for infection, an acute Charcot’s needs to be considered.
This will be a very different foot from the burnt out Charcot’s where there is little or no
temperature difference and the foot is rigid and misshapen.
73Basil Tumaini, May Shoo
74. Acute vs chronic Charcot’s
arthropathy• Unilateral
• Warm, swollen
• Relatively pain free
• Bounding pedal
pulses
• Deformity may be
present
• No temperature
difference
• Rigid foot deformity
• Grossly misshapen foot
74Basil Tumaini, May Shoo
77. The typical
appearance of a later-
stage Charcot foot
with a rocker-bottom
deformity4
77Basil Tumaini, May Shoo
78. Lateral X-ray of a Charcot foot deformity
Dislocation of the tarsometatarsal joint with break in the talo-first
metatarsal line (dashed lines) and a reduced calcaneal inclination
angle
4
78Basil Tumaini, May Shoo
79. 79
Lee C. Rogers, et al. The Charcot Foot in Diabetes. Diabetes Care Sep 2011, 34 (9)
2123-2129; DOI: 10.2337/dc11-0844
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80. Charcot’s arthropathy –
treatment
• Acute phase
– Non weight-bearing
– Total contact cast
• Chronic phase
– Orthopaedic surgery
80Basil Tumaini, May Shoo
81. Management4
Offloading
• Offloading at the acute active stage of the Charcot foot
is the most important management strategy
• could arrest the progression to deformity
• the foot should be immobilized in an irremovable total
contact cast (TCC)
• the patient should use crutches or wheelchair and
should be encouraged to avoid weight bearing on the
affected side
Others: Surgical
81Basil Tumaini, May Shoo
82. Autonomic neuropathy
• Vasodilation Oedema
• ↓Sweating thus foot is warm, dry, scaly
which predisposes to fissure formation
Callus formation at pressure points
and dry skin are substrate for
ulceration
Pes cavus resulting in callus formation
over the pressure points
82Basil Tumaini, May Shoo
86. Peripheral vascular disease
• Cause: decreased perfusion
due to macrovascular disease
• Sites: more distal
Tibial and peroneal arteries
(segment between the knee and
the ankle but aortic-illiac to knee
less frequently)
86Basil Tumaini, May Shoo
87. Peripheral vascular disease in
diabetes
• 15-40 times more likely to
have lower limb amputation
• People over 70 years have a
70-fold increased risk of
amputation
87Basil Tumaini, May Shoo
88. Risk factors characteristics of
atherosclerosis in diabetes
• More common
• Affects young age group
• No sex difference
• Smoking
• Faster in progress
88Basil Tumaini, May Shoo
91. Signs of vascular disease
• Diminished or absent
pedal pulses
• Coolness of the feet
and toes
• Poor skin and nails
• Absence of hair on feet
and legs
91Basil Tumaini, May Shoo
92. Peripheral vascular disease
and diabetes
• Symptoms and signs of peripheral
vascular disease
• There are four stages:
1. Occlusive disease without symptoms
2. Intermittent claudication
3. Ischaemic rest pain (nighttime)
4. Ulceration/gangrene
92Basil Tumaini, May Shoo
93. Vascular assessment
Palpation of foot pulses
– Dorsalis pedis (10% absent
due to anatomical reasons)
– Tibialis posterior
93Basil Tumaini, May Shoo
94. Peripheral vascular disease
non-invasive evaluation
• Methods
– Doppler pressure studies (ABI)
– Duplex arterial imaging
• Rationale- The degree of vascular disease can
be used to:
– Identify and confirm presence of disease
– predict whether the ulcer will heal without
surgical intervention.
– determine need for early surgical intervention
94Basil Tumaini, May Shoo
95. Peripheral vascular disease
non-invasive evaluation
• Doppler ultrasound
– |The ABI- Measures pressure at brachial, pedal and
toe arteries
– The ABI is an estimate of the lower limb blood flow
– The SBP of the brachial artery is divided into the SBP
of the pedal arteries.
– Ankle Brachial Index (ABI)
<0.9 abnormal
0.9 to 1.0 normal
>1.3 non-compressible
95Basil Tumaini, May Shoo
96. Peripheral vascular disease
non-invasive evaluation
• Duplex arterial imaging – allows narrowing or
obstruction of blood vessels to be localized
• through the detection of either disturbance or
absence of flow.
• An accurate roadmap of all the arteries in the
leg can be generated using this technique,
which avoids the pitfalls associated with the
interpretation of Doppler pressure
measurements and calcification
96Basil Tumaini, May Shoo
97. Peripheral vascular diseaseTreatment
• Quit smoking
• Walk through pain
– Surgical intervention Studies have shown that the results from angioplasty
and a formal exercise programme – ‘walking through the pain barrier’ –
are similar.
• People should be reassured that walking with claudication is not
dangerous.
97Basil Tumaini, May Shoo
98. Peripheral vascular disease
• They should be asked to continue walking after the onset of
claudication to encourage the development of collateral blood
supply to the limbs.
• If this fails, bypass surgery is required.
• In the past this has always been considered unsatisfactory in
people with diabetes because the vessels that are involved in the
lower limbs are smaller.
• In recent times, however, the success rate has improved.
98Basil Tumaini, May Shoo
102. Do not forget the shoes !
102Basil Tumaini, May Shoo
103. Neuropathic vs Ischemic Ulcer
Neuropathic Ischaemic
Position Pressure areas
Plantar Aspect
Lateral and medial aspects
due to compression
Swelling Dry Swollen
Pain Painless Very painful
Warmth No Yes
Necrosis +/- Yes
Appearance Clean Ulcer Pus & Smelling
103Basil Tumaini, May Shoo
104. Classification - Wagner
• Grade 0 - Skin intact, no foot deformity
• Grade 1 - Superficial ulcer
• Grade 2 - Deep ulcer
• Grade 3 - Deep ulcer with infection
• Grade 4 - Limited necrosis
• Grade 5 - Necrosis of the entire foot
104Basil Tumaini, May Shoo
113. Imaging
Plain X-rays
- Osteomyelitis, fractures
- Soft tissue gas
- Dislocations in neuropathic arthropathy
CT Scan
Technetium bone scans - osteomyeletis
MRI - osteomyelitis
113Basil Tumaini, May Shoo
114. VASCULAR AND NEUROLOGICAL
INVESTIGATIONS
• Indicated to evaluate the extend of occlusive vascular
disease and assessment of healing potential
Doppler segmental arterial pressure
Ankle brachial Index(ABI) normal is 1.1 while <0.9 abnormal
Toe pressure measurement,
• Sensory examination with a 5.07 Semmes Weinstein
monofilament wire
Single most practical measure of risk assessment
BUT is cost effective
114Basil Tumaini, May Shoo
115. MANAGEMENT
• Five aspect of patient treatment
1. Mechanical control
2. Metabolic control
3. Microbial control
4. Vascular management
5. Education
115Basil Tumaini, May Shoo
116. Management
• Preventative foot care
• Diabetic foot ulcer (DFU) care
• Ischemia management
• Neuropathy management
• Surgery
116Basil Tumaini, May Shoo
117. Preventative foot care
Podiatry - Regular inspection of the foot, appropriate nail
care, warm (32oC) soaks, moisturizing creams, early
detection of new lesions
Optimally fitted footwear – well cushioned sneakers,
custom molded shoes
Pressure reduction – cushioned insoles, custom orthoses
Patient education — need for daily inspection and
necessity for early intervention, avoidance of barefoot
walking
Physician education — significance of foot lesions,
importance of regular foot examination, and current
concepts of diabetic foot management
117Basil Tumaini, May Shoo
118. Diabetic Foot Ulcer care
Debridement – of callus and necrotic tissue using sharp
debridement till bleeding tissue, lavage with 0.9%NaCl
Dressing Honey, Mabble cream or Paraffin gauze
Open dressing advisable
Avoid corrosive solutions like – Eusol, H2O2, Spirit or Iodine
Offloading of the ulcer site to reduce ischaemia via total
contact cast, non weight bearing (crutches, bedrest, wheel
chair)
Wound management – maintenance of a moist wound with
regular cleaning and dressing
Infections treated with broad spectrum antibiotics based on
culture results. Clindamycin/flouroquinolone/metronidazole
suitable empiric therapy
118Basil Tumaini, May Shoo
119. Ischemia/neuropathy
• Angiography evaluates for chance of catheter
intervention or vascular surgery
• Vascular bypass surgery successful if occlusion is
supramalleolar but less so in inframalleolar PAOD
• Aspirin is useful for primary and secondary
prevention
• Neuropathy treated pharmacologically with
agents such as carbamazepine, gabapentin and
pregabalin and prevention of minor trauma that
will go undetected due to insensate foot
119Basil Tumaini, May Shoo
120. Surgery
• Sharp debridement
• Local procedures to remove areas of
chronically elevated pressure (deformities)
causing non healing ulcers
• Sequestrectomies
• Amputation
• Correct structural deformities — hammer
toes, bunions, Charcot
120Basil Tumaini, May Shoo
121. Indications for amputation
• Uncontrollable infection or sepsis
• Inability to obtain a plantar grade, dry foot
that can tolerate weight bearing
• Non ambulatory patient
121Basil Tumaini, May Shoo
122. Common pathway Cause of diabetic amputation
A person with diabetes has neuropathy and/or peripheral
vascular disease.
Trauma may occur that causes ulceration.
If this fails to heal, infection and osteomyelitis can ensue.
If the infection is not arrested, the patient might ultimately
require an amputation.
However in
some hot and humid countries,
in people with poor glycaemic control,
underlying neuropathy and/or vascular disease do not
need to be present;
people can progress quickly from trauma to infection to
amputation.
Basil Tumaini, May Shoo
123. Cause of diabetic amputation
Pecararo
Trauma
Ulcer
Failure to heal
Infection
Amputation
Neuropathy or vascular disease
123Basil Tumaini, May Shoo
124. This slide says it all…
• This figure is terrifying especially when we
know that up to 85% of amputations are
preventable with early identification of the
• at-risk foot and prompt treatment by a
skilled multidisciplinary footcare team.
124Basil Tumaini, May Shoo
125. Lessons from The Step by Step Foot Project2
• Training personnel in diabetic foot management,
facilitating transfer of knowledge and expertise,
and improved patient education improves:
• foot ulcer management
• reduces the incidence of foot ulcers
• reduces amputation rates
125Basil Tumaini, May Shoo
126. References
1. Boulton AJM, et al. Comprehensive Foot Examination and
Risk Assessment: A report of the Task Force of the Foot Care
Interest Group of the American Diabetes Association, with
endorsement by the American Association of Clinical
Endocrinologists. Diabetes Care 2008; 31:1679.
2. Abbas ZG, Lutale JK et al, The ‘Step by Step’Diabetic Foot
Project in Tanzania: a model for improving patient outcomes
in less-developed countries. Int Wound J. 2011 Apr;8(2):169-
75 availabe at
http://www.ncbi.nlm.nih.gov/pubmed/21266010 Accessed on
01/06/2016.
126Basil Tumaini, May Shoo
127. References ...
3. Chiwanga, Faraja S., and Marina A. Njelekela. Diabetic Foot:
Prevalence, Knowledge, and Foot Self-Care Practices among
Diabetic Patients in Dar Es Salaam, Tanzania – a Cross-
Sectional Study. Journal of Foot and Ankle Research 8
(2015): 20. PMC. Web. 1 June 2016.
4. Lee C. Rogers, et al. The Charcot Foot in Diabetes. Diabetes
Care Sep 2011, 34 (9) 2123-2129; DOI: 10.2337/dc11-0844
5. Previous slides from Prof. Lutale and former students.
127Basil Tumaini, May Shoo