CME General Surgery in the Solomon Islands

1. Presenter: Simon Holara
Surgical Intern

2. 1. Diabetes Overview
2. DFU definition
3. Pathophysiology
4. Classification
5. Clinical
6. Investigations
7. Microbiology
8. Diagnosis
9. Management
10. Reference
OUTLINE

3. Is a chronic, progressive disease, in which the body’s ability to produce
or respond to the hormone insulin is impaired, resulting in abnormal
metabolism of carbohydrates and elevated levels of glucose in the blood.
Diabetes can lead to complications in many parts of the body and
increase the risk of dying prematurely:
1. Stroke
2. Blindness
3. Heart attack
4. Kidney failure
5. Amputations (2ndary to DFS/DFU)
DIABETES MELLITUS

6. Dr Ghabu said diabetes cases reported at the NRH were becoming more
common, everyday.
He said the most common type of diabetes seen at the hospital was leg
infection and there had been an increase in leg amputations at the
hospital.
“Today, surgeons at the national referral hospital perform two to three
amputations in a week,” he said.

7. • Diabetic foot ulcer is a major complication of diabetes mellitus and
probably the major component of the diabetic foot.
• Defined as a foot affected by ulceration, associated with peripheral
neuropathy and/or arterial disease of the lower limbs in a diabetic
patient
• Uncontrolled diabetes leads to the breaking down of skin tissue and
revealing the layers underneath the foot. The diabetic foot ulcer can be
very deep and may affect bones, tendons, and foot muscles.
DIABETIC FOOT ULCER

8. Diabetic foot lesions are responsible for more hospitalizations than any other
complication of diabetes
Among patients with diabetes, 15% develop a foot ulcer, and 12-24% of individuals
with a foot ulcer require amputation.
In fact, every year approximately 5% of diabetics develop foot ulcers and 1% require
amputation
EPIDEMIOLOGY

9. DFU are a combined effect of the :
1. Peripheral neuropathy (Neuropathy)
2. Peripheral arterial disease (Vasculopathy)
3. Extraordinary susceptibility to infection (Immunopathy)
PATHOPHYSIOLOGY

11. 1. SENSORY NEUROPATHY
Impaired protective sensation and altered pain response
Vulnerable to unnoticed trauma and extrinsic forces
Callous formation, tissue necrosis and development of cavities filled
with serous fluid
Erupt into surface, forming and ulcer

12. Muscle Weakness and wasting and intrinsic foot muscle Imbalance
Foot deformities
Abnormal gait
Ulceration
2. MOTOR NEUROPATHY

13. Diminish effectiveness of perfusion and elevate skin temperatures
Loss of sweat and Oil gland Function
Diabetic foot becomes dry and keratinized
Crack and fissures
Ulceration
3. AUTONOMIC NEUROPATHY

14. Decreased local blood flow
Poor antibiotic penetration
Poor wound healing
VASCULOPATHY
1. Macroangiopathy:
• Atherosclerosis of large arteries
2. Microangiopathy:
• increased thickness of basement
membrane & endothelial proliferation
• Altered nutrient exchange
• Tissue hypoxia
• Microcirculation ischemia

15. Inherent susceptibility to infection
Defects in leukocyte function
Decreased polymorphonuclear leukocyte migration
Decreased intracellular killing
Decreased chemotaxis
IMMUNOPATHY

16. 1. According to Etiology
2. King’s Classification
3. Wagner's Classification of Diabetic Ulcer
4. Texas Classification
5. Pedis Classification
CLASSIFICATION

17. 1. Neuropathic foot (neuropathy is Dominant)
 With infection
 Without infection
1. Ischaemic Foot (Vascular disease is dominant)
 With infection
 Without infection
1. ACCORDING TO AETIOLOGY

18. STAGES CLINICAL CONDITION
1 Normal
2 High Risk
3 Ulcerated
4 Cellulitic
5 Necrotic
6 Major ampuation
2. KINGS CLASSIFICATION

20. Grade Characteristics
0 Pre-ulcerative area without open lesion
(high risk Foot)
1 Superficial Ulcer (partial /full
thickness)
2 Ulcer deep to tendon, capsule, Bone
3 Deep ulcer with abscess, osteomyelitis
or Septic arthritis
4 Localized Gangrene (foot or forefoot)
5 Global foot Gangrene
3. WAGNER'S CLASSIFICATION

22. 4. TEXAS CLASSIFICATION
Grade 0 Grade 1 Grade 2 Grade 3
Stage 1 Preulcerative
or post
ulcerative
lesions
completely
epithelialized
Superficial
wound
Deep wound
penetrating to
tendon or
capsule
Wound
penetrating to
bone or joint
Stage 2 Infection
Stage 3 Ischemia
Stage 4 Infection and ischemia

23. 5. PEDIS CLASSIFICATION
Based on FIVE parameters :
Perfusion : presence of ischemia or arteriopathy
Extension: Wound size (cm2)
Depth: superficial or deep
Infection: presence and level of infection
Sensitivity: Loss or No loss of protective sensation

24. CLINICAL FEATURES
Foot ulcer
Increased pain
Swelling
Pus discharging
Foul-smelling odor

25. The foot has diminished sensation
Invariably warm, with intact often pounding
pulses
Ulcers are mostly seen on PRESSURE POINTS
in the Plantar surface and STRESS areas on the
Dorsal surface
Ulcer often preceded by CALLUS formation
Can lead to cellulitis, abscess and osteomyelitis
Painful
Foot pulses are absent
Foot is not warm (cold feet)
Lesion on the MARGINS of the foot and TIPS
of the toes
Absence of CALLUS is characteristic feature
Neuropathic Ischemic
CLINICAL FEATURES

26. FBC
Pus swab
Plain X-RAYS
osteomyelitis
soft tissue gas
dislocations
INVESTIGATIONS

27. Polymicrobial infections
Most common: gram positive Cocci; STAPHYLOCOCCUS AUREUS and
Gram negative rods such PSEUDOMONAS AERUGINOSA.
Infection with anaerobic organism such as CLOSTRIDIUM PERFRINGES
may lead to ischemia or gangrene
MICROBIOLOGY

28. History : Diabetic hx, previous ulcer or amputation, symptoms of
peripheral neuropathy & ischemic problem, contributing
comorbidities
Physical Examination: deformity, hyper callosity, ulcerations,
absence of peripheral pulse
Investigations. X-rays for osteomyelitis
DIAGNOSIS

29. 5 principles of DFU treatment
1. Mechanical control: drainage, debridement and amputations
2. Metabolic control: diabetic diet and glucose control meds
3. Microbiological control: systemic Antibiotics
4. Vascular management: arterial reconstruction
5. Education: regular foot inspection, avoid barefoot walking, nail care,
moisturizing creams, pressure reduction footwear
MANAGEMENT

30. 1. DFU is the major complication of Diabetes Mellitus
2. The diabetic foot TRIAD include neuropathy, vasculopathy, and
immunopathy
3. Following the 5 principles of DFU management, further complication
can be prevented which include Amputations, sepsis, and death.
CONCLUSION

31. REFERENCE
Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996. 35:5
28‐531
Schwartz LS, Spencer . PRINCIPLES OF SURGERY. Second edition
Brodsky JW. The diabetic foot, in Mann RA, Coughlin MJ (eds): The Diabetic Foot, ed 6. St. Louis, MO,
Mosby-Year Book, pp 1361-467, 1992
Boulton AJ, Kirsner RS, Vileikyte L. Clinical practice. Neuropathic diabetic foot ulcers. N Engl J Med
351(1):48-55, 2004