Amputation Prevention


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Educational presentation on preventing amputations in patients with diabetes, neuropathy and peripheral vascular disease.

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  • Bring Semmes Weinstein tester and vibration tester
  • Affects C Fibers and A delta (small ones first)
  • Prevention 4 RCTs of pressure relieving interventions were identified. Interventions for the prevention of diabetic foot ulcers indicated that in-shoe orthotics are of benefit. The relative merits of different in-shoe orthotics are unclear; cushioning and pressure redistribution appear of equal benefit. Other pressure relieving interventions such as running shoes have not been adequately evaluated and removable casts (Scotchcast or Hope) or foam inlays do not appear to have been evaluated at all in randomised controlled studies. Treatment 1 RCT of total contact casting indicated that it was effective in the treatment of diabetic ulcers although the evidence was limited .
  • Topical negative pressure therapy for treating chronic wounds Topical negative pressure (TNP) therapy is the application of negative pressure across a wound to aid wound healing. The pressure is thought to aid the drainage of excess fluid, reduce infection rates and increase localised blood flow. TNP is also known as vacuum assisted closure (VAC) and sealed surface wound suction. Seven trials compared TNP with either moistened gauze dressings or other topical agents and found no difference in effects. One very small, poor quality trial (7 wounds) showed a reduction in wound volume and depth in favour of TNP. There is no valid or reliable evidence that topical negative pressure increases chronic wound healing.
  • There is evidence to suggest that hydrogel increases the healing rate of diabetic foot ulcers compared with gauze dressings or standard care and larval therapy resulted in significantly greater reduction in wound area than hydrogel. More research is needed to evaluate the effects of a range of widely used debridement methods and of debridement per se.
  • Amputation Prevention

    1. 1. Amputation Prevention – Keeping Your Feet Healthy With Diabetes Don Pelto, DPM Central Massachusetts Podiatry, PC Worcester, MA
    2. 2. Why should I listen? <ul><li>You or a loved one will probably develop diabetes during your lifetime </li></ul><ul><li>1-4% of people with diabetes get ulcers every year and 15-25% will get one in their lifetime </li></ul><ul><li>15% of ulcers lead to amputation </li></ul><ul><li>85% of amputations start as ulcers </li></ul><ul><li>45% of people with an ulcer will die within 5 years </li></ul>
    3. 3. Poor Circulation - PAD
    4. 4. Neuropathy
    5. 5. Neuropathy <ul><li>Neuropathy </li></ul><ul><ul><li>Medication Oral </li></ul></ul><ul><ul><li>Topical Medication </li></ul></ul><ul><ul><li>ENFB (Epidermal Nerve Fiber Biopsy) </li></ul></ul>
    6. 6. Foot Deformity - Bunions and Hammerotes
    7. 7. Foot Deformity – Callous / Corn <ul><li>Thickened skin caused by chronic rubbing or irritation of a bony prominence by the ground or shoe gear </li></ul>
    8. 8. Callous / Corn Treatment <ul><li>Trimming Callus </li></ul><ul><li>Callus Cream & Pumice Bar </li></ul><ul><li>Padding </li></ul><ul><li>Decreasing friction </li></ul><ul><li>Don't use acid pads </li></ul>
    9. 9. Diabetic Ulcer
    10. 10. Diabetic Ulcer
    11. 11. Diabetic Ulcer <ul><li>4 Reasons Why Won’t Heal </li></ul><ul><ul><li>High Blood Sugar </li></ul></ul><ul><ul><li>Poor Circulation </li></ul></ul><ul><ul><li>Deeper Infection </li></ul></ul><ul><ul><li>Walking on Wound </li></ul></ul>
    12. 12. Diabetic Ulcer Spencer SA. Pressure relieving interventions for preventing and treating diabetic foot ulcers. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD002302. DOI: 10.1002/14651858.CD002302.
    13. 13. Diabetic Ulcer Ubbink DT, Westerbos SJ, Evans D, Land L, Vermeulen H. Topical negative pressure for treating chronic wounds. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD001898. DOI: 10.1002/14651858.CD001898.pub2.
    14. 14. Diabetic Ulcer <ul><li>Callus </li></ul><ul><ul><li>Diabetic shoes </li></ul></ul><ul><li>Ulceration </li></ul><ul><ul><li>VAC </li></ul></ul><ul><ul><li>Debridement </li></ul></ul><ul><ul><li>Dermal Skin Substitute </li></ul></ul><ul><ul><li>Platelet Rich Plasma </li></ul></ul>
    15. 15. Charcot Foot Edwards J, Stapley S. Debridement of diabetic foot ulcers. Cochrane Database of Systematic Reviews 2010, Issue 1.
    16. 16. Diabetic Shoes Most patient’s with Diabetes Qualify for a pair of Diabetic Shoes each year. <ul><ul><li>Partial/Complete Amputation </li></ul></ul><ul><ul><li>Previous Ulceration </li></ul></ul><ul><ul><li>Pre-Ulcerative Callus </li></ul></ul><ul><ul><li>Neuropathy with Callus </li></ul></ul><ul><ul><li>Poor Circulation </li></ul></ul><ul><ul><li>Foot Deformity </li></ul></ul>
    17. 17. Common Foot Problems <ul><li>For people with and without diabetes </li></ul>
    18. 18. Plantar Fasciitis / Heel Spur <ul><li>Inflammation and partial tearing of a ligament band </li></ul><ul><li>Spur may be present </li></ul><ul><li>Pain first thing in morning </li></ul>
    19. 19. Plantar Fasciitis Treatment <ul><li>New shoes </li></ul><ul><li>Ice </li></ul><ul><li>NSAIDs </li></ul><ul><li>Night Splint </li></ul><ul><li>Stretching vs Deep Tissue Massage </li></ul>
    20. 20. Plantar Fasciitis Treatment <ul><li>Steroid Injection </li></ul><ul><ul><li>25G Needle </li></ul></ul><ul><ul><li>3cc Syringe </li></ul></ul><ul><ul><li>1cc 1% Lidocaine </li></ul></ul><ul><ul><li>1cc 0.5% Marcaine </li></ul></ul><ul><ul><li>0.5cc Kenalog </li></ul></ul><ul><ul><li>0.5cc Dexamethasone </li></ul></ul>
    21. 21. Flat Feet <ul><li>Congenital or acquired </li></ul><ul><li>Pain may occur in the feet, ankles, knees or back </li></ul>
    22. 22. Flat Feet Treatment <ul><li>Supportive Shoes </li></ul><ul><li>Orthotics </li></ul><ul><li>Arizona Brace </li></ul>
    23. 23. Morton’s Neuroma <ul><li>Compressed Nerve </li></ul><ul><li>Most often 3 rd interspace </li></ul><ul><li>Burning / pain on the ball of the foot or toes </li></ul><ul><li>r/o stress fracture, metatarsalgia </li></ul>
    24. 24. Morton’s Neuroma Treatment <ul><li>Wide shoes </li></ul><ul><li>No high heel shoes </li></ul><ul><li>NSAIDs </li></ul><ul><li>Physical Therapy </li></ul><ul><li>Orthotics </li></ul><ul><li>Metatarsal Pad </li></ul><ul><li>Steroid Injection </li></ul><ul><li>Sclerosing Injection 4% </li></ul><ul><ul><li>48cc 0.5% Marcaine with epi </li></ul></ul><ul><ul><li>2cc Dehydrated Alcohol </li></ul></ul>
    25. 25. Hallux Valgus <ul><li>Painful bump secondary to increase IM angle </li></ul><ul><li>Poor biomechanics </li></ul><ul><li>Hurts in shoes </li></ul><ul><li>Usually bump pain vs joint pain </li></ul><ul><li>Wider shoes help </li></ul><ul><li>Orthotics slow or stop progression and pain </li></ul>
    26. 26. Hallux Valgus Treatment <ul><li>Radiographs </li></ul><ul><li>Wider shoes </li></ul><ul><li>Padding, Bunion Bra </li></ul><ul><li>Trimming Keratoma </li></ul><ul><li>Corticosteroid Injection </li></ul><ul><ul><li>Bump vs Joint </li></ul></ul><ul><li>Orthotics slow or stop progression and pain </li></ul>
    27. 27. Tailor’s Bunion / Bunionette <ul><li>Bony deformity which is located on the outside part of the foot. </li></ul><ul><li>The bump, bunionette or Tailor’s Bunion, can become very painful due to shoe irritation. </li></ul>Note prominent 5 th metatarsal head
    28. 28. Hallux Rigidus <ul><li>Arthritis of 1 st MPJ </li></ul><ul><li>Poor biomechanics </li></ul><ul><li>Painful to walk </li></ul>
    29. 29. Hallux Rigidus Treatment <ul><li>Cortisone injection </li></ul><ul><li>Physical therapy </li></ul><ul><li>NSAIDS </li></ul><ul><li>Orthotics </li></ul>
    30. 30. Hammertoe Deformity <ul><li>Digital contracture can be flexible or rigid in nature </li></ul><ul><li>Usually PIPJ </li></ul><ul><li>May have MPJ dorsiflexion </li></ul><ul><li>May have callus </li></ul><ul><li>Pre-ulcerative in patients with diabetes </li></ul>
    31. 31. Hammertoe Treatment <ul><li>Debridement </li></ul><ul><li>Padding </li></ul><ul><li>Shoe gear change </li></ul>
    32. 32. Athlete's Foot <ul><li>Fungal infection (Dermatophyte). </li></ul><ul><li>May occur anywhere on the foot and may burn and/or itch </li></ul><ul><li>The affected areas of skin will often peel or may have small blisters </li></ul>
    33. 33. Athlete's Foot Treatment <ul><li>Topical Antifungal – Cream vs Gel </li></ul><ul><li>Topical Steroid </li></ul><ul><li>May be dermatitis </li></ul><ul><li>Biopsy if not responding </li></ul>
    34. 34. Plantar Wart <ul><li>Human Papilloma Virus (HPV) </li></ul><ul><li>Contagious </li></ul><ul><li>Usually plantar on foot </li></ul>
    35. 35. Verruca Treatment <ul><li>Debridement </li></ul><ul><li>Chemocautery </li></ul><ul><li>Laser </li></ul><ul><li>Topical treatments </li></ul><ul><li>Oral Cimetidine for pediatric usage (30-40Mg/Kg in 3 divided doses) </li></ul><ul><li>Liquid Nitrogen not very effective on thick plantar foot skin </li></ul>
    36. 36. Ganglion Cyst <ul><li>Benign soft tissue mass which arises from a weak area in a tendon lining or joint </li></ul><ul><li>Cyst is often filled with a gelatinous fluid </li></ul><ul><li>Cyst may change size depending on irritation </li></ul>
    37. 37. Ganglion Cyst Treatment <ul><li>Aspiration </li></ul><ul><li>Cortisone Injection </li></ul><ul><li>Trauma </li></ul><ul><li>Pressure </li></ul>
    38. 38. Eczema/Fissures <ul><li>Skin inflammatory condition </li></ul><ul><li>Worse in winter </li></ul><ul><li>Make sure not ulceration </li></ul>
    39. 39. Ezema/Fissure Treatment <ul><li>Cream </li></ul><ul><li>Pumice Stone </li></ul><ul><li>Off-loading Boot </li></ul>
    40. 40. Eczema/Fissure Treatment
    41. 41. Ingrown Nails/Paronychia <ul><li>Painful to edge of nail with pressure or tight shoes </li></ul><ul><li>Erythema, edema, purulent exudate </li></ul>
    42. 42. Ingrown Nail Treatment <ul><li>Antibiotic </li></ul><ul><li>Massaging Nail Edge </li></ul><ul><li>I&D </li></ul><ul><li>Phenol & Alcohol (P&A) </li></ul>
    43. 43. Onychomycosis <ul><li>Dermatophyte </li></ul><ul><li>Often seen with skin manifestations </li></ul><ul><li>Usually acquired but may be inherited </li></ul><ul><li>May be caused by trauma </li></ul>
    44. 44. Onychomycosis Treatment <ul><li>Debridement </li></ul><ul><li>Topical/Oral Antifungal </li></ul><ul><li>Laser </li></ul><ul><li>Nail Avulsion </li></ul><ul><li>Matrixectomy </li></ul><ul><li>Nail Biopsy </li></ul>
    45. 45. Fungal Laser <ul><li>Kills the pathogens that cause toenail fungus (Onychomycosis). </li></ul><ul><li>Painless-no anesthesia needed. </li></ul><ul><li>No side effects. </li></ul><ul><li>Does not harm the nail or skin. </li></ul><ul><li>Usually only one treatment required. </li></ul><ul><li>Shoes and nail polish can be worn immediately after treatment. </li></ul>
    46. 46. Nail Injury <ul><li>Chronic injury (i.e. athletic activities) </li></ul><ul><li>Isolated injury (trauma) </li></ul><ul><li>Nail bed laceration </li></ul>
    47. 47. Nail Injury Treatment <ul><li>Watch and wait </li></ul><ul><li>Nail avulsion </li></ul><ul><li>Puncture </li></ul>
    48. 48. Subungual Exostosis <ul><li>Bone and cartilage growth under the great toe nail </li></ul><ul><li>Pain may arise if pressure is placed over the area </li></ul>
    49. 49. Subungual Exostosis Treatment <ul><li>Shoe Modification </li></ul><ul><li>Toe Cap </li></ul><ul><li>Nail Avulsion </li></ul><ul><li>Cortisone Injection </li></ul><ul><li>Exostectomy </li></ul>
    50. 50. Haglund’s Deformity / Retrocalcaneal Exostosis <ul><li>Prominent bone on the back of the heel. </li></ul><ul><li>Back of the heel is irritated by shoes and activity. </li></ul>
    51. 51. Haglund’s Deformity / Retrocalcaneal Exostosis Treatment <ul><li>Open Backed Shoes </li></ul><ul><li>Steroid Injection around Bursa </li></ul><ul><li>Orthotics </li></ul>
    52. 52. Fractures <ul><li>5 th Metatarsal – Difficulty healing </li></ul><ul><li>Digital </li></ul><ul><li>Calcaneus </li></ul><ul><li>Stress Fracture </li></ul>
    53. 53. Fracture Treatment <ul><li>Surgical Shoe </li></ul><ul><li>CAM Walker </li></ul><ul><li>Bone Stimulator </li></ul><ul><li>Buddy Taping </li></ul><ul><li>MRI vs CT </li></ul>
    54. 54. Thank You Don Pelto, DPM Central Massachusetts Podiatry, PC Worcester, MA [email_address] (508) 757-4003