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Diabetic Foot 2016
- 1. Diabetic Foot Management Diabetic Foot Protection Service Tallaght Hospital, Dublin, Ireland Sean Tierney
- 2. Vascular surgery @ Tallaght The problem
- 3. Vascular surgery @ Tallaght The problem
- 4. Vascular surgery @ Tallaght Mechanism of ulceration Neuropathy
- 5. Vascular surgery @ Tallaght Semmes-Weinstein monofilament • Loss of – protective sensation in feet – proprioception – vibration – Pain • Asymptomatic – 50% of insensate patients have no symptoms Sensory neuropathy Diabetes Care. 2006;2 9: S24 Diabetes Care. 2004; 27: 1591
- 6. Vascular surgery @ Tallaght • Demonstrate on forearm or hand • Place monofilament perpendicular & bow into C-shape for 1 second • 4 sites/foot • Avoid – Heel (does not predict ulcer) – calluses, scars, and ulcers Sensory neuropathy Diabetes Care. 2006;2 9: S24 Diabetes Care. 2004; 27: 1591
- 7. Vascular surgery @ Tallaght Sensory neuropathy • -ve predictive value = 90%-98% • +ve predictive value = 18%-36% J Fam Pract. 2000;49:S30 Diabetes Care. 1992;15:1386
- 8. Vascular surgery @ Tallaght Ipswich Touch test • If ≥2 (of 6) missed • Sensitivity 77% • Equivalent to SWMF Rayman G. Diabetes Care. Jul 2011; 34(7): 1517–1518.
- 9. Vascular surgery @ Tallaght Other sensory modalities
- 10. Vascular surgery @ Tallaght Other sensory modalities
- 11. Vascular surgery @ Tallaght Other sensory modalities Sales Sensory Motor Autonomic
- 12. Vascular surgery @ Tallaght Motor neuropathy Diabetes Care. 2001;24:1442 Diabetes Metab. 2003;29:261
- 13. Vascular surgery @ Tallaght Autonomic neuropathy
- 14. Vascular surgery @ Tallaght Vascular disease Neuropathy Deformity Trauma UlcerHealing
- 15. Vascular surgery @ Tallaght Vascular disease Neuropathy Deformity Trauma UlcerHealing Limb loss Ischaemia Infection
- 16. Vascular surgery @ Tallaght UT classification University of Texas Wound Classification System Lavery et al. J Foot Ankle Surg 35 : 528-531,1996
- 17. Vascular surgery @ Tallaght
- 18. Vascular surgery @ Tallaght Foot assessment in diabetics Structural Skin and soft tissue Innervation Perfusion
- 19. Vascular surgery @ Tallaght Arterial supply Poitier et al, Eur J Vasc Endovasc 2011 • PAOD prevalence 9.5% - 13.6% • (~ 50% with ulcer) • distal > proximal • Medial artery calcification more common
- 20. Vascular surgery @ Tallaght Vascular assessment in diabetics
- 21. Vascular surgery @ Tallaght Is palpation of pulses reliable? DP only PT only Both Sensitivity 64 70 73 Specificity 81 83 92 NPV * 91 92 94 PPV 43 49 81 Accuracy 77 81 95 absent pulses • Negative predictive value of palpable pulses in excluding PAOD is 94% (vs ABI <0.9 as gold standard) Armstrong et al. Can J Cardiol 2010
- 22. Vascular surgery @ Tallaght Where is the patient on the spectrum? Normal pulses Impalpable pulses
- 23. Vascular surgery @ Tallaght ABI in Diabetes Poitier et al, Eur J Vasc Endovasc 2011
- 24. Vascular surgery @ Tallaght ABI in Diabetes Poitier et al, Eur J Vasc Endovasc 2011
- 25. Vascular surgery @ Tallaght <120s 60o <120s Beurger’s test -ve +ve
- 26. Vascular surgery @ Tallaght Toe pressure P>SBP
- 27. Vascular surgery @ Tallaght Toe pressure measurements • Less affected by medial calcification (neuropathy, CRF) • absolute toe pressure of <30 mmHg = critical ischemia • 1o in 85% TP >45 mmHg vs 36% ≤45 mmHg (p < .001) * Brooks et al. Diabetic Medicine 2001, 18(12):528-532. * Apelqvist et al. Diabetes Care June 1989 12:6 373-378
- 28. Vascular surgery @ Tallaght Tissue oxygenation
- 29. Vascular surgery @ Tallaght Tissue oximetry & healing Londahl et al. Diabetolgia 2011
- 30. Vascular surgery @ Tallaght Tissue oximetry (summary) • tissue hypoxia is defined as “a TcPO2 <40 mm Hg” • associated with reduced likelihood of amputation healing • in critical limb ischemiaTcPO2 typically < 30 mm Hg Oxygen response • TcPO2 increases by > 40 mm Hg on 100% O2 usually associated with subsequent healing Fife et al. Undersea and Hyperbaric Medicine. 2009
- 31. Vascular surgery @ Tallaght Choices Structural & neuropathy Offload Ischaemia Revascularisation Infection Drain, debride, ABx
- 32. Vascular surgery @ Tallaght Risk based ulcer prevention Risk Level Foot Ulcer %/yr % in clinics (diabetes clinics) 3: Prior amputation Prior ulcer 28.1% 18.6% 7% 2: Insensate and foot deformity or absent pedal pulses 6.3% 10% 1: Insensate 4.8% 17%-30% 0: All normal 1.7% 66%
- 33. Vascular surgery @ Tallaght Vascular Intervention Ischaemia Revascularisation
- 34. Vascular surgery @ Tallaght Imaging • Duplex • CT angio • MRI • Angiogram
- 35. Vascular surgery @ Tallaght Imaging
- 36. Vascular surgery @ Tallaght Issues • Calcification • Contrast – Renal fxn – Metformin – Prevention AKI • Level
- 37. Vascular surgery @ Tallaght Pedal Bypass surgery • 1998-2008 • N= 28 (4 asynchronous bilateral) • M:F = 5:1 • Mean age 63y (37 – 92) • Autologous vein used in all patients Good et al Ir J Med Sci 2010
- 38. Vascular surgery @ Tallaght Pedal Bypass surgery Good et al Ir J Med Sci 2010 Proximal site • Popliteal (n=28) Distal sites • Dorsalis paedis (n=13) • Plantar artery (n= 15)
- 39. Vascular surgery @ Tallaght Pedal Bypass surgery Primary graft patency 0 20 40 60 80 100 0 6 12 18 24 30 36 42 48 54 60 Time after surgery (months) Graftpatencyasapercentage Primary patency Good et al Ir J Med Sci 2010
- 40. Vascular surgery @ Tallaght Primary & Secondary graft patency 0 20 40 60 80 100 0 6 12 18 24 30 36 42 48 54 60 Time after surgery (months) Graftpatencyasapercentage Primary Secondary Pedal Bypass surgery Good et al Ir J Med Sci 2010
- 41. Vascular surgery @ Tallaght Pedal Bypass surgery 0 20 40 60 80 100 0 6 12 18 24 30 36 42 48 54 60 Limbsurvivalasapercentage Time after surgery (months) Limb Salvage Good et al Ir J Med Sci 2010
- 42. Vascular surgery @ Tallaght Patient Survival after Popliteo-pedal bypass 0 20 40 60 80 100 0 6 12 18 24 30 36 42 48 54 60 Time after surgery (months) Survivalasapercentage Pedal Bypass surgery Good et al Ir J Med Sci 2010
- 43. Vascular surgery @ Tallaght Meta-analysis (pop pedal bypass) • N=1,2320 (79 studies) • @ 5 years • 1o patency 63% • 2o patency 71% • Limb salvage 78% • * 5 yr mortality ~50% Albers et al J Vasc Surg. 2006 43:498-503. *Hinchcliffe et al Diabetes Metab Res Review 2012
- 44. Vascular surgery @ Tallaght Innovation
- 45. Vascular surgery @ Tallaght Technical considerations • Consent • Ipsilateral (antegrade) • Local • ? 4/5Fr • ? ultrasound
- 46. Vascular surgery @ Tallaght Tibial artery disease • Sub-intimal vs luminal • Target vessels • Re-assessment Lida O et al. J Vasc Surg. 2012; 55(2):363-370
- 47. Vascular surgery @ Tallaght Tibial angioplasty - results • 40 mo • 61 limbs in 53 patients (41 male, median age 73) • Rest pain /tissue loss) • TASC D O Connor et al ASGBI 2014
- 48. Vascular surgery @ Tallaght TASC Norgren et al. JVS 2007
- 49. Vascular surgery @ Tallaght TASC Norgren et al. JVS 2007
- 50. Vascular surgery @ Tallaght Grazziani L Graziani L, et al Eur J Vasc Endovasc Surg.
- 51. Vascular surgery @ Tallaght Tibial angioplasty – results 2 • Technical success 81.3% (49/61 limbs) • Revascularisation n=12 (4 distal bypass) • Survival (3 y) 72% • AFS (3 yr) 64% O Connor et al ASGBI 2014
- 52. Vascular surgery @ Tallaght Tibial angioplasty – meta-analysis • N = 2653 • Technical success = 90% @ 3 years • 1o patency 49% • 2o patency 63% • Limb salvage 80% • Survival 68% Romiti et al J Vas Surg 2008
- 53. Vascular surgery @ Tallaght Tibial angioplasty – meta-analysis • N = 2653 • Technical success = 90% • @ 3 years • 1o patency 49% • 2o patency 63% • Limb salvage 80% • Survival 68% Romiti et al J Vas Surg 2008 vs Bypass (@5 years) 63% 71% 78% 50% Albers et al J Vasc Surg. 2006 43:498-503.
- 54. Vascular surgery @ Tallaght PAOD – critical ischaemia
- 55. Vascular surgery @ Tallaght Multidisciplinary care Nason et al. Ir J Med Sci 2013
- 56. Vascular surgery @ Tallaght Choices Structural & neuropathy Offload Ischaemia Revascularisation Infection Drain, debride, ABx
- 57. Vascular surgery @ Tallaght Neuropathic ulcer Structural & neuropathy Offload
- 58. Vascular surgery @ Tallaght Neuropathic ulcer Lewis J et al. Cochrane Database Syst Rev. 2013
- 59. Vascular surgery @ Tallaght Neuropathic ulcer
- 60. Vascular surgery @ Tallaght Infection • Debride • Probes to bone • Xray • ? Bone scan • ? MRI Infection Drain, debride, ABx
- 61. Vascular surgery @ Tallaght Infection • Antibiotics • Sliding scale • Surgical Debridement • Drainage • Minor amputation
- 62. Vascular surgery @ Tallaght Infection • Multiple procedures • VAC closure • Offloading
- 63. Vascular surgery @ Tallaght Think feet… think vascular
- 64. Vascular surgery @ Tallaght Plantar ulcer
- 65. Vascular surgery @ Tallaght Heel ulcer
- 66. Vascular surgery @ Tallaght Fore foot ulcer
- 67. Vascular surgery @ Tallaght Pain & Swelling
- 68. Vascular surgery @ Tallaght 3 months later
- 69. Vascular surgery @ Tallaght
- 70. Vascular surgery @ Tallaght
- 71. Vascular surgery @ Tallaght • STIR and T1-weighted images: abnormal signal intensity in the cuboid bone indicative of osteomyelitis. • Contrast enhanced images +/-fat saturation: Enhancement of cuboid and soft tissues = osteomyelitis very likely.