This document provides an overview of diabetic foot. It begins with an introduction explaining that diabetic foot is the most costly complication of diabetes. It then covers classification and staging of diabetic foot, discussing neuropathic, ischemic, and mixed types. The pathogenesis involves neuropathy, angiopathy, and immune dysfunction from long-term high blood sugar levels. Clinical features depend on the type, and management addresses metabolic, mechanical, vascular, and infection issues. Prevention focuses on patient education and foot care guidelines.

1. Diabetic Foot
Dr. Wilson Njeru
M.D. MBBS

2. Flow of our presentation
• Introduction
• Definition
• Classification & Staging
• Pathogenesis
• Clinical features
• Management
• Prevention guidelines
• A quick recap
• Conclusion
• Literature

3. Introduction
• From foot deformities, to ulceration, infection,
necrosis, gangrene & eventually amputation,
“diabetic foot”
is by far the most COSTLY complication of DM
(according to WHO).

4. Introduction
• Diabetes is the most common cause of non-
traumatic amputations of lower limbs.
• It accounts for >70% of lower limb
amputations.
• This leads to long periods of hospitalization,
rehabilitation, not to mention disability & its
impending socio-economical & psychological
impacts.
• I can not emphasize enough on this morbidity!

6. A quick review on all complications of DM;
Complications of DM
Acute complications Chronic complications
“emergencies” Diabetic -
-DKA *MACROangiopathies
(CAD, CVD, PAD)
-NKHHS *Microangiopathies
(Retinopathy, Nephropathy)
-Lactic Acidosis *Neuropathy
(Central & Peripheral)
-Hypoglycemia *Diabetic foot
{mainly caused by peripheral
polyneuropathy or angiopathy}

7. Definition
• Diabetic foot (DF) is a pathological condition
of the foot in diabetic patients, xrised by skin
& soft tissue lesions, damage to joints &
bones, presenting as formation of ulcers, joint
deformities, infection, necrotic and
gangrenous processes.
• It is one of the several chronic complications of DM,
but it stems from the others, as we’ve already seen
in the previous slide.

9. Classification
&
Staging

10. Classification & Staging
• A standard classification of DF is useful in:
Assessing the etiology
Designing appropriate Rx
Assessing prognosis
Monitoring the course of disease/progress

11. Classification on basis of etiology:
1. Neuropathic foot
2. Ischemic foot
3. Neuro-ischemic foot (mixed)

12. Classification on basis of etiology:
Neuropathic foot
o Due to peripheral PolyNeuropathy i.e. “somatic + autonomic”,
both sensory & motor neuropathies.
• W or w/o CHARCOT joint disease (i.e. neuro-OSTEOARTHROPATHY)
Ischemic foot
oMainly macroangiopathy i.e. PAD of lower limbs
• W or w/o infection
Neuro-ischemic foot (mixed)

14. Staging according to clinical condition
(ME Edmond et AV Foster staging):
Stage Clinical condition of FOOT
I. Normal foot
II. HIGH risk foot
III. Ulcerated foot
IV. Cellulitic foot
V. Necrotic foot
VI. Major Amputation

16. Wagner’s classification
of diabetic foot ulcer (2001)
The most widely used classification
Grades diabetic foot based on severity of
ulcer penetration

17. Wagner’s classification
of diabetic foot ulcer (2001)
Grade Physical Findings Description
0. INTACT skin No ulcer (but HIGH risk foot i.e.
deformities, callus, or insensitivity)
1. Superficial ULCER Only skin involvement
2. Deep ULCER Involving tendons or ligaments
3. OsteoMyelitis Deeper ULCER with bone involvement
4. Partial GANGRENE Of toes or forefoot
5. Total GANGRENE Of entire foot

19. Pathogenesis

20. Pathogenesis
• Development of DF is multi-factorial & complex.
• First & foremost it involves longstanding high levels of
HYPERglycemia. This in turn contributes to the
following disorders, through various mechanisms:
1. Neuropathy
2. Angiopathy
3. Immune dysfunction

21. Neuropathy
a) Somatic Sensory neuropathy
Loss of pain sensation
Unnoticed trauma (mechanical, thermal, chemical)
Unchecked worsening of the lesion
Formation of Callus
Tissue damage & necrosis beneath the callus
Dev of cavity filled with serous fluid
Cavity erupts to the surface
Resulting in ULCERation

23. Neuropathy
b) Somatic Motor neuropathy
Weakness & decreased contraction of foot muscles
Atrophy /wasting of these muscles
Foot deformity
Abnormal gait
Easy ULCERation

24. Foot deformities that predispose to
ULCERATION include:
» Clawed toes
» Hammer toes
» Pes cavus
» Pes planus
» Charcot joint
» Talipes equinus (ankle joint rigidity)
» Hallux varus/valgus/rigidus
» Bunions (bony bump of hallux joint)
» Nail deformities
» Deformities from previous trauma/surgery

32. Neuropathy
c) Autonomic neuropathy
Decreased sweat secretion
Dry & brittle skin
Easily cracks & fissures
Infection occurs
ULCERation

34. In general, Factors contributing to foot
ulceration include

35. MACROangiopathy
Atherosclerosis of large arteries
(i.e. PAD)
Increased peripheral resistance
Microangiopathy
Thickening of basement
membranes of capillaries
Decreased capillary permeability
Angiopathy
Decreased perfusion of foot structures
Decreased supply of immune components & Antibiotics
Poor wound healing
GANGRENE

39. Immune dysfunction
• Impaired defenses against infections:
Decreased Leukocyte migration
Decreased Phagocytosis
Decreased Intracellular killing
Decreased Chemotaxis

41. Clinical Features

46. Ddx in clinical forms of Diabetic Foot
Xristic Neuropathic Ischemic
Skin Temp Warm Cold
Color Not altered Pink  Cyanotic
Pulse BOUNDING pulse DIMINISHED  Pulseless
Sensation Painless Painful
Skin Dry, thickened, fissures Atrophic, thin,
Callus + at pressure points Usually Absent
Ulceration On pressure points On toe tips, heels, foot margins
Complication Charcot foot
(osteoarthropathy)
Gangrene

48. Management

49. Management includes 5 aspects:
1. Metabolic control
-effective blood sugar control, neuropathy Rx
2. Mechanical control
-reduce risk of trauma, treat deformities
3. Vascular management
4. Infection Prophx and Rx
5. Patient EDUCATION

74. Prevention guidelines

77. A Quick Recap

78. “Diabetic foot” is a pathological condition of the foot
in people with longstanding diabetes.
It is by far the most COSTLY complication of
diabetes (according to WHO).
It has 3 main etiological factors, and many
predisposing risk factors.
Pathogenesis is multi-factorial.
Management is case dependant.

79. Conclusions

80. • Close coordination between a physician,
nurse, surgeon, orthopedic, physiotherapist,
psychotherapist & the patient is vital in the
care of a diabetic foot.
• Most foot problems can be prevented.
• Each & every patient should be educated &
issued with a pamphlet containing
straightforward safety & footcare
instructions!

81. Literature
• WHO guidelines on diabetes (WDF – world diabetes foundation)
• National clinical guidelines for management of DM (MoH, GOK)
• DM textbook for overseas medical students (Nizhny Novgorod State
Medical University, 2015 edition)
• Diabetic foot by Dr. Hardik Pawar, Orthopedic specialist
• Many images thanks to GOOGLE.