Published on

Lecture on Diabetic foot problems with overview of problem,evaluation and treatment from an orthopedic surgeon's standpoint

Published in: Health & Medicine
1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide


  1. 1. The foot in Diabetes M. “How Sweet it is!!!!” J. Gleason/Honeymooners Rev. Steven C. Sheskier,M.D. Presiding
  2. 2. Prevalence of Impaired Fasting Glucose in People Ages 20 Years or Older, United States, 2007 25.9 percent of U.S. adults ages 20 years or older had IFG 35.4 percent of adults ages 60 years or older. at least 57 million American adults had pre-diabetes in 2007 IFG prevalence among U.S. adults ages 20 years or older in 2003 to 2006 was 21.1 percent for non-Hispanic blacks, 25.1 percent for non-Hispanic whites 26.1 percent for Mexican Americans. (After adjusting for population age and sex differences)
  3. 3. Prevalence of Diagnosed and Undiagnosed Diabetes in the United States, All Ages, 2007 Total: 23.6 million people—7.8 percent of the population—have diabetes. Diagnosed: 17.9 million people Undiagnosed: 5.7 million people
  4. 4. Growing Problem Estimated Diabetes Costs in the United States in 2007 Total—direct and indirect: $174 billion Direct medical costs: $116 billion
  5. 5. After adjusting for population age and sex differences, average medical expenditures among people with diagnosed diabetes were 2.3 times higher than what expenditures would be in the absence of diabetes
  6. 6. Complications of DM Heart Disease/Stroke HBP Blindness Renal Disease Nervous System Amputations
  7. 7. Circulatory System large vessel > 10% absent pedal pulse progressive with time infra-popiteal vessels small vessel/micro
  8. 8. Peripheral arterial disease in diabetic and nondiabetic Patients: A comparison of severity and outcome:Diabetes care 2001, vol. 24, no8 Diabetic Patients had greater severity of arterial disease in the profunda femoris and all arterial segments below the knee (P = 0.02). A greater number of amputations occurred in the diabetic group: diabetic patients were five times more likely to have an amputation (41.4 vs. 11.5%, odds ratio [OR] 5.4, P < 0.0001). Mortality was higher in DM
  9. 9. Nervous System Disease • About 60 to 70 percent of people with diabetes have mild to severe forms of nervous system damage. The results of such damage include impaired sensation or pain in the feet or hands, slowed digestion of food in the stomach, carpal tunnel syndrome, erectile dysfunction, or other nerve problems. • Almost 30 percent of people with diabetes ages 40 years or older have impaired sensation in the feet—for example, at least one area that lacks feeling. • Severe forms of diabetic nerve disease are a major contributing cause of lower-extremity amputations
  10. 10. Neuropathy Peripheral neuropathy affects • toes • feet • legs • hands • arms Autonomic neuropathy affects • heart and blood vessels • digestive system • urinary tract • sex organs • sweat glands • eyes • lungs Proximal neuropathy affects • thighs • hips • buttocks • legs Focal neuropathy affects • eyes • facial muscles • ears • pelvis and lower back • chest • abdomen • thighs • legs • feet
  11. 11. DIABETES AS A MODEL of DSPN* Autonomic nerves Small fiber Large fiber *Distal symetrical polyneuropathy versus OTHER presentations
  12. 12. Epidemiology 40-45% diabetics have DSPN1 No difference between Type 1 and 2 DM Increased with years of disease and glycemic control2 1.Rochester Diabetic Neuropathy Study 2.Pirart,J. Prospective study of 4,400 patients
  13. 13. Autonomic Dysfunction Increased blood flow ??Factor in Charcot??? Dry skin Fissuring = increased risk of infection
  14. 14. Autonomic Neuropathy • Orthostatic hypotension, leg edema • Loss of sympathetic tone, arteriovenous shunting • Distended dorsal foot veins • Denervation of sweat glands, dry, atrophic skin with severe cracking
  15. 15. Deformity due to: Muscle imbalance Claw toes Tight achilles (increased forefoot pressure) Charcot Neuroarthropathy
  16. 16. Charcot Arthropathy inciting factors: - peripheral neuropathy - unrecognized injury - continued repetitive stress on injured structures - increased local blood flow; - excessive osteoclastic activity w/o a concomitant increase in osteoblastic function; - pathoanatomy: - includes cartilaginous fibrillation and destruction and subchondral/enchondral bone formation; - charcot joint can result in fragmentation of periarticular areas & subluxations: - usually affects midtarsal joints and can lead to prolapse of the arch or valgus deviation of the forefoot
  17. 17. Temporal Stages of Charcot Arthropathy (Eichenholtz) Stage I: Acute Inflammation, redness, swelling, bony fracture Stage II: Coalescence Improved joint integrity, consolidation of bone Stage III: Resolution Reduced bony fragmentation, joint stability,
  18. 18. Charcot (con’t) - Radiographic Studies: - early changes: - may present as a low energy fracture with joint subluxation; - bone fragmentation may be seen in early stages; - wt bearing radiographs help accentuate joint subluxation if it present; - mid stage changes: - resorption and coalescence of fragments (large fragments may fuse together); - bone surrounding the joint becomes sclerotic - absorption of the fine debris occurs - late changes: - reconstruction and reconstitution phase; - osteolysis may be present w/ both Charcot joints and osteomyelitis; - hypertrophic changes can accompany joint destruction; - remodeling occurs with reduction of the sclerosis; - there is rounding of the major fragments; - there is an attempt at reformation of the joint architecture;
  19. 19. Patterns of Charcot* I. IPJ/MTP and metatarsals II.Tarsometatarsal joints III. Midfoot (Navicular- cuneiform,TN,CC) IV. Ankle V. Calcaneus
  20. 20. Other • People with diabetes are more susceptible to many other illnesses and, once they acquire these illnesses, often have worse prognoses. For example, they are more likely to die with pneumonia or influenza than people who do not have diabetes. • People with diabetes ages 60 years or older are two to three times more likely to report an inability to walk a quarter of a mile, climb stairs, do housework, or use a mobility aid compared with people without diabetes in the same age group
  21. 21. Diabetes, Neuropathy, and Gait Sensory and proprioceptive loss Postural instability Gait abnormalities Velocity Stride length Stride width and double support Center of pressure (COP) trajectory Van Deursen, Simoneau, JOSPT, 1999;29:718-726
  23. 23. PagePage
  24. 24. Inspection Skin (dry.hair,callosities,ulcers,scars) Deformities Fixed vs. Flexible Shoes
  25. 25. Palpation Pulses edema prominences
  26. 26. Assess gastrosoleus complex!!!
  27. 27. INTERPRETATION OF THE ABI ABI Normal 0.91-1.30 Mild obstruction 0.71-0.90 *Moderate obstruction0.41-0.70 *Severe obstruction  0.40 **Poorly compressible >1.30 2° to medial Ca++ *Poor ulcer healing with ABI  0.50©2006. American College of Physicians. All Rights Reserved.
  28. 28. Neurologic Exam Semmes-Weinstein 5.07 (10 gm.) monofilament (loss of protective sensation) Vibratory perception threshold > 25 V Neuropathy Disability Score Single stance test Proprioception testing
  29. 29. USING THE 5.07/10gm MF (Tool-Kit) • Demonstrate sensation on the forearm or hand • Place monofilament perpendicular to test site • Bow into C-shape for one second • Test four sites/foot: Predicts 95% of ulcer formers vs. 8 sites • Heel testing does not discriminate ulcer formers • Avoid calluses, scars, and
  30. 30. Testing EMG/NCV Vibratory Perception Threshold QSART (sweat test/autonomic function)
  31. 31. 2 degrees C
  32. 32. ULCERS
  33. 33. Ulcer prevalence 15% history of ulceration(s) <30 y/o higher prevalance men slightly> women increase with age 3% diabetes related admissions were for “ulcer”
  34. 34. PRE-ULCER CUTANEOUS PATHOLOGY Neuropathy  inappropriate footwear: – Persistent erythema after shoe removal – Callus – Callus with subcutaneous hemorrhage: “pre-ulcer” Autonomic neuropathy and secondary dry skin: – Fissure  ulceration – Augment callus formation Poor self-care of the feet: – Interdigital maceration with fungal infection – Nail pathology
  35. 35. Wagner Grading System for Ulcers- 0 - Intact Skin - 1 - Superficial ulcer of skin or subcutaneous tissue - 2 - Ulcers extend into tendon, bone, or capsule - 3 - Deep ulcer with osteomyelitis, or abscess - 4 - Gangrene of toes or forefoot - 5 - Midfoot or hindfoot gangrene
  36. 36. This is what I am talking about!
  37. 37. Etiology of Ulceration Neuropathy Increased pressure poor circulation DORSAL ULCER=Arterial Insufficency
  38. 38. Causal Pathways for Foot Ulcers Neuropathy Deformity ULCER % Causal Pathways Neuropathy: 78% Minor trauma: 79% Deformity: 63% Behavioral ?   Poor self-foot care Minor Trauma - Mechanical (shoes) - Thermal - Chemical
  39. 39. Risk Factors for Diabetic Foot Male Sex DM > 10 years duration Peripheral neuropathy Abnormal foot structure Peripheral arterial disease Smoking H/O previous ulceration / amputation Poor glycemic control
  40. 40. Risk stratification for ulcer risk Risk Level Foot Ulcer %/yr 3: Prior amputation Prior ulcer 28.1% 18.6% 2: Insensate and foot deformity or absent pedal pulses 6.3% 1: Insensate 4.8% 0: All normal 1.7%
  41. 41. TREATMENT
  42. 42. Treatment Offloading Debridement Wound dressing Antibiotics Revascularisation Amputation
  43. 43. Early Management immobilization and off loading tendon “balancing” Achilles tendon Multiple tendon (Ach+peroneals+PTT) ORIF of Unstable fractures
  44. 44. Off-loading Appliances
  45. 45. Off-loading Appliances
  46. 46. Total Contact Cast: Indications Neuropathic Foot Ulcers Wagner grade 1 and 2 ? Wagner grade 3 Neuroarthropathy (Charcot’s Foot) Forefoot Midfoot Ankle
  47. 47. Total Contact Cast: Basic Protocol Initial cast application: 3-7 days Repeat, serial casting every 1-2 weeks Wound and/or Charcot evaluation at each cast change Limit ambulation, use of assistive device Therapeutic shoe ware at completion of casting
  48. 48. Contraindications Grossly infected wounds Uncontrolled osteomyelitis Deep infection or abscess Poor skin integrity Excessive edema
  49. 49. Total Contact Cast Studies AUTHOR HEALED MEAN HEALING TIME Myerson 64/71(90%) 30 days forefoot/ 63 rear Helm 16/22(75%) 38.8 days Mueller 19/21(95%) 42 days Sinacore 27/33(82%) 43.6 days Walker 55/55(100%) 31 days forefoot/ 42 rear Armstrong 25/25(100%) 38.8 days Lavery 22/22(100%) 28.4 days midfoot ulcers
  50. 50. Problem:Tight Achilles tendon
  51. 51. Good Literature Support for Tendon Lengthening for Forefoot UlcersInt. J. Leprosy,1971,Yosipovitch et al,39:631-2 Orthopaedics,1996,Lin et al,19(5):465-74 J.B.J.S,1999,Armstrong et al,81A(4):535-8 J. S. Ortho. Assoc.,2003,Laborde,12(2):60-5 J.B.J.S.,2003,Mueller et al,85A(8):1436-45 Surg. Clin. N. Am.,2003,Nishimoto et al,83:707- 26 Foot & Ankle Int.,2005,Strauss;26(1):5-14 Wounds,2005,Laborde,17(5):122-130
  52. 52. Vulpius Procedure Intramuscular Lengthening(recession) of Gastroc-Soleus No Wound Problems No Over-Correction Immediate Full Weight Outpatient
  53. 53. Tenotomy
  54. 54. Ulcer Tendon Lengthening Met. Head 1-5 Gastroc-Soleus 1st Met. Head Peroneus Longus 5th Met.Head Posterior Tibial
  55. 55. Charcot Meta-analysis 301 patients from 15 outcome studies Average healing time with immobilization: was 5.7 +/- 3.5 months, range 3-18 months Failed non-surgical management: 21% Prolonged or permanent bracing:28% Partial or complete amputation: 6.6% Sinacore and Withrington, JoOrth&SportsPT, 1999;29:736-746
  57. 57. Late Management orthotics/bracing exostectomies arthrodesis reconstruction amputations
  58. 58. Assess clinical probabilities, including history, exam and X-ray “Probes-to-Bone” assessment MRI most helpful to evaluate infection May require deep debridement or percutaneous sampling for diagnosis
  59. 59. General indications for Reconstruction Unshoeable deformity Recurrent ulceration Instability PAIN Cosmesis (make xray look better) BEWARE!!!!!
  60. 60. Not unreasonable to tell the patient that reconstructive surgery is an alternative to a amputation and that be very well be the ULTIMATE outcome…
  61. 61. When to operate Failure of conservative Rx Eichenholtz stage (Stage 3) Medical condition optimal DO NOT FORGET =Nutritional status Non-smoking Skin/ulcer status
  62. 62. Midfoot
  63. 63. Problem: Rocker bottom foot • midfoot ulceration
  64. 64. Ankle Indicatons Instability Unbraceable Ulceration Patterns Varus Valgus
  65. 65. Internal Fixation
  66. 66. OOPS!?!
  67. 67. Wedge resection
  68. 68. BEAUTIFUL!!!!
  69. 69. Subtalar / peritalar dislocation Most common area to come to treatment
  70. 70. hindfoot
  71. 71. Hindfoot
  72. 72. FOREFOOT
  73. 73. “By any means necessary” Malcolm X
  74. 74. Simple exostectomy
  75. 75. Amputations • More than 60 percent of nontraumatic lower- limb amputations occur in people with diabetes. • In 2004, about 71,000 nontraumatic lower- limb amputations were performed in people with diabetes.
  76. 76. FOOT ULCERS IN DIABETES (85% all amputations) “Rule of 15” • 15% of diabetes patients Foot ulcer in lifetime • 15% of foot ulcers Osteomyelitis • 15% of foot ulcers Amputation Clinical Care of the Diabetic Foot, 2005
  77. 77. AMPUTATIONS IN DIABETES Tragic: “Rule of 50” • 50% of amputations transfemoral/transtibial level • 50% of patients 2nd amputation in  5y • 50% of patients Die in  5y Clinical Care of the Diabetic Foot, 2005
  79. 79. Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus (Foot and ANkle Int. 1999 Using a computer database, we conducted a retrospective review of all ankle fractures treated at our institution from March 1985 to October 1996. Twenty-one patients with diabetes mellitus and isolated ankle fractures that were treated operatively met all inclusion criteria. Seven had insulin-dependent diabetes, and 14 had non-insulin-dependent diabetes. A randomly selected control group of 46 patients without diabetes who also underwent operative treatment of ankle fractures during this same time period were matched for age, sex, and fracture severity. The complication rate was 43% with 13 complications in nine patients with diabetes. There were seven (15.5%) complications in the control group. Complications in the diabetic group included seven infections (five deep, two superficial) and three losses of fixation. The complications were more severe in our diabetic population, requiring seven additional procedures including two below-knee amputations; a third patient refused an amputation. No additional procedures were required in our control group. All complications in our control group resolved with treatment. The relative risk for postoperative complications in patients with diabetes who sustained ankle fractures that were treated operatively was 2.76 times greater than the control group's (95% confidence interval, 1.57- 3.97)
  80. 80. Operative management of ankle fractures in patients with diabetes mellitus Foot Ankle Int 2007 Abstract BACKGROUND: Multiple studies have documented increased risks associated with treatment of ankle fractures in patients with diabetes mellitus. We reviewed our results in the largest series to date of this complex patient group to determine the frequency of complications. METHODS: Eighty-four patients with diabetes had open reduction and internal fixation using standard fixation techniques for acute, closed ankle fractures. The 51 men and 33 women had an average age was 49.3 (22 to 77) years. The average followup was 4.1 years (11 to 97 months). Seventy-five fractures were closed and nine were open. Thirty-nine patients used insulin and 45 used oral hypoglycemics or diet for control of their diabetes. Diabetic complications, including nephropathy, hypertension, peripheral vascular disease, and neuropathy were evaluated. The management of diabetes, fracture classification, and presence of diabetic complications were assessed with chi-square, ANOVA, and univariate logistic regression to determine the presence of statistical significance for these factors. RESULTS: Twelve of the 84 patients developed postoperative complications. Ten patients developed infections (eight deep and two superficial). Four of 12 patients with preoperative evidence of peripheral neuropathy developed Charcot arthropathy. Ten of 12 patients who had absent pedal pulses preoperatively developed complications (p<0.0001) and 11 of 12 patients with peripheral neuropathy had complications (p<0.0001). A trend towards complications was noted with nephropathy (two of five patients) and hypertension (nine of 12 patients). Open fractures, insulin dependence, patient age, and fracture classification had no significant effect on outcome. CONCLUSIONS: Most patients with diabetes can undergo open reduction and internal fixation of acute ankle fractures without complications. Patients with absent pedal pulses or peripheral neuropathy are at increased risk for
  81. 81. Why such a high non-union rate? Decreased platelet derived growth factor expression during fracture healing in diabetic animals. Clin Orthop 2003 Mar;(408):319- 30 (ISSN: 0009-921X) The effects of blood glucose control upon fracture healing in the BB Wistar rat with diabetes mellitus. J Orthop Res 2002 Nov;20(6):1210-6 (ISSN: 0736-0266) Alterations of cartilage and collagen expression during fracture healing in experimental diabetes. Connect Tissue Res 2000;41(2):81- 91 (ISSN: 0300-8207)
  82. 82. Sound familiar??? Decreased platelet derived growth factor expression during fracture healing in diabetic animals. Clin Orthop 2003 Mar;(408):319-30 • Fracture healing as a post-natal developmental process: molecular, spatial, and temporal aspects of its regulation. J Cell Biochem 2003 Apr 1;88(5):873-84 (the role of three key groups of soluble factors, pro-inflammatory cytokines, the TGF-beta superfamily, and angiogenic factors, during repair ) Nitric oxide regulates alkaline phosphatase activity in rat fracture callus explant cultures. Redox Rep 2000;5(2-3):126-7 (ISSN: 1351-0002) Expression of cathepsins B, H, K, L, and S and matrix metalloproteinases 9 and 13 during chondrocyte hypertrophy and endochondral ossification in mouse fracture callus. Calcif Tissue Int 2000 Nov;67(5):382-90 (ISSN: 0171-967X)
  83. 83. Bottom Line: Regardless of the specifics of treatment, adherence to the basic principles of preoperative planning, meticulous soft-tissue management, and attention to stable, rigid fixation with prolonged, protected immobilization are paramount in minimizing problems and yielding good functional outcomes.
  84. 84. Non-limb threatening Infection Oral therapy cephalexin, clindamycin amoxicillin/clavulonate quinalone Topical: no evidence, ? pexiganin Antiseptic agents: cytotoxic
  85. 85. Limb-threatening Infection Debridement Deep wound and blood cultures Broad spectrum intravenous therapy Imipenem/cilastin Vancomycin/aztreonam/metronidazole Lactam/lactamase inhibitor Clindamycin plus quinalone
  86. 86. WAKE UP!!! The lecture is over...