THE DIABETIC FOOT - University of Pittsburgh

THE DIABETIC FOOT - University of Pittsburgh

THE DIABETIC FOOT DR.SEIF I M ELMAHI MD, FRCSI University of Khartoum, Sudan

CONTENT

Definition Epidemiology Social & Economic factors Pathophysiology of foot ulceration

Diabetic Neuropathy Peripheral Vascular Disease & Diabetes Biomechanics of Foot Wear The Diabetic Foot Ulcer Outcome & Management Neuro-osteoarthropathy Amputation in Diabetic Patient

Prevention of Foot Problem Diabetic Foot Definition: Infection, ulceration or

destruction of deep tissues associated with neurological abnormalities & various degrees of peripheral vascular diseases in the lower limb definition)

(based on WHO Epidemiology 40%

- 60% of all non traumatic lower limb amputation 85% of diabetic related foot amputation are preceded by foot ulcer 4 out of 5 ulcer in diabetics are precipitated by trauma

4% -10% is the prevalence of foot ulcer in diabetics Epidemiology In Sudan: Prevalence of DM ? 6 12 %

DSF inpatient KTH : 30% - 40% risk of major amputation 8% - 20% mortality Social & Economic Factors

Diabetic foot complications are expensive : (cost of healing 7000-10000 USD) (healing with amp. 43000In Khartoum :

Intervention 63000USD) (4 weeks dressing cost 110000SD)

of foot care is cost effective in most societies Scarce information regarding long term prognosis Pathophsiology of Foot Ulceration

Neuropathic Ischemic Neuro -ischemic

STAGES OF ULCER DEVELOPMENT STAGES OF ULCER DEVELOPMENT Diabetic Neuropathy Sensorimotor

& peripheral sympathatic neuropathy are major risk factors for ulcer History & careful foot examination are mandatory to diagnose neuropathy

Up to 50%of type2 diabetic patient have significant neuropathy & at risk of foot ulcer Periphral vascular disease& diabetic PVD

PVD is the most important factors related to outcome of diabetic foot ulcer PVD is diagnosed by simple clinical examination non invasive vascular test determines probability

of healing Symptoms of ischemia may be masked by neuropathy Microangiopathy shouldn't be accepted as primary cause of ulcer Conservative approach for treatment

Outcome of revascularization is similar to that in non-diabetic Biomechanics of foot wear Biomechanical abnormalities are consequence of neuropathy, they lead to

abnormal foot pressure Foot deformity & neuropathy increase the risk of ulcer Pressure relief is essential for ulcer healing and/or prevention Frequent inspection of shoes & insoles is

mandatory Appropriate foot wear significantly reduce ulcer recurrence Diabetic Foot Infection

Infection in diabetic foot is limb threatening Signs of infection may be absent in diabetic pt. with foot ulcer Superficial infection is usually caused by gram +ve cocci, deep infection is poly microbial

Surgical debridment is essential in acute deep infection Osteomylitis( diagnoses & treatment) Neuro-osteoarthropathy

Non- infective pathology Should be suspected in any swollen hot erythematous foot Differentiation from infection is

important to prevent misdiagnosis & possible amputation Treatment should aim at preventing severe deformity Diabetic Foot Ulcer Treatment

Multidisciplenary approach Staging dictate the treatment option Continuity of care & life long

observation Amputation in Diabetic Patient Increased minor\major amputation

increased the no. of deformed feet Minor amputation is needed : *Gangrene *As part of debriment *for correction of foot deformities Minor

amputation doesnt significantly compromise walking ability Major Amputation

Risk of loss walking ability

Mortality Risk of contra-lateral amputation Strict indication Careful choice of the level How To Prevent Foot Problems

5 corner stones Regular inspection & examination of foot & foot wear Identification of high risk patient

Education of patient, family & health care providers Appropriate foot wear Treatment of non ulcerative pathology SENSORY NEUROPATHY

Diabetic Neuropathy PERIPHRAL VASCULAR DISEASE Biomechanics of foot wearAREAS AT

RISK OF ULCERATION FOOT WEAR FOOT WEAR

OSTEOMYLITIS Diabetic Foot Ulcer Treatment Modalities Microbiological Wound

control control Vascular control Mechanical control

Metabolic control Educational control Staging of Diabetic Foot Stage 1

2 3 4 5 6

Clinical condition Normal High risk Ulcerated cellulitic Necrotic

Major amputation Assessment of Diabetic Foot Neuropathy Ischemia Deformity

Callus Swelling Skin breakdown Infection

Necrosis NEURO-OSTEOARTHROPATHY(CHARCOT FOOT) NEURO-OSTEOARTHROPATHY(CHARCOT

FOOT)Neuro-osteoarthropathy PODIATRY

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