Principles of management of diabetic foot lesions and its prevention
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Principles of management of diabetic foot lesions and its Prevention. Dr AK Verma Department of Endocrine Surgery Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow. Introduction. Foot lesions- 7% of people with Diabetes mellitus Costly to- both patients and state

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Principles of management of diabetic foot lesions and its prevention l.jpg

Principles of management of diabetic foot lesions and its Prevention

Dr AK Verma

Department of Endocrine Surgery

Sanjay Gandhi Postgraduate Institute of Medical Sciences

Lucknow


Introduction l.jpg
Introduction Prevention

  • Foot lesions- 7% of people with Diabetes mellitus

  • Costly to- both patients and state

  • Factors delaying wound healing

    • Impaired wound healing in DM

    • Barrier to early referral and assessment

  • Amputations due to Peripheral vascular disease, Neuropathy and severe infection


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Introduction Cont. Prevention

  • Common in- Older patients and those with longer duration

  • Treatment options-limited, but coordinated care is needed

  • Infection- mostly secondary to ulcer

  • Nature and severity of infection varies

  • Of all amputations – 80% done in diabetics


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Predisposing factors Prevention

  • Old Age, Atherosclerosis

  • Long standing/ brittle diabetes, poor control

  • Associated disease states and immunosuppressive states

  • Post transplantation

  • Hypoproteinemia and prolonged diseases


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Causative factors Prevention

  • Foreign bodies

  • Improper nail pairing

  • Nail infections

  • Sensory and motor loss

  • Corns, callosities

  • Foot deformities

  • Trauma, burns

  • Bare foot walking and improper shoe wear


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Foreign body

Last updated on 25 January 2000. This page is maintained by Department of PodiatryPlease send comments to Cameron Kippen © Department of Podiatry 2000


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Peripheral neuropathy

Last updated on 25 January 2000. This page is maintained by Department of PodiatryPlease send comments to Cameron Kippen © Department of Podiatry 2000


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Fungal infection

Last updated on 25 January 2000. This page is maintained by Department of PodiatryPlease send comments to Cameron Kippen © Department of Podiatry 2000


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Skin Corn Hard

Last updated on 25 January 2000. This page is maintained by Department of PodiatryPlease send comments to Cameron Kippen © Department of Podiatry 2000


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Corn hard after shaving

Last updated on 25 January 2000. This page is maintained by Department of PodiatryPlease send comments to Cameron Kippen © Department of Podiatry 2000


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Skin Fissure

Last updated on 25 January 2000. This page is maintained by Department of PodiatryPlease send comments to Cameron Kippen © Department of Podiatry 2000


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Clinical presentation Prevention

  • Wide clinical spectrum

  • Localised cellulitis

  • Nonhealing ulcer

  • Ulcer with minimal discoloration

  • Gangrene of the toe/toes

  • Gangrene of forefoot/whole foot(dry/wet)

  • Deformities

  • Deformities with ulcerations


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Gangrene

Last updated on 25 January 2000. This page is maintained by Department of PodiatryPlease send comments to Cameron Kippen © Department of Podiatry 2000


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Principles of management-1 Prevention

A multidisciplany Approach

  • Resuscitation first, diagnosis later (biochemistry/haematology/radiology/microbiology)

  • General supportive measures

    -Correction of Anaemia/ hypoproteinemia/renal failure/dehydration

    -switching over to IV Insulin therapy

    -high calorie/protein diet

    -IV broadspectrum poly antimicrobial therapy( covering aerobes and anaerobes)

    -monitoring of polymicrobial infections by frequent microbial studies


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Principles of management-2 Prevention

III. Local care

Guiding principle: Limb saving attitude

  • Assesment of vascularity:

    Clinical: skin colour, temperature, hairs, nail colour and circulation, pulses.

    Poor pulse: best assessed by doppler

    A/B Index: N=0.8, if <0.5 chances of tissue survival is poor


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Doppler ultrasound

Last updated on 25 January 2000. This page is maintained by Department of PodiatryPlease send comments to Cameron Kippen © Department of Podiatry 2000


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Principles of management-3 Prevention

  • Localisation of abscess

    Clinical, Ultrasound, CT/ MRI

  • Assessment of neuropathy

    touch, temperature, position and joint senses (cotton,blunt,pin, biosthesiometer)

  • Look for other diabetic complications

    renal, opthalmic, cardiac, neurologic etc


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Surgical management-1 Prevention

  • Guiding principle- Limb saving attitude

    • Minimum but adequate surgery

    • Quick/Emergency debridement under whatever anaesthesia possible

    • All dead and necrotic tissue must be removed

    • Don’t do primary closure

    • Frequent daily minor debridements are a must

    • Limb elevation if edematous


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Surgical management-2 Prevention

  • Open tendon sheaths liberally

  • Excise tendons if necessary

  • Explore all possible pus pockets

  • Institute double drainage for larger and deeper pus pockets

  • Have lots of patience

  • Frequent OT debridements may be required


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Revascularisation procedures Prevention

  • Angioplasty

  • Angioplasty with stenting

  • Arterial bypass

  • Insitu Saphenous vein bypass


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Role of orthotics Prevention

  • Pressure of loading-significance

  • Devices-

    • Casts

    • Insoles

    • Custom made shoes

    • Artificial limbs


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Newer aids for wound healing Prevention

  • Platelet derived growth factors( regranex)

  • Granulocyte stimulating factors(cGSF)

  • Electrical stimulation-magnetotherapy etc

  • Plantar pressure measurement and recording systems


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Prevention-I Prevention

  • An ounce of prevention is better than a pound of cure

  • Foot rehydration especially at night

  • Proper foot wear

    • Well fitting, pressure offloading,washable,soft, no shoe laces.

    • No bare foot walking

    • Socks-cotton, wash daily,wear reversed, change frequently


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Prevention-2 Prevention

  • Foot care

    • Examination at bed time: cut, abrasion, foreign body, redness, blister, callosity/corn and local rise of temperature at any point. Must be done by some one with good vision in good light

    • Pairing of nails

    • Interdigital web cleaning and examination, use of antiseptic powder


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Prevention-3 Prevention

  • Must examine shoe before wearing

  • Must be treated like a small newborn child

  • Foot examination should be a part of every clinical visit

  • Must contact the doctor at the slightest problem


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THANK YOU Prevention


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