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Diabetic foot and ankle

Diabetic foot and ankle. Marie-france rancourt november 2012. outline. Diabetes Evaluation and Work Up Charcot Diabetic Ulcers Case OITE Questions. diabetes in canada. 2 359 252 people with diagnosed diabetes 6.4% of the population 3rd highest prevalence in the World (USA, Portugal)

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Diabetic foot and ankle

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  1. Diabetic foot and ankle • Marie-france rancourt • november 2012

  2. outline • Diabetes • Evaluation and Work Up • Charcot • Diabetic Ulcers • Case • OITE Questions

  3. diabetes in canada • 2 359 252 people with diagnosed diabetes • 6.4% of the population • 3rd highest prevalence in the World (USA, Portugal) • 9.6% Overweight (BMI average = 29) Source: Public Health Agency of Canada (July 2011)

  4. Evaluation &Work up

  5. presentation • Incidental finding • Bloodwork • Xrays • Foot monitoring in diabetics • Swelling • Ulcers • Pain

  6. diabetic neuropathy • The gold standard : Nerve conduction studies • Semmes-Weinstein monofilament test • 10g of pressure with 5.07 nylon • Most commonly used • Sensitivity of 91% • Specificity of 86% • 128-Hz tuning fork • Vibration testing • More sensitive predictor of early neuropathy

  7. diabetic vasculopahty • Palpation of pulses • If pulses absent, further tests... • Ankle-Brachial Index • < 0.4-0.5: poor wound healing • Transcutaneous oxygen pressure measurements (TcpO2) • Measures partial pressure of O2 diffusing through the skin • > 40mmHg: good wound healing potential • < 30mmHg: poor wound healing potential • CT angio

  8. work up • CBC, lytes, BUN, Cr • Infection work up • ESR, CRP • Bone Scan • Technetium: may be misleading • Indium: cold for neuropathy and hot for osteomyelitis (sensitivity 93%, specificity 80%) • MRI: osteomyelitis • RBS, HBA1C • HBA1C more than 0.08 = poor wound healing • Albumin (malnourishment<3.5 g/dL))

  9. charcot

  10. jean-marie charcot • 1825-1893 • French neurologist • 1868 - Tertiary Syphilis • Charcot-Marie-Tooth, Multiple Sclerosis, Parkinson’s, Hysteria • Pupils • Sigmund Freud • George de la Tourette • Joseph Babinski

  11. Une leçon clinique à la Salpêtrière - André Brouillet - 1887

  12. definition • Chronic progressive destruction of joint following loss of protective sensation • Neuropathic arthropathy • Diabetes and Charcot • 0.4% of patients with diabetses • 7.5% of patients with diabetes + neuropathy • Monitor other foot (involved in 9-35%)

  13. pathomechanism • Neurotrauma: • Loss of peripheral sensation and proprioception • Repetitive microtrauma • Inflammatory resorption of traumatized bone • Neurovascular: • Dysregulated autonomic system • De-sensitized joints receive significantly greater blood flow • Hyperemia leads to increased blood flow and metabolism • Osteoclastic resorption of bone • Osteopenia

  14. presentation • Type 1 Diabetes: in fifth decade (20-24 yrs post onset) • Type 2 Diabetes: in sixth decade (5-9 yrs post onset) • Swollen • Warm (may be up to 3 degrees warmer than contralateral side) • Pain (50%) • Erythematous • Unstable • Mimics infection • Elevate the affected limb

  15. charcot

  16. Brodsky’s anatomicclassification

  17. Brodsky’s anatomicclassification • Type 1 • Most common (60%) • Rocker bottom foot • Valgus • At risk for ulcers • Type 2 • 10% • Unstable, long immobilization • Type 3 A • 20% • Ulcerations/Osteomyelitis over malleoli • Type 3 B • Post calcaneal fractures

  18. brodsky type 1eichenholtz stage 0 - 3

  19. treatment van der Ven et al. (JAAOS, 2009)

  20. non surgical treatment • Total Contact Casting • 75% success • Q2wks • 4 months (forefoot-midfoot) to 1 yr (hindfoot-ankle) • Non weight bearing vs protected weight bearing • Appropriate footwear and insole • CROW • Bisphosphonates

  21. surgery • Eichenholtz Stage 3 • Arthrodesis • High complication rate • Up to 69% • Infection, hardware failure, ulcerations, fractures • Long time to fusion (11-22 wks) • NWB x 3 months • External fixation • Dynamic ring • Total ankle arthroplasty contraindicated • Amputation (2.7% annual rate)

  22. surgical treatment

  23. Long-term follow-up of tibiocalcaneal arthrodesis in diabetic patients with early chronic Charcot osteoarthropathy.Caravaggi CM et al.J Foot Ankle Surg. 2012 Jul-Aug;51(4):408-11. doi: 10.1053/j.jfas.2012.04.007. Epub 2012 May 26. • Arthrodesis in the coalescence or remodeling (subacute and chronic) stages of the disease before the onset of joint instability, severe deformity, and ulcer formation. • Observational study • 45 diabetic patients • Mean follow-up duration of 5 ± 2.85 years • 39 (86.67%) patients returned to independent ambulation wearing custom-made shoes with molded insoles • 2 (4.44%) others required pneumatic casts for ambulation. • 2 (4.44%) others underwent below-the-knee amputation shortly after the ankle arthrodesis because of postoperative infection

  24. diabetic foot ulcers

  25. presentation • Seen in 10-15% of diabetic patients • 10-20% of ulcers develop into osteomyelitis

  26. pathophysiology • Autonomic dysfunction • Lack of glandular function • Dry Skin • Skin more prone to stress • Lack of sensory protective mechanism • Decrease of healing blood supply

  27. mechanics • Tight Achilles tendon • Plantarflexion deformity • FOREFOOT Pressure Malalignment Bone Loss HINDFOOT Pressure Vascular Insufficiency Architectural collapse (cuneifrom, cuboid) MIDFOOT Pressure Skin breakdown

  28. wagner classification

  29. wound healing

  30. treatment Anakwenze et al. (JAAOS, 2012)

  31. non-operative treatment • Antibiotics • Started post cultures • Custom made Orthotics • Rocker soles to relieve forefoot pressure • Total Contact Casting • Wagner grade 1 & 2 (in absence of osteomyelitis) • 4 - 6 weeks of treatment

  32. surgical treatment • Correction of deformity or pressure point • Forefoot: • I & D • Achilles tendon lenghtening • Syme amputation • Midfoot: • resection of offending bone (Brodsky 1) • Realignement fusion if recurring ulceration and unbracable deformity • Hindfoot: • Partial calcanectomy • Sural fasciomusculocutaneous free flap • BKA

  33. syme amputation • patent tibialis posterior artery • more energy efficient than midfoot even though it is more proximal • stable heel pad is most important factor

  34. Syme Ankle Disarticulation in Patients with DiabetesBY MICHAEL S. PINZUR (JBJS 2003) • 97 adult patients with diabetes mellitus • Retrospective • 84.5% ultimately achieved wound-healing • vascular inflow (ultrasound Doppler ischemic index of 0.5 or transcutaneous partial pressure of oxygen between 20 and 30 mm Hg) and tissue nutrition (serum albumin of 2.5 g/dL) were met • The overall infection rate was 23%, and it was three times greater in smokers. • Minimum 2years follow up all but 2 patient walked with a prosthesis • 31 patients died at an average of 57.1

  35. Below knee amputation • Pre operative physiatry consult • Walking energy expenditure increases by 25-40% • Surgery • Incision: post flap longer than ant flap • Level: junction of proximal and middle third of tibia, below tibial tubercle, 15cm below medial joint line, fibula 2cm shorter than tibia • Bone cuts: transverse and beveled • Avoid periosteal stripping (avoid HO, synostosis) • Nerves: identify, gentle traction, injection of local, sharply transected • Vessels: tie on both sides (2 prox and 1 distal) • Larger posterior flap to bring over • Incision closure: more anterior than distal, no tension

  36. Below knee amputation • Post op • Cast vs Dressing • Keep dressing on for around 5 days • Suture removal • Medical comorbidity management, good diet

  37. A Comparison of Rigid vs Soft Dressings in the Healing of Below Knee Amputations (BKA)Journal of Vascular Surgery (November 2012), 56 (5), pg. 1479-1479Shine et al. • We hypothesized that rigid dressings would facilitate faster wound healing and residual limb maturation by minimizing postsurgical edema and pain, preventing knee flexion contracture, and protecting the residual limb from trauma. • Methods: Our retrospective analysis compared 151 patients (2000 to 2012) at Yale New Haven Hospital, after which • 60 patients received soft dressings and knee immobilizers (soft) • 92 were placed in a rigid plastic or plaster prosthesis (rigid). • Results: Age and diabetic status was not statistically different between the soft (61.0 years, 82.8% with diabetes) and rigid groups (58.6 years, 78.0% with diabetes). • After 60 days, 58.24% of the rigid group was cast vs 38.33% of soft group

  38. clinical case

  39. cases • Pace, Trina 35995299 • Venables, Laura 10097442 • Lajeunesse, Michelle 09442948

  40. L.V. 10097442 • 81 yo lady • Past medical history: Diabetes mellitus with neuropathy, right total knee arthroplasty, hypertension • Allergies: Penicillin with rash • Social history: Nonsmoker, no EtOH • Medications: Lasix, metformin, insulin, amlodipine, pantoprazole, Lipitor, Celebrex

  41. surgeries • 2003: necrotic 3rd toe dislocation • right 3rd toe amputation • 2009: Rocker bottom neuropathic foot, plantar ulcer, Achilles tendon contracture • Midfoot medial closing wedge osteotomy • Mid tarsal fusion • Achille tendon lenghtening: percutaneous triple hemisection

  42. https://www.youtube.com/watch?v=2odmA_kgxG0

  43. Progression - 2012 • Valgus deformity of the ankle • Lateral tilt of tibial plafond • Swelling • Minimal pain • No ulcers • Neuropathy, good pulses

  44. surgeries • 2012: Right ankle Charcot • Right ankle arthrodesis • Right subtalar arthrodesis • Procedure • Direct lateral and posteromedial approach • Remove distal 8 cm of fibula • Medial malleolus osteotomy • Distal tibia and talar dome osteotomy • Slight ER, Valgus • Wright Medical Valor Nail + 7.3mm screw

  45. Post arthrodesis • 2 ulcers with purulent discharge: ankle + plantar surface • No cultures • Ciprofloxacin x 2 weeks then Keflex x 3 months • No systemic symptoms. • Diabetes is well controlled • Followed by ID, Wound Care • Hardware removal at around 6 months

  46. 3 months post op

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