MANAGEMENT OF DIABETIC FOOT SYNDROME

1. MANAGEMENT OF DIABETIC FOOT SYNDROME BY DR AKPOJEVWE E.O. CONSULTANT ORTHOPAEDIC/TRAUMA SURGEON DELSUTH OGHARA NIGERIAN MEDICAL ASSOCIATION, DELTA STATE CME SERIES MAY 2014

2. OUTLINE • OVERVIEW • PATHOPHYSIOLOGY • CLINICAL PRESENTATION • GRADING • INVESTIGATION • TREATMENT OPTIONS • LOCAL/ REGIONAL CHALLENGES • RECENT ADVANCES • PREVENTION • CONCLUSION

3. OVERVIEW • GROUP OF METABOLIC DISEASES CHARACTERISED BY HYPERGLYCAEMIA • DEFECTS IN INSULIN SECRETION, INSULIN ACTION OR BOTH • LONG TERM DAMAGE AND DYSFUNCTION OF MULTIPLE ORGAN SYSTEMS • TYPE 1 DIABETES MELLITUS AND TYPE 2 DIABETES MELLITUS • OTHER TYPES- GESTATIONAL, ENDOCRINOPATHIES, DRUG/CHEMICAL INDUCED, IMMUNE-MEDIATED, DISEASES OF THE EXOCRINE PANCREAS • IMPAIRED GLUCOSE TOLERANCE • IMPAIRED FASTIG GLUCOSE

4. FASTING BLOOD SUGAR <100MG/DL NORMAL 100-125MG/DL IMPAIRED FASTING GLUCOSE ≥126MG/DL PROVISIONAL DIAGNOSIS OF DM • 2- HOURS POST PRANDIAL GLUCOSE <140MG/DL NORMAL GLUCOSE TOLERANCE 140-199MG/DL IMPAIRED GLUCOSE TOLERANCE ≥200MG/DL PROVISIONAL DIAGNOSIS OF DM • DIAGNOSIS OF DIABETES MELLITUS FBS ≥ 126MG/DL OR SYMPTOMS OF HYPERGLYCAEMIA + RBS >200MG/DL OR 2-HOURS POST PRANDIAL GLUCOSE ≥ 200MG/DL HbA1c ≥ 6.5%

5. WORLD WIDE EPIDEMIC • 171 MILLION CASES OF DM WORLDWIDE IN 2000 (2.8% PREVALENCE) • 366 MILLION CASES PROJECTED FOR 2030 (4.4% PREVALENCE) • 15% OF DIABETICS DEVELOP DFU THEIR LIFETIME • 11.7- 19.1% PREVALENCE OF DFU AMONG DIABETICS IN NIGERIA • AMPUTATION RATES UP TO 53% • MORTALITY RATES UP TO 29% • MEAN COST OF TREATMENT N180,581.60K • $28,000.00 SPENT PER PATIENT OVER 2 YEARS FOR EACH EPISODE OF DFU • LEADING CAUSE OF NON-TRAUMATIC LOWER EXTREMITY AMPUTATIONS IN USA • LEADING CAUSE OF LOWER EXTREMITY AMPUTATIONS IN NIGERIA

6. MALE PREPONDERANCE UP TO 85% • TYPE 2 DM IN UP TO 88% OF CASES • MEAN AGE IS THE 6TH DECADE OF LIFE • 50% NEUROISCHAEMIC, 35% NEUROPATHIC, 15% ISCHAEMIC • POLYMICROBIAL CULTURES COMMONEST IN CHRONIC ULCERS • STAPHYLOCCOCUS AUREUS AS SINGLE ISOLATE IN 38% ON NON-GANGRENOUS LIMBS • ANAEROBES; 16% GAS GANGRENE • 60% RESISTANCE TO PENICILLINS

7. HIGHLIGHT ONE LIMB IS AMPUTATED EVERY 20 SECONDS DUE TO DIABETIC COMPLICATIONS

8. PATHOPHYSIOLOGY • MULTIFACTORIAL • TETRAD OF NEUROPATHY, VASCULOPATHY, DEFORMITY AND INFECTION • IMPAIRED IMMUNITY • ATHEROSCLEROSIS AND NEUROPATHY OCCUR WITH INCREASED FREQUENCY IN DM • NON-ENZYMATIC GLYCOSYLATION OF LIGAMENTS CAUSING STIFFNESS • STIFFNESS + NEUROPATHY INCREASES MECHANICAL STRESSES ON FOOT

9. DIABETIC ATHEROSCLEROSIS • THICKENED CAPILLARY BASEMENT MEMBRANE • ARTERIOLAR HYALINOSIS • ENDOTHELIAL PROLIFERATION • MONCKEBERG’S SCLEROSIS • HIGH AFFECTATION OF INFRAPOPLITEAL AND DIGITAL ARTERIES • HIGH LDL, VLDL, • ELEVATED PLASMA VON WILLEBRAND FACTOR • INHIBITION OF PROSTACYCLIN SYNTHESIS • ELEVATED PLASMA FIBRINOGEN • INCREASED PLATELET ADHESIVENESS

10. DIABETIC PERIPHERAL NEUROPATHY • OCCLUDED VASA NERVORUM • ENDONEURAL DYSFUNCTION • DIMINISHED Na-K ATPase ACTIVITY • CHRONIC HYPEROSMOLARITY CAUSING NERVE TRUNK OEDEMA • EFFECTS OF INCREASED SORBITOL AND FRUCTOSE • LOSS OF SENSATION – REPETITIVE STRESS, UNNOTICED INJURIES AND FRACTURES • STRUCTURAL FOOT ABNORMALITIES • UNNOTICED EXCESSIVE HEAT/COLD • PRESSURE FROM ILL FITTING SHOES

11. COMMON PRECIPITATING FACTORS • TRAUMA • BLISTERING • ILL FITTING/NEW SHOES • NAIL CUTTING • BURNS • TINEA PEDIS • FURUNCLES

12. RISK FACTORS FOR FOOT ULCERATION • PREVIOUS HISTORY OF FOOT ULCERATION OR AMPUTATION • VISUAL IMPAIRMENT • DIABETIC NEPHROPATHY • POOR GLYCAEMIC CONTROL • CIGARETTE SMOKING • MALESEX • LOW SOCOECONOMIC STATUS • POOR EDUCATION • POOR ACCESS TO HEALTH CARE

13. CLINICAL PRESENTATION • PRESENT AS INFECTION, ULCER, ABSCESS OR GANGRENE • 4% -13.1% NEWLY DIAGNOSED AS DIABETIC AT PRESENTATION • 11.7% - 21.1% OF DIABETIC ADMISSIONS IN NIGERIA • MEAN DURATION OF DM 7-12 YEARS • ONSET OF SYMPTOMS TO PRESENTATION AVERAGELY 6 WEEKS

14. SYMPTOMS • SYMPTOMS OF DM POLYURIA POLYDIPSIA POLYPHAGIA WEIGHTLOSS • SYMPTOMS OF PERIPHERAL NEUROPATHY HYPERESTHESIA HYPOESTHESIA PARAESTHESIA DYSESTHESIA ANHYDROSIS RADICULAR PAIN

15. SYMPTOMS OF PERIPHERAL ARTERIAL INSUFFICIENCY INTERMITTENT CLAUDICATION REST PAIN NON-HEALING ULCERATION OF FOOT FRANK ISCHAEMIA • SYMPTOMS OF INFECTION GANGRENE SEPSIS: LOCAL, GENERALISED • SYMPTOMS REFERRABLE TO OTHER ORGAN SYSTEMS RETINOPATHY, NEPHROPATHY, HYPERTENSION

16. PHYSICAL EXAMINATION • GENERAL EXAMINATION – FEVER, PALLOR, JAUNDICE, DEHYDRATION, REGIONAL LYMPH NODES, LEG SWELLING, WEIGHT LOSS • FULL SYSTEMIC EXAMINATION • MANDATORY EYE EXAMINATION • MUSCULOSKELETAL SYSTEM EXAMINATION FOOT/ULCER POWER SENSATION REFLEXES PULSES

17. EXAMINATION OF THE ULCER • LOCATION, SIZE, DEPTH • DETERMINE TYPE- NEUROPATHIC, ISCHAEMIC OR NEUROISCHAEMIC • MUSCULOSKELETAL SYSTEM ABNORMALITIES • COLOUR AND STATE OF WOUND • EXPOSED BONE • NECROSIS OR GANGRENE • INFECTION: LOCAL AND SYSTEMIC • MALODOROUS • LOCAL PAIN • EXUDATE • WOUND EDGE : CALLUS, MACERATION, OEDEMA • CLINICAL PHOTOGRAPHS

18. DFU FEATURES ACCORDING TO AETIOLOGY

19. GRADING SYSTEMS • SEVERAL SYSTEMS IN USE • OLDER CLASSIFICATIONS WAGNER-MEGGIT UNIVERSITY OF TEXAS CLASSIFICATION GIBBONS FORREST FRYKBERG AND COLEMAN’S • NEWER CLASSIFICATIONS PEDIS KINGS KOBE’S AMIT JAIN’S SAD

20. WAGNER-MEGGIT CLASSIFICATION OF DIABETIC FOOT • DEVELOPED IN 1977 • WIDELY ACCEPTED, UNIVERSALLY USED,SIMPLE • DOES NOT ADDRESS DIABETIC ULCERATIONS AND INFECTION ADEQUATELY • LIMITED IN IDENTIFYING/DESCRIBING VASCULAR DISEASE • GRADE 0 FOOT AT RISK • GRADE 1 SUPERFICIAL ULCER • GRADE 2 DEEP ULCER • GRADE 3 ULCER WITH BONE INVOLVEMENT • GRADE 4 FOREFOOT GANGRENE • GRADE 5 FULL FOOT GANGRENE

21. UNIVERSITY OF TEXAS CLASSIFICATION • VALIDATED, GENERALLY PREDICTIVE OF OUTCOME • INCREASING USE IN CLINICAL TRIALS AND DIABETIC FOOT CENTERS

22. DIABETIC FOOT SEVERITY SCORE(DFSS)- UMEBESE AND OGBEMUDIA • BEING VALIDATED • GRADES ULCER, PULSES, SENSATION, COLOUR, AGE AND RADIOGRAPHS OF THE FOOT • PREDICTS LIMB SALVAGEABILITY • ≤ 11 UNSALVAGEABLE • 21 BEST PROGNOSTIC INDEX • 6 WORST PROGNOSTIC INDEX • COMPLEX • DIFFICULT TO MEMORISE

23. COLOUR OF FOOT NORMAL 3 DARKER DISCOLOURATION 2 BLACK 1 • PERIPHERAL PULSES DORSALIS PEDIS AND POSTERIOR TIBIAL PALPABLE 4 POSTERIOR TIBIAL ONLY 3 DORSALIS PEDIS ONLY 2 NONE 1 • SENSATION NORMAL LIGHT TOUCH AND PIN PRICK 3 DIMINISHED HYPOESTHESIA 2 INSENSIBILITY TO INSENSATE 1

24. ULCER GRADING GANGRENE LIMITED TO 1 OR 2 TOES 5 FULL THICKNESS ULCERATION OF DORSALSKIN 4 ULCER INVOLVEMENT OF >2 TOES OR BALL OF FOOT 3 OPEN PENETRATING ULCER >50% OF SOLE 2 WHOLE FOOT GANGRENE + SUPRAMALLEOLAR 1 NECROTISING CELLULITIS • AGE 40 YEARS 3 41- 60 YEARS 2 > 61 YEARS 1 • RADIOGRAPH OF FOOT NORMAL 3 COM OR CALCIFIED PERIPHERAL VESSELS 2 COM + CPV 1

25. DIFFERENTIAL DIAGNOSES • DIABETIC DERMOPATHY • ERUPTIVE XANTHOMAS • NECROBIOSIS LIPOIDICA • ARTHRITIS • MUSCLE PAIN • THROMBOPHLEBITIS • RADICULAR PAIN • MYEXDEMA • VASCULITIC NEUROPATHIES • METABOLIC NEUROPATHIES • AUTONOMIC NEUROPATHY

26. INVESTIGATIONS • ESTABLISH DIAGNOSIS/ GLYCAEMIC CONTROL FASTING BLOOD SUGAR 2-HOUR POST PRANDIAL GLUCOSE HbA1c ASSAY • BASELINE FULL BLOOD COUNT ERYTHROCYTE SEDIMENTATION RATE C-REACTIVE PROTEIN ASSAY ELECTROLYTE/UREA/CREATININE URINALYSIS 24-HOUR URINE FOR PROTEIN ESTIMATION

27. DIABETIC FOOT DEEP TISSUE CULTURE/HISTOLOGY ASPIRATE M/C/S PULSE VOLUME RECORDING(PVR) ANKLE-BRACHIAL INDEX PLAIN RADIOGRAPHS DOPPLER/DUPLEX ULTRASOUND SCANS MONOFILAMENT TESTING BIOTHESIOMETER CONTACT THERMOGRAPHY

28. CT SCAN/MRI • BONE SCANS • ANGIOGRAPHY • TRANSCUTANEOUS TISSUE OXYGEN STUDIES • INVESTIGATE FOR RETINOPATHY, NEPHROPATHY, CARDIAC DISEASE ETC

29. TREATMENT • NON-SURGICAL • SURGICAL

30. APPROACH CONSIDERATIONS FOR TREATMENT • OFFLOAD THE WOUND WITH APPROPRIATE FOOT WEAR • DEBRIDEMENT • DAILY WOUND DRESSING • ANTIBIOTICS • OPTIMAL CONTROL OF GLUCOSE, HYPERTENSION AND HYPERLIPIDAEMIA • EVALUATE/ CORRECT PERIPHERAL VASCULAR INSUFFICIENCY • MULTIDISCIPLINARY ENDOCRINOLOGIST INFECTIOUS DISEASE SPECIALIST CARDIOLOGIST PLASTIC SURGEON NEPHROLOGIST PROSTHETIST/ ORTHOTIST PODIATRIST NUTRITIONIST ORTHOPAEDIC SURGEON WOUND CARE SPECIALIST VASCULAR SURGEON

31. NON-SURGICAL TREATMENT • WOUND DRESSING • AUTOLYTIC DEBRIDEMENT • ENZYMATIC DEBRIDEMENT • LARVAL THERAPY • VACUUM ASSISTED CLOSURE • HYDROTHERAPY • HYPERBARIC OXYGEN THERAPY • OFFLOADING THE FOOT: TCC, RCW, ITCC, CRUTCHES, WHEEL CHAIR

32. ANTIBIOTICS • HEMORRHEOLOGIC AGENTS: PENTOXIFYLLINE, CILOSTAZOL • ANTIPLATELET AGENTS: CLOPIDOGREL, SOLUBLE ASPIRIN • WOUND HEALLING AGENTS: BECAPLERMIN • GEL(REGRANEX) • SUPPORTIVE THERAPY: ANALGESIA, FLUID AND ELECTROLYTE CORRECTION, BLOOD TRANSFUSION, GLYCAEMIC CONTROL

33. DRESSING AGENTS • WET TO DAMP DRESSINGS • ABILITY TO ABSORB EXUDATE AND PROTECT HEALTHY SKIN • OPSITE; TEGADERM • NORMAL SALINE • ISOTONIC SALINE GEL(NORMGEL) • HYDROCOLLOIDS: DUODERM, INTRASITE – DRY WOUNDS • CALCIUM ALGINATES: KALTOSTAT, CURASORB – EXUDATIVE WOUNDS • IMPREGNATED GAUZE (MESALT) – VERY EXUDATIVE WOUNDS • HYDROFIBRES (AQUACEL) – VERY EXUDATIVE WOUNDS

34. DERMAZINE, BACITRACIN, NEOSPORIN – INFECTED WOUNDS • DRY DRESSING + BETADINE – ESCHAR • HONEY – INFECTED WOUNDS • CYTOTOXIC AGENTS: NOT ADVISED EXCEPT IN INFECTED WOUNDS HYDROGEN PEROXIDE POVIDONE IODINE SODIUM HYPOCHLORITE ACETIC ACID EUSOL

35. SURGICAL TREATMENT • SHARP DEBRIDEMENT • REVISION SURGERIES • VASCULAR RECONSTRUCTION • SOFT TISSUE COVERAGE • AMPUTATION

36. SHARP DEBRIDEMENT • MUST PRECEDE NON-SURGICAL TREATMENT • REMOVE INFECTED AND NON-VIABLE TISSUES • REMOVE EXCESS CALLUS • CURETTAGE OF UNDELYING OSTEOMYELITIC BONES • REDUCES PRESSURE • ALLOWS FULL INSPECTION OF UNDERLYING TISSUES • HELPS DRAINAGE OF SECRETIONS AND PUS • HELPS OPTIMSE EFFECTIVENESS OF TOPICAL PREPARATONS • STIMULATES HEALING

37. VASCULAR RECONSTRUCTION • EARLY REFERRAL TO THE VASCULAR SURGEON • INTRACTABLE REST OR NOGHTPAIN • INTRACTABLE FOOT ULCERS • IMPENDING GANGRENE • FEMORO-POPLITEAL BYPASS

38. REVISION SURGERIES • FOR BONY ARCHITECTURE • REMOVE PRESSURE POINTS • RESECTION OF METATARSAL HEADS, OSTECTOMY

39. SOFT TISSUE COVERAGE • SKIN GRAFTING AUTOGRAFT CADAVERIC • TISSUE CULTURED SKIN SUBSTITUTES DERMAGRAF APLIGRAF • XENOGRAFT

40. AMPUTATION • 85% OF AMPUTATIONS ARE PRECEDED BY ULCERS • AMPUTATION RATES AVERAGELYBETWEEN 5-24% • 53% AMPUTATION RATES HAVE BEEN QUOTED • 26% RE-AMPUTATION RATE • PREDICTORS FOR MAJOR AMPUTATION SMOKING LIMB ISCHAEMIA OSTEOMYELITIS ULCER SIZE ELEVATED WBC,ESR,CRP REDUCED Hb, ALBUMIN LOCAL OR DIFFUSE GANGRENE

41. INDICATONS FOR AMPUTATION • ISCHAEMIC REST PAIN THAT CANNOT BE MANAGED BY ANALGESIA OR REVASCULARISATION • LIFE THREATENING FOOT INFECTION THAT CANNOTBE MANAGED BY OTHER MEASURES • NON-HEALING ULCER ACCOMPANIED BY HIGHER BURDEN OF DISEASE THAN WOULD RESULT FROM AMPUTATION

42. TYPES OF AMPUTATION • RAY AMPUTATION • FOOT CONSERVING AMPUTATIONS: TRANSMETATARSAL, LISFRANC’S • BELOW KNEE AMPUTATION • ABOVE KNEE AMPUTATIONS • DISARTICULATIONS

43. STEPS TO AVOID AMPUTATION: GLOBAL WOUND CARE PLAN • DIAGNOSIS OF DM +/- PERIPHERAL SENSORY NEUROPATHY DFU PREVENTION CARE PLAN TREAT COMORBIDITIES GOOD GLYCAEMIC CONTROL OFFLOAD FOOT ANNUAL PROFESSIONAL FOOT EXAMINATION REGULAR REVIEW AND PATIENT EDUCATION • DEVELOPMENT OF DFU DETERMINE CAUSE OF ULCER AGREE TREATMENT WITH PATIENT AND IMPLEMENT WOUND CARE PLAN INITIATE ANTIBIOTIC TREATMENT

44. REVIEW OFFLOADING DEVICE OPTIMISE GLYCAEMIC CONTROL VASCULAR ASSESSMENT PATIENT EDUCATION • DEVELOPMENT OF VASCULAR DISEASE EARLY REFERRAL TO VASCULAR SURGEON OPTIMSE DM CONTROL • INFECTED ULCER ANTIMICROBIALS OFFLOAD PRESSURE THERAPY DIRECTED AT BIOFILM

45. REASONS FOR POOR TREATMENT OUTCOMES • POOR HEALTH LITERACY • LOW ACCESS TO QUALITY MEDICAL CARE • NON-COMPLIANCE TO MEDICATION • LACK OF ACCESS TO DIABETES INFORMATION AND SERVICES • WEAK REFERRAL SYSTEMS • ABSENCE OF ROUTINE SCREENING FOR DM • POVERTY • LACK OF CAPACITY FOR MANAGEMENT OF DM IN LOWER LEVELS OF HEALTH CARE • BELIEF IN ALTERNATIVE REMEDIES

46. LOCAL AND REGIONAL CHALLENGES • LATE PRESENTATION • ALTERNATIVE UNORTHODOX CARE • THE MIRACLE PHENOMENON • POOR PERIPHERAL HEALTH CARE SERVICES • DEARTH OF SKILLED MANPOWER • LACKED OF DEDICATED FOOT SERVICE • DELAYED REFERRALS

47. POOR PATIENT COMPLIANCE • POOR FOLLOW UP • REFUSAL TO GIVE CONSENT FOR SURGERY • LOW LEVELS OF COMMUNITY/ PATIENT AWARENESS AND PRACTICES • LACK OF POLITICAL WILL

48. PREVENTION • DAILY FOOT INSPECTION • GENTLE SOAP AND WATER CLEANSING • APPLICATION OF SKIN MOISTURISERS • INSPECTIONS OF SHOES FOR SUPPORT AND FIT • PROMPT TREATMENT OF MINOR WOUNDS • AVOID HOT SOAKS,HEATING PADS,IRRITATING TOPICAL AGENTS • STOP CIGARETTE SMOKING • CONTROL OF BLOOD SUGAR, BLOOD PRESSURE AND SERUM LIPIDS • PROPHYLACTICPODIATRIC SURGERY • AVOID USE OF SHARPS TO PARE NAILS • WEAR CLEAN SOCKS • NEVER WALK BARE FOOT • CHECK INSIDE SHOES BEFORE WEARING THEM

49. RECENT ADVANCES • BIOENGINEERED SKIN SUBSTITUTES: DERMAGRAF • EXTRACELLULAR MATRIX PROTEINS: HYAFF,PROMOGRAN • MMP MODULATOR(MATRIX METALLOPROTENASES): DERMAX • AUTOLOGOUS PLATELET-RICH PLASMA