DIABETIC FOOT

 Diabetic

foot is a syndrome involving pain, deformity, inflammation, infection, ulceration and tissue loss of the foot in Diabetic patients.  5-10% of the Diabetics suffer from foot ulcerations  Diabetes accounts for about 50% of the non traumatic amputations  1% of the Diabetics have undergone an amputation

PATHOPHYSIOLOGY
NEUROPATHIC DAMAGE

SUPERIMPOSED INFECTION

ARTERIAL DISEASE/ISCHAEMIA

NEUROPATHY
Sensory Motor Autonomic Asymmetrical Symmetrical Progressive Reversible Pressure palsies

DISTAL SYMMETRICAL NEUROPATHY
 The

phrase that describes Diabetic Neuropathy  Sensory – glove and stocking type  Motor – wasting of muscles and deformity  Autonomic – AV shunting and decreased sweating  Callus formation

AV shunting •Causes impairment of nutritive capillary circulation •Gangrenous toe with bounding pulses •Distension of leg veins which fail to empty even when elevated •O2 tension in the veins increase

SMALL FIBRE NEUROPATHY
 Seen

mostly in Type I diabetes  Neuropathic pain with relative sparing of large fiber functions(vibration and Proprioception)  Burning, deep aching  Autonomic neuropathy  Males might have erectile dysfunction  Early manifestation?

ACUTE PAINFUL NEUROPATHY
Of Poor glycaemic control  Neuropathic Cachexia  Allodynia  Peak pain with Background pain  Small fiber Neuropathy  Complete resolution in 10 months Of Rapid glycaemic control  NO WEIGHT LOSS  Insulin Neuritis  Resolves in 10 months

Pathogenesis of Distal symmetrical Neuropathy
 Chronic

Hyperglycemia*  Polyol pathway hyperactivity  Non enzymatic Glycation  Neurotrophic Factors  Protein C kinase activation  Abnormalities of nerve growth  Nerve microvascular dysfunction

MICROANGIOPATHY
 Most

common microvascular complication is Diabetic Retinopathy  NOT AN OCCLUSIVE DISEASE  Thickening of the basement membrane  Functional microvascular impairment  O2 diffusion unimpaired  Reduces Hyperaemic response  Affects axon reflex  Abnormal endothelial function

MACROVASCULAR DISEASE
 Accelerated

atherosclerosis and higher prevalence in Diabetics branches involved

 Infrageniculate  Pedal

vessels spared

PRESENTATION OF ARTERIAL DISEASE
• Claudication • Rest pain •Tissue loss  Foot Ulceration Gangrene

P

a

t h

w

a

y

t o

f o

o

t

u

l c

e

r a

t i o

n

D L i m M A O C b n a o o i t e d t o r m r j Do i i n a tb me t oi c b iN l i e t yu AD u a tm o

i a r o p

b a

e t e s t h R y M i c r o v a e sM c n

s m o k H y p e D y s l i p

u a l ca rr o dv u

D S a em n

as o g r e y

an go e m

e d u i c D

c e d T i s s u a m a g e a e m c e p i a t i o n

t r i t i o

R a l e df o u o c t e dp

r p e a s A si nu - r a e V n s d s h p u r no o t p r e s s u

tIp i s rn c i g ho r e s

r t h o p h a r c o

e d i c p r o b l e m s I t n h c r ro e p a a s t e h d y f o t 's A r

C

a l l u

s

f o

r m

a tUi o

Ln C

E

R

A

T

I O

N

I n

f e

c

t i o

n

Wound Classification Systems
MEGITT WAGNER’S Classification  Grade 0 – High risk, no ulcer 1. Peripheral Neuropathy 2. Peripheral Vascular Disease 3. Previous foot ulcers 4. Presence of callus 5. Foot deformity 6. Blind or partly sighted 7. Nephropathy 8. Elderly especially if living alone 9. Unable to reach feet unaided 10. Poor understanding of Diabetes 11. Inability to feel Semmes Weinstein Nylon monofilament

Grade

infected Grade II – Deep ulcer, often with cellulitis. No abscess or bone infection Grade III – Deeper ulcer with bony involvement or Abscess Grade IV – Localized Gangrene(Toe, forefoot , heel) Grade V – Gangrene of the whole foot

I – Superficial ulcer, not clinically

Grade 1 Stage A

Grade 2

Grade 3 Wound involving capsule or tendon With infection With ischaemia

Grade 4 Wound penetrating to bone or joint With infection With ischaemia

Lesion Superficial completey wound,no epithelialize tendon, d capsule or bone With infection With infection

Stage B Stage C Stage D

With With ischaemia ischaemia Both of the Both of the above above

Both of the Both of the above above

INFECTION
 Diagnosed

clinically  Purulent discharge  Two or more signs of inflammation  Temperature > 102o F suggests infection involving deep spaces of the foot and tissue necrosis  Limb threatening usually polymicrobial having 4.1 – 5.8 species/culture  40% show both Aerobes & Anaerobes

Classification of foot infections(Lipsky’s)
Superficial Deep soft Tissue Systemic ulcer or tissue of bone Necrosis or Toxicity or cellulitis involved gangrene metabolic instability Mild Moderate + + -

+/+/No gas/fascitis Minimal +/+/-

Severe

+

+

MICROBIOLOGY
 Aspiration  Curettage  Biopsy

of pus

of ulcer base

of affected tissue

 Osteomyelitis

COMMONEST ORGANISMS • Staphylococcus Aureus in more than 50 % • Group B Streptococcus • Facultative gram negative Bacilli like E.coli, Proteus, Enterobacter, and Klebsiella • Anaerobes like peptostreptococcus and Bacteroides species esp. B Fragilis • Pseudomonas, Actinobacter, MRSA from Chronic wounds

What is a limb threatening infection ? 1. If associated with ishaemia 2. Deep ulcer with a rim of cellulitis >/= 2cms 3. Fever > 102oF 4. University of Texas Grade 1- 3 5. Lipsky’s moderate to severe

Charcot foot OR Neuropathic Osteoarthropathy
A

non infectious and progressive condition of single or multiple joints characterized by joint dislocation, pathological fractures, and sever destruction of the pedal architecture that is closely associated with peripheral neuropathy  Presisposing factor is usually trauma leading to the cascade of events

Pathogenesis
 Neurotraumatic

(German) theory Due to protective sensory loss repetitive micro and macro trauma causes intracapsular effusions, ligamentous laxity, and joint instability. This does not explain the occurrence of artropathy in bed ridden patients

• Neurovascular (French) theory Increased blood peripheral blood flow owing To autonomic neuropathy leads ot hyperemic Bone resorption

• A combination of both of the above theories

Clinical features of Acute Charcot Joint
 Vascular

– Bounding pedal pulse, erythema, swelling, warmth  Neuropathic – Absent or diminished pain, proprioception or deep tendon reflex; Anhidrosis  Skeletal – Rocker bottom deformity, Digital subluxation, Hypermobility, Rearfoot Equinovarus  Cutaneous – Neuropathic ulcer, Hyperkeratosis, Infection

BIBLIOGRAPHY
 Handbook  Bailey

of Vascular Surgery (2004)

(2004)

and Love’s Short Practice of Surgery, 24th Edition

A

Concise Textbook of Surgery by S. Das, 3rd Edition (2004 Reprint) Diabetic Foot by Veves (2003) Textbook on Diabetology (2002)

 The

 Williams

NET SEARCH
• www.google.com/images Key word: diabetic foot, charcot joint • www.emedicine.com Key word: diabetic foot infections, Diabetic neuropathy