Diabetic Foot: A Surgical Look Badr Aljabri, MD, FRCSC Associate Professor & Consultant Vascular Surgery King Saud University
Part I Diabetic Foot: The Basics • What is a diabetic foot? • What is the burden of diabetic foot? • What is the etiology of diabetic foot? • How does these patient present? • How to evaluate and mange patients with diabetic foot?
Part II Diabetic Foot: The Role of Vascular Surgeons • When to refer? • What can we offer the patients with diabetic foot?
Diabetic Foot: The Basics
What is a diabetic foot? • Diabetic foot is a disease complex that can develop in the skin, muscles, or bones of the foot as a result of the nerve damage, poor circulation and/or infection that is associated with diabetes.
What is the burden of diabetic foot? • International Diabetes Federation has chosen to focus on the global burden of diabetic foot disease in 2005 • lifetime risk of a person with diabetes developing a foot ulcer could be as high as 25% resulting in more hospital stay days than all other diabetic complications combined Singh et al, . JAMA 2005; 293: 217 28.
What is the burden of diabetic foot? • Foot ulcers cause Substantial morbidity Impair quality of life Engender high treatment costs (US$ 17 500 – 27 987, UK£ 9533 – 15 246) Most important risk factor for lower-extremity amputation
• Every 30 seconds a lower limb is lost somewhere in the world as a consequence of diabetes
Singh et al, . JAMA 2005; 293: 217 28.
What is the burden of diabetic foot? In the United States • The cause of 50% of all the nontraumatic amputations • 50,000 amputations / year • 3 year mortality is 50%.
What is the burden of diabetic foot? In Saudi Arabia • ??? • DM prevalence 23.7% (in 30-70 yrs old) • ?? 3% to 6% Diabetic foot prevalence
AlNozha et al, Saudi med J 2004; 25: 1603-10.
What is the burden of diabetic foot? PAD is 4-6 folds more prevalent in diabetic between 45-75 years than nondiabetic
What is the etiology of diabetic foot? Multifactorial • Neuropathy • Ischemia • Infection
Neuropathy affects more than 50% of diabetics • Sensory loss • Motor loss • Autonomic neuropathy
Ischemia (PAD) • More than 50% diabetics get significant atherosclerotic disease • “Large vessel PAD” – often with tibial involvement with relative sparing of proximal and pedal vessels • “Microcirculatory” disease – intimal and basement membrane thickening
• Combination of PAD & Neuropathy
• Combination of PAD & Neuropathy • Risk of injury • Invasive soft tissue infection • Osteomylitis • Chronic ulceration • Gangrene
Clinical presentation • Evidence of PAD Intermittent Claudication Critical limb Ischemia / Ulcers • Evidence of Neuropathy Deformities Ulcers • Infection Cellulitis Invasive soft tissue infection Osteomylitis
Evaluation & Management • Investigation – Plain films / Nuclear Medicine – Non-invasive (Duplex / Digital pressures/ ABI, CTA, MRA) – Invasive test (Arteriography)
Investigations
Investigations
Ankle Brachial Index
ABI= Ankle SBP(PT or DP)/ Highest Arm SBP
Ankle Brachial Index ABI value
Indicates
<0.9
Abnormal
0.8- 0.9
Mild PAD
0.5- 0.8
Moderate PAD
<0.5
Severe PAD
<0.25
Very Severe PAD
The ABI has limited use in evaluating calcified vessels that are not compressible as in Diabetics
Investigations Toe pressure Segmental pressure
Arterial duplex
Investigations
Investigations
Evaluation & Management Goals of tr eating patients with Diabeti c F oot
Relief symptoms Improve quality of life Limb salvage Prolong survival
Evaluation & Management Treatment
• Preventive Measures Patient Education Local- footwear, cotton socks, nail care can reduce amputation rate by 40 to 80% Systemic- Risk factors modification
Patient Education • Importance of risk factors control • Avoidance of trauma and minor cuts • Proper foot care • Medical visit with early signs of infection or ulcer development
Local Foot Care
Risk Factors Modification AHA 2005
• Tobacco cessation.
ACC 2003
• Physical Activity.
AHA/ACC 2006
• Dietary modification. • Weight reduction. • BP control. • total chol & LDL. • Anti-PLT therapy. • ACE inhibitors. • Glycemic control
Evaluation & Management Treatment
• Specific Measures – Eradication of infection- debride, drain, local amputation, metatarsal head reduction, Antimicrobial therapy – Revascularization- where possible – Major amputation – where all else fails or no alternative
Diabetic Foot: The Role of Vascular Surgeons
When to Seek Vascular Surgery Consultation? Evidence of PAD - Intermittent Claudication - Critical Limb Ischemia Rest Pain Impeding soft tissue compromise Tissue Loss Frank ulceration or gangrene.
Evaluation & Management • Questions – Is there associated deeper infection? – Is this related to ischemia? – Will this heal?
What can we offer the patients with diabetic foot?
• Specific Measures – Eradication of infection- debride, drain, local amputation, metatarsal head reduction, Antimicrobial therapy – Revascularization- where possible – Major amputation – where all else fails or no alternative
Strategies in treating patients with diabetic foot Eradication of Infection Debridment Drainage Minor amputations • • •
Strategies in treating patients with diabetic foot Major amputation Primary vs Secondary BKA vs AKA • •
Take home message
• Diabetic Foot is a major and an increasing public-health problem • Etiology is Multifactorial • Multi-displinary approach is the key for better outcomes