Diabetic Foot Surgical Look

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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

How do patients with PAD present?

How do patients with neuropathy  present?

How do patients with infection  present?

Evaluation & Management • Multi-displinary Approach  –  Diabetologists  –  Primary Care Physicians  –  Specialized Nurses  –  Social Workers  –  Diabetes Educators  –  Foot Care Specialists  –  Physiotherapists/ Occupational therapists  –  Radiologists  –  Vascular Surgeons

Evaluation & Management • Clinical Assessment  –  History  –  Physical Examination

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 Improve Lower Limb Circulation Conservative (Exercise Program) Intervention ( Revascularization) - Angioplasty +/- Stenting - Surgical Bypass • •

Percutanous Transluminal Angioplpasty PTA

Surgical Bypass

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

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