Diabetic Foot 2016

Diabetic FootManagement

Diabetic Foot Protection ServiceTallaght Hospital, Dublin, Ireland

Sean Tierney

Vascular surgery @ Tallaght

The problem


The problem


Mechanism of ulceration

Neuropathy


Semmes-Weinstein monofilament

• Loss of – protective sensation in feet– proprioception– vibration– Pain

• Asymptomatic– 50% of insensate patients

have no symptoms

Sensory neuropathy

Diabetes Care. 2006;2 9: S24Diabetes Care. 2004; 27: 1591


• Demonstrate on forearm or hand

• Place monofilament perpendicular

& bow into C-shape for 1 second

• 4 sites/foot

• Avoid – Heel (does not predict ulcer)

– calluses, scars, and ulcers

Sensory neuropathy

Diabetes Care. 2006;2 9: S24Diabetes Care. 2004; 27: 1591


Sensory neuropathy

• -ve predictive value = 90%-98%

• +ve predictive value = 18%-36%

J Fam Pract. 2000;49:S30Diabetes Care. 1992;15:1386


Ipswich Touch test

• If ≥2 (of 6) missed• Sensitivity 77%• Equivalent to

SWMF

Rayman G. Diabetes Care. Jul 2011; 34(7): 1517–1518.


Other sensory modalities





Sales

Sensory

Motor Autonomic


Motor neuropathy

Diabetes Care. 2001;24:1442Diabetes Metab. 2003;29:261


Autonomic neuropathy


Vascular disease

Neuropathy

Deformity

Trauma

UlcerHealing


Vascular disease

Neuropathy

Deformity

Trauma

UlcerHealing Limb loss

Ischaemia

Infection


UT classification

University of Texas Wound Classification SystemLavery et al. J Foot Ankle Surg 35 : 528-531,1996



Foot assessment in diabetics

Structural

Skin and soft tissue

Innervation

Perfusion


Arterial supply

Poitier et al, Eur J Vasc Endovasc 2011

• PAOD prevalence 9.5% - 13.6%

• (~ 50% with ulcer)• distal > proximal • Medial artery

calcification more common


Vascular assessment in diabetics


Is palpation of pulses reliable?

DP only PT only BothSensitivity 64 70 73Specificity 81 83 92NPV * 91 92 94PPV 43 49 81Accuracy 77 81 95

absent pulses

• Negative predictive value of palpable pulses in excluding PAOD is 94% (vs ABI <0.9 as gold standard)

Armstrong et al. Can J Cardiol 2010


Where is the patient on the spectrum?

Normal pulses

Impalpable pulses


ABI in Diabetes



ABI in Diabetes



<120s

60o

<120s

Beurger’s test

-ve +ve


Toe pressure

P>SBP


Toe pressure measurements

• Less affected by medial calcification(neuropathy, CRF)• absolute toe pressure of <30 mmHg =

critical ischemia• 1o in 85% TP >45 mmHg vs 36% ≤45

mmHg (p < .001) *

Brooks et al. Diabetic Medicine 2001, 18(12):528-532. * Apelqvist et al. Diabetes Care June 1989 12:6 373-378


Tissue oxygenation


Tissue oximetry & healing

Londahl et al. Diabetolgia 2011


Tissue oximetry (summary)

• tissue hypoxia is defined as “a TcPO2 <40 mm Hg”• associated with reduced likelihood of amputation

healing • in critical limb ischemiaTcPO2 typically < 30 mm Hg

Oxygen response • TcPO2 increases by > 40 mm Hg on 100% O2 usually

associated with subsequent healing

Fife et al. Undersea and Hyperbaric Medicine. 2009


Choices

Structural & neuropathy

Offload

Ischaemia

Revascularisation

Infection

Drain, debride, ABx


Risk based ulcer prevention

Risk Level Foot Ulcer %/yr

% in clinics(diabetes clinics)

3: Prior amputationPrior ulcer

28.1%18.6% 7%

2: Insensate andfoot deformity orabsent pedalpulses

6.3% 10%

1: Insensate 4.8% 17%-30%

0: All normal 1.7% 66%


Vascular Intervention

Ischaemia

Revascularisation


Imaging

• Duplex• CT angio• MRI• Angiogram


Imaging


Issues

• Calcification

• Contrast– Renal fxn– Metformin– Prevention AKI

• Level


Pedal Bypass surgery

• 1998-2008

• N= 28 (4 asynchronous bilateral)

• M:F = 5:1• Mean age 63y (37 – 92)• Autologous vein used in

all patients

Good et al Ir J Med Sci 2010




Proximal site• Popliteal (n=28)

Distal sites• Dorsalis paedis (n=13)• Plantar artery (n= 15)


Pedal Bypass surgeryPrimary graft patency

0

20

40

60

80

100

0 6 12 18 24 30 36 42 48 54 60

Time after surgery (months)

Gra

ft pa

tenc

y as

a p

erce

ntag

e Primary patency


Vascular surgery @ Tallaght Primary & Secondary graft patency

0

20

40

60

80

100

0 6 12 18 24 30 36 42 48 54 60


Gra

ft pa

tenc

y as

a p

erce

ntag

e Primary

Secondary





0

20

40

60

80

100

0 6 12 18 24 30 36 42 48 54 60

Lim

b su

rviv

al a

s a

perc

enta

ge


Limb Salvage


Vascular surgery @ TallaghtPatient Survival after Popliteo-pedal bypass

0

20

40

60

80

100

0 6 12 18 24 30 36 42 48 54 60


Surv

ival

as

a pe

rcen

tage




Meta-analysis (pop pedal bypass)

• N=1,2320 (79 studies)

• @ 5 years• 1o patency 63%• 2o patency 71%• Limb salvage 78%• * 5 yr mortality ~50%

Albers et al J Vasc Surg. 2006 43:498-503.*Hinchcliffe et al Diabetes Metab Res Review 2012


Innovation


Technical considerations

• Consent

• Ipsilateral (antegrade)

• Local• ? 4/5Fr• ? ultrasound


Tibial artery disease

• Sub-intimal vs luminal• Target vessels• Re-assessment

Lida O et al. J Vasc Surg. 2012; 55(2):363-370


Tibial angioplasty - results

• 40 mo

• 61 limbs in 53 patients (41 male, median age 73)

• Rest pain /tissue loss)

• TASC D

O Connor et al ASGBI 2014


TASC

Norgren et al. JVS 2007


TASC

Norgren et al. JVS 2007


Grazziani L

Graziani L, et al Eur J Vasc Endovasc Surg.


Tibial angioplasty – results 2

• Technical success 81.3% (49/61 limbs)

• Revascularisation n=12 (4 distal bypass)

• Survival (3 y) 72%

• AFS (3 yr) 64%

O Connor et al ASGBI 2014


Tibial angioplasty – meta-analysis

• N = 2653• Technical success = 90%

@ 3 years• 1o patency 49%• 2o patency 63%• Limb salvage 80%• Survival 68%

Romiti et al J Vas Surg 2008


Tibial angioplasty – meta-analysis

• N = 2653• Technical success = 90%• @ 3 years• 1o patency 49%• 2o patency 63%• Limb salvage 80%• Survival 68%

Romiti et al J Vas Surg 2008

vs Bypass (@5 years)63%71%78%50%

Albers et al J Vasc Surg. 2006 43:498-503.


PAOD – critical ischaemia


Multidisciplinary care

Nason et al. Ir J Med Sci 2013


Choices


Offload

Ischaemia

Revascularisation

Infection

Drain, debride, ABx


Neuropathic ulcer


Offload


Neuropathic ulcer

Lewis J et al. Cochrane Database Syst Rev. 2013


Neuropathic ulcer


Infection

• Debride• Probes to bone• Xray• ? Bone scan• ? MRI

Infection

Drain, debride, ABx


Infection

• Antibiotics

• Sliding scale• Surgical

Debridement• Drainage

• Minor amputation


Infection

• Multiple procedures

• VAC closure• Offloading


Think feet… think vascular


Plantar ulcer


Heel ulcer


Fore foot ulcer


Pain & Swelling


3 months later




• STIR and T1-weighted images: abnormal signal intensity in the cuboid bone indicative of osteomyelitis.

• Contrast enhanced images +/-fat saturation:Enhancement of cuboid and soft tissues = osteomyelitis very likely.

www.perfuse.net@theseant

http://www.slideshare.net/stierneyhttp://goo.gl/jmtHb3

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Diabetic Foot 2016

Healthcare