Diabetic Foot Diabetic Foot UlcersUlcers
Sonja Lichtenstein, MD, FACS, UHMSonja Lichtenstein, MD, FACS, UHMZone Medical Director, National Healing Zone Medical Director, National Healing
CorporationCorporation
ObjectivesObjectivesReview the risk factors for development Review the risk factors for development of diabetic foot ulcersof diabetic foot ulcers
Methods to use to help prevent diabetic Methods to use to help prevent diabetic foot ulcersfoot ulcers
Basic management of diabetic foot Basic management of diabetic foot ulcersulcers
Diabetes Diabetes epidemicepidemic
Incidence of diabetes in the world in Incidence of diabetes in the world in 2000 was 171,000,0002000 was 171,000,000
Projected incidence in 2030 is Projected incidence in 2030 is 366,000,000366,000,000
In 2010, 12.3% of adults in the United In 2010, 12.3% of adults in the United States had diabetesStates had diabetes
Cost in Developed Cost in Developed CountriesCountries
25% of diabetic patients develop a foot problem 25% of diabetic patients develop a foot problem in their lifetimein their lifetime
2008: estimated 20.8 million with DM in USA 2008: estimated 20.8 million with DM in USA
Total of $19bn spent on diabetic foot ulcersTotal of $19bn spent on diabetic foot ulcers
$11bn spent on amputation$11bn spent on amputation
Up to $21bn could be saved annually with Up to $21bn could be saved annually with practical and effective preventative foot-care practical and effective preventative foot-care educationeducation
Rogers et al, JAPMA, Rogers et al, JAPMA, 2008;98:1662008;98:166
Cost in Cost in Undeveloped Undeveloped
CountriesCountries2010: estimated 51 million with DM in India 2010: estimated 51 million with DM in India
Population-based study from ChennaiPopulation-based study from Chennai
Cost of illness study: 4677 subjects screened: 1050 Cost of illness study: 4677 subjects screened: 1050 with DM, 718 agreed to take partwith DM, 718 agreed to take part
Median direct cost for DM $526, indirect $103Median direct cost for DM $526, indirect $103
Costs increased according to complicationsCosts increased according to complications
Extrapolated to all India – annual cost of Diabetes in Extrapolated to all India – annual cost of Diabetes in India – US$32bn.India – US$32bn.
Tharkar et al, DRCP 2010;89:334Tharkar et al, DRCP 2010;89:334
Who is at Risk for Who is at Risk for Ulceration?Ulceration?
NeuropathyNeuropathy
Peripheral Vascular Disease Peripheral Vascular Disease
Past history of foot ulcerationPast history of foot ulceration
Foot deformityFoot deformity
AmputationAmputation
SmokingSmoking
Poor glycemic controlPoor glycemic control
CallousesCallouses
Diabetic Foot Diabetic Foot UlcersUlcers
63% of all diabetic ulcers are due to a 63% of all diabetic ulcers are due to a combination of:combination of:
Neuropathy Neuropathy
TraumaTrauma
DeformityDeformity
Many are further complicated by Many are further complicated by Peripheral Arterial Disease (PAD) and Peripheral Arterial Disease (PAD) and infectininfectin
How do we screen How do we screen patients?patients?
Comprehensive foot examComprehensive foot exam
HgA1CHgA1C
History reviewing risk factorHistory reviewing risk factor
NeuropathyNeuropathyIncorporates metabolic and vascular Incorporates metabolic and vascular defectsdefects
Results in neuronal demyelination and Results in neuronal demyelination and atrophyatrophy
Motor – muscle atrophyMotor – muscle atrophy
Autonomic – decrease in perspirationAutonomic – decrease in perspiration
Sensory – loss of protective sensationSensory – loss of protective sensation
Trauma Resulting from Trauma Resulting from Neuropathic ChangesNeuropathic Changes
Motor neuropathy Motor neuropathy
Altered gait and foot Altered gait and foot deformitiesdeformities
Autonomic Autonomic neuropathyneuropathy
Dry skin and fissuresDry skin and fissures
Sensory neuropathySensory neuropathyUnrecognized trauma Unrecognized trauma
Ill fitting shoesIll fitting shoes
Stepping on pins, Stepping on pins, pebbles, etcpebbles, etc
Deformity Resulting Deformity Resulting from Neuropathic from Neuropathic
ChangesChangesIncludes:Includes:
BunionsBunions
Hammer-toesHammer-toes
Prominent metatarsal headsProminent metatarsal heads
Charcot jointCharcot joint
Deformity Resulting from Deformity Resulting from Neuropathic ChangesNeuropathic Changes
Cause high compressive & Cause high compressive &
frictional forces around frictional forces around
area of deformity = skin area of deformity = skin
breakdownbreakdown
Directly related to ill Directly related to ill
fitting footwearfitting footwear
Prevention in Prevention in Patients with Patients with NeuropathyNeuropathyNeed to screen patient for Need to screen patient for
neuropathyneuropathy
Test with Test with Semmes-Weinstein Semmes-Weinstein MonofilamentMonofilament
Uses touch pressure sensation by Uses touch pressure sensation by utilizing a 10 gram monofilamentutilizing a 10 gram monofilament
Defines level of loss-of-protective Defines level of loss-of-protective sensationsensation
Failed monofilament test defined as Failed monofilament test defined as inability to sense 4 of 10 locations inability to sense 4 of 10 locations per plantar aspect of the footper plantar aspect of the foot
Peripheral Peripheral Arterial DiseaseArterial Disease
• Diabetes Mellitus increases the risk of lower Diabetes Mellitus increases the risk of lower extremity PADextremity PAD
• PAD leads to additional healing complications PAD leads to additional healing complications and increased risk for infectionand increased risk for infection
• One in three patients with diabetes over the age One in three patients with diabetes over the age of 50 has PADof 50 has PAD
• The American Diabetes Association recommends The American Diabetes Association recommends screening for PAD in all diabetic patients older screening for PAD in all diabetic patients older than 50 yearsthan 50 years
Screening for PADScreening for PADFeeling for pulses at all levels in the Feeling for pulses at all levels in the lower extremitylower extremity
ADA/ACC recommend that all those patients ADA/ACC recommend that all those patients >50 years old should have an annual ABI>50 years old should have an annual ABI
Ankle-brachial indexAnkle-brachial indexLess than 0.80: abnormalLess than 0.80: abnormalLess than 0.45: severe, limb-threateningLess than 0.45: severe, limb-threatening
Absolute toe systolic pressure - less Absolute toe systolic pressure - less than 45 mmHg is abnormalthan 45 mmHg is abnormal
Handheld DopplerHandheld Doppler
Every patient with a Every patient with a lower extremity ulcer lower extremity ulcer receives Hand Held receives Hand Held Doppler assessmentsDoppler assessments
Assesses macro-Assesses macro-circulationcirculation
Used to auscultate Used to auscultate flow velocityflow velocity
T.K. Carlson
Structural Structural DeformityDeformity
Leads for focal area of high pressureLeads for focal area of high pressure
Due to atrophy of the intrinsic Due to atrophy of the intrinsic musculature responsible for stabilizing musculature responsible for stabilizing the toesthe toes
Other FactorsOther FactorsGlycemic controlGlycemic control
ObesityObesity
Impaired visionImpaired vision
SmokingSmoking
CallousCallous
Physician Physician Responsibilities Responsibilities Inspect patient’s shoes for areas of Inspect patient’s shoes for areas of inadequate support or improperinadequate support or improper
Most patients are okay with athletic Most patients are okay with athletic shoes and thick absorbent socksshoes and thick absorbent socks
Patients with deformities or special Patients with deformities or special support needs benefit from custom shoessupport needs benefit from custom shoes
Provide education about proper care and Provide education about proper care and follow upfollow up
Control blood sugarsControl blood sugars
Patient EducationPatient EducationDaily foot inspection by the patient or Daily foot inspection by the patient or caregivercaregiver
Gentle cleansing with soap and water, Gentle cleansing with soap and water, followed by topical moisturizersfollowed by topical moisturizers
Minor foot injuries and infections can be Minor foot injuries and infections can be unintentionally exacerbated by home unintentionally exacerbated by home remedies that impede healingremedies that impede healing
Avoid hot soaks, heating pads, hydrogen Avoid hot soaks, heating pads, hydrogen peroxide, betadineperoxide, betadine
Cleanse minor wound and apply topical Cleanse minor wound and apply topical antibiotic to maintain a moist wound antibiotic to maintain a moist wound environmentenvironment
Development of Development of UlcersUlcers
Typically painless, even with severe Typically painless, even with severe infectioninfection
Often just report soiled socksOften just report soiled socks
A diabetic foot ulcer A diabetic foot ulcer should heal if:should heal if:
There is adequate arterial inflowThere is adequate arterial inflow
Any infection is appropriately managedAny infection is appropriately managed
Pressure is removed from the wound and its Pressure is removed from the wound and its marginsmargins
Diabetic Lower Extremity Diabetic Lower Extremity UlcersUlcers
Cascade of Events:Cascade of Events:
• NeuropathyNeuropathy
• Ischemic changesIschemic changes
• InjuryInjury
• Massive tissue disruptionMassive tissue disruption
(tunneling, undermining, cavity formation)(tunneling, undermining, cavity formation)
• Cellular dysfunction leukocytes / Cellular dysfunction leukocytes / macrophagesmacrophages
• InfectionInfection
How Should Diabetic How Should Diabetic Foot Ulcers Be Foot Ulcers Be
Treated?Treated?Multidisciplinary Approach to TreatmentMultidisciplinary Approach to Treatment
May involve a number of the following:May involve a number of the following:PodiatryPodiatryVascular surgeryVascular surgeryDieticiansDieticiansInfectious diseaseInfectious diseaseEndocrinologyEndocrinologyDiabetes EducatorsDiabetes EducatorsRadiologyRadiologyPhysical TherapyPhysical TherapyOrthotistOrthotistNursingNursing
Care Plan ObjectivesCare Plan ObjectivesDetermine and Manage EtiologiesDetermine and Manage Etiologies
Comprehensive History and Physical Comprehensive History and Physical AssessmentAssessmentNon-invasive studiesNon-invasive studiesManagement of etiologiesManagement of etiologies
Laboratory EvaluationLaboratory EvaluationNutrition statusNutrition statusGlucose controlGlucose controlCo-morbid disease managementCo-morbid disease management
Ulcer managementUlcer management
Off-loadingOff-loading
Patient EducationPatient Education
Determine and Manage Determine and Manage EtiologiesEtiologies
History and PhysicalHistory and PhysicalPatient and their family medical historyPatient and their family medical historyHistory of the ulcerHistory of the ulcerThorough assessment of the patientThorough assessment of the patient
Lower Extremity AssessmentLower Extremity AssessmentSemmes Weinstein and Tuning Fork - Semmes Weinstein and Tuning Fork - Assesses for neuropathyAssesses for neuropathyHand-held Doppler - Dorsalis pedis and Hand-held Doppler - Dorsalis pedis and posterior tibial pulse signalsposterior tibial pulse signals
Non-invasive studiesNon-invasive studiesVascular studiesVascular studiesRadiographic studiesRadiographic studies
Transcutaneous Oximetry (TcPOTranscutaneous Oximetry (TcPO22) – ) – measures the measures the oxygenation of the tissues around the ulceroxygenation of the tissues around the ulcer
Skin Perfusion Pressure (SPP) Skin Perfusion Pressure (SPP) - measures the - measures the pressure at which blood flow first returns to the pressure at which blood flow first returns to the capillaries following a controlled release of capillaries following a controlled release of occlusion from a blood pressure cuff. occlusion from a blood pressure cuff.
Arterial Duplex Ultrasound Arterial Duplex Ultrasound - Duplex - Duplex ultrasonography of the arteriesultrasonography of the arteries
Ankle-Brachial Index (ABI)/Segmental Ankle-Brachial Index (ABI)/Segmental Pressures/Toe Pressures Pressures/Toe Pressures - Assess pressure at - Assess pressure at multiple levels on the limb or digitmultiple levels on the limb or digit
AngiographyAngiography – invasive study providing detailed – invasive study providing detailed imaging of the arteries imaging of the arteries
Vascular StudiesVascular Studies
Radiographic Radiographic StudiesStudies
X-ray – X-ray – should be performed on all diabetic should be performed on all diabetic foot ulcerations to rule out foreign body foot ulcerations to rule out foreign body presencepresence
MRI – MRI – recommended by ADA as best non-recommended by ADA as best non-invasive diagnostic imaging for osteomyelitisinvasive diagnostic imaging for osteomyelitis
Bone Biopsy - Bone Biopsy - the definitive diagnostic study the definitive diagnostic study for osteomyelitis allowing for culture and for osteomyelitis allowing for culture and sensitivity of the specimensensitivity of the specimen
Management of Management of EtiologiesEtiologies
PAD and Osteomyelitis are two common PAD and Osteomyelitis are two common secondary etiologies affecting healing of the secondary etiologies affecting healing of the diabetic ulcerdiabetic ulcer
Both must be identified and Both must be identified and corrected/optimized for successful ulcer corrected/optimized for successful ulcer healing to occurhealing to occur
Other etiologies also need to be identified and Other etiologies also need to be identified and corrected/optimized for successful ulcer corrected/optimized for successful ulcer healinghealing
Ulcer ManagementUlcer Management
Diagnose and treat underlying Diagnose and treat underlying etiologiesetiologies
Adequate debridement Adequate debridement
Dressing choice based on ulcer needsDressing choice based on ulcer needs
Treatments that stimulate healingTreatments that stimulate healingNegative Pressure Wound Therapy (NPWT)Negative Pressure Wound Therapy (NPWT)Biologic productsBiologic products
Bioengineered tissuesBioengineered tissuesGrowth factorsGrowth factors
Hyperbaric Oxygen Therapy (HBOT)Hyperbaric Oxygen Therapy (HBOT)
Offload!!!!Offload!!!!
Adequate DebridementAdequate Debridement
Serial sharp ulcer bed Serial sharp ulcer bed preparationpreparation
Removes senescent Removes senescent cells, necrotic tissue, cells, necrotic tissue, converts a chronic ulcer converts a chronic ulcer to an acute wound, to an acute wound, re-initiates healing re-initiates healing cascadecascade
Centers that utilize Centers that utilize sharp debridement sharp debridement exhibit the highest exhibit the highest degree of healing. degree of healing.
T.K. Carlson
Approaches to ulcer Approaches to ulcer Care For the Diabetic Care For the Diabetic
PatientPatientSimple dressings that meet the needs of the ulcerSimple dressings that meet the needs of the ulcer
Antimicrobial therapy – topically and systemicallyAntimicrobial therapy – topically and systemically
Advanced Treatment ModalitiesAdvanced Treatment ModalitiesGrowth FactorsGrowth FactorsBio-engineered TissueBio-engineered TissueNegative Pressure Wound TherapyNegative Pressure Wound TherapyHyperbaric Oxygen TherapyHyperbaric Oxygen Therapy
Plastic surgery – skin grafts/flapsPlastic surgery – skin grafts/flaps
Advanced dressings can reduce costs up to Advanced dressings can reduce costs up to 50% particularly when you consider the 50% particularly when you consider the cost of an infectioncost of an infection
Utilizing the wrong dressing can increase Utilizing the wrong dressing can increase the cost of treating ulcers and cause the cost of treating ulcers and cause further complications for the patientfurther complications for the patient
Thoroughly assess the Thoroughly assess the ““state of the ulcer state of the ulcer bedbed”” before prescribing treatment before prescribing treatment plan/dressingsplan/dressings
Nothing works well on the DFU without Nothing works well on the DFU without proper offloadingproper offloading
Advanced Treatment Advanced Treatment ModalitiesModalities
Off-Loading: A Off-Loading: A Standard of CareStandard of Care
Proper off-loading:Proper off-loading:
Reduces pressureReduces pressure
Reduces shearReduces shear
Reduces shockReduces shock
Transfers weigh from sensitive or painful areasTransfers weigh from sensitive or painful areas
Corrects or supports flexible deformitiesCorrects or supports flexible deformities
Accommodates fixed deformitiesAccommodates fixed deformities
Off-Loading: A Off-Loading: A Standard of CareStandard of Care
Off-loading includes:Off-loading includes:Rest/elevationRest/elevationFelt/foamFelt/foamMulti- podus splint/bootMulti- podus splint/bootRemovable cast walker/walking bootRemovable cast walker/walking bootTotal contact casting (TCC)Total contact casting (TCC)Wedge shoeWedge shoeSurgical shoe with pressure relief insoleSurgical shoe with pressure relief insole
Other assistive devices used in additionOther assistive devices used in additionCrutchesCrutchesWheelchairsWheelchairsWalkersWalkers
Orthotics For Ulcers That Orthotics For Ulcers That DoDo Heal Heal
Therapeutic Therapeutic footwear should be footwear should be placed upon healingplaced upon healing
Prevents recurrencePrevents recurrence
Accommodates Accommodates deformitiesdeformities
Distributes the Distributes the pressure equally pressure equally throughout the footthroughout the foot
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Patient EducationPatient EducationMust take an active role in their careMust take an active role in their care
Ulcer managementUlcer managementRoutine nail careRoutine nail careDisease managementDisease management
Decreases the chance of reoccurrenceDecreases the chance of reoccurrenceFoot hygieneFoot hygieneDaily inspectionDaily inspectionProper footwearProper footwearPrompt treatment of new lesionsPrompt treatment of new lesions
Elective surgery to correct structural Elective surgery to correct structural deformities before ulcerations occurdeformities before ulcerations occur
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Summarizing the Summarizing the InformationInformation
With the increase in diabetes in both the With the increase in diabetes in both the younger and aging population, we are at risk for younger and aging population, we are at risk for greater complicationsgreater complications
Total National Annual Cost: $174 billion Total National Annual Cost: $174 billion dollars.5dollars.5
Common causes of Diabetic Foot Ulcers include: Common causes of Diabetic Foot Ulcers include: neuropathy, trauma, deformity, high plantar neuropathy, trauma, deformity, high plantar pressurespressures
Common secondary etiologies include: Common secondary etiologies include: peripheral arterial disease (PAD) and peripheral arterial disease (PAD) and osteomyelitisosteomyelitis
Summarizing the Summarizing the InformationInformation
Treatment Objectives of Diabetic foot Treatment Objectives of Diabetic foot ulcersulcers
Determine and manage the etiologiesDetermine and manage the etiologies
Establish blood supplyEstablish blood supply
Off-loading followed by therapeutic footwear Off-loading followed by therapeutic footwear upon healingupon healing
Patient educationPatient education
Off-loading the pressure at the site of the Off-loading the pressure at the site of the ulcer is a ulcer is a standard of carestandard of care
Summarizing the Summarizing the InformationInformation
Treating the diabetic foot often includes:Treating the diabetic foot often includes:
Debridement (clinical and/or surgical) Debridement (clinical and/or surgical)
Advanced treatment options Advanced treatment options
HBOHBO
NPWTNPWT
Biologic products:Biologic products:
Growth factorsGrowth factors
Bio-engineered tissuesBio-engineered tissues
Diabetic patients must be active Diabetic patients must be active participants in their care to decrease the participants in their care to decrease the chance of reoccurrencechance of reoccurrence