CME INDIA Presentation by Dr R K Modi, MD FICP, Graduate Dip in Diabetes, Modi’s Diabetes Research Centre, Purnea, Bihar.

Diabetic Foot – Management Pearls

Complex interplay

• Diabetes is chronic metabolic disorder affecting nerves, eyes, kidney, blood vessels and heart.
• Diabetic foot is the result of either neuropathy or vasculopathy or from its combination and Diabetic foot disease is a result of complex interplay between neuropathy, peripheral arterial disease, foot deformities and infection.
• In India 75-90% of major foot problem in diabetes is due to neuropathy.
• Diabetic foot has become a matter of concern because it is a major cause of morbidity and mortality with great economic burden.

Magnitude of the problem

• Inadequate management of diabetic foot disease (DFD) can end in amputation of limb. It is the commonest cause of non-traumatic amputation of limb (70%).
• In every 30 second one limb is amputated somewhere in world. ADA has estimated that 50% of limb with foot ulcer can be saved if both health care provider and patient fulfill their respective responsibilities.
• Spectrum of complications includes superficial cellulitis to chronic osteomyelitis and gangrene necessitating lower limb amputation.

Prevalence and Risk factors

• Globally prevalence of DFD ranges from 1.5% – 16.6%.
• In India, the prevalence is 11.6%. Risk factors are Smoking, DPN with LOPS, PAD, Foot deformity, CKD, Callus or Corn, history of DFU or amputation, poor glycaemic control and visual impairment

Human foot is a great mechanical marvel.

• It has 26 bones, 29 joints and 42 ligaments; a very sensitive & protective skin blanket with exquisite nerve supply.
• It has great vascularity with rich collaterals.

Why diabetic foot disease? Why not diabetic hand?

• It is due to attainment of erect posture from tetra pod to bipedal posture. Which resulted in weight bearing of whole body on two limbs instead of four and secondly less care taken by the body because the distance of feet from the eye is increased. Lastly neuropathy and vasculopathy affects peripheral parts classically in diabetes.

Why to give more attention to diabetic foot?

• Because of poor healing of wound due to abnormal cellular/inflammatory pathway-fibroblast, neutrophil, AGEs (advanced glycation end products) associated peripheral neuropathy with loss of protective sensation. Other factors are poor neuro inflammatory response (autonomic neuropathy) and wound hypoxia (micro & macro vascular disease)

Diabetic foot ulcer (DFU)

• There is 25% risk of developing an ulcer in life time. It results from mechanical trauma unnoticed due to LOPS. Commonest site is fore foot.
• Ulcer develops at sites of high-pressure zone on either side planter or dorsal surface caused by bony prominence/ill- fitting foot wear/toe deformity. Continuous abnormal pressure causing tissue ischemia.
• LJM (limited joint mobility) is another contributory factor for development of foot ulcer.
• Bony deformity and callus are the marker of elevated planter pressure.

Examination

1. Inspection for dry skin cracks, fissure, callosity, corn, fungal infection of toes, cellulitis and ulceration.                                                         
2. Neuropathy detection by 10g nylon monofilament and 256 Hz tuning fork.        
3. Vasculopathy detection– by palpation of peripheral pulses and ankle brachial index (ABI) measurement by vascular Doppler.   
4. Foot wear examination– Impression on insole & wearing out of outsole points high pressure area of foot. A rigid out sole, soft in sole (MCR) roomy toe box, wide mouth, extra depth of shoe with a counter are the features of good diabetic foot wear.

Pearls in Management:

• It is a team work and a Multi-disciplinary approach is required. Physician or Diabetologist has a key role to play. Other members of team – Surgeon, Nutritionist, Diabetic nurse, Foot care worker, Diabetic educator & Diabetic cobbler; all are important for salvaging of a diabetic foot.
• Proper workup of diabetic patient is essential to establish neuropathy/ vasculopathy or both. Tight metabolic control is an essential factor.
• First step is to classify DFD – It may be one of the three types. (a) Non-limb threatening (uninfected/infected) (b) Limb threatening and(c) Life threatening (metabolic instability)
• OPD Management – Non limb threatening conditions like:- callosity and corn;  Dermatophytosis of web space,  deformities like hallux vulgas, hammer toes, fissures and cracks, hypertrophic bursitis  can be managed in outpatient basis by giving proper advice regarding foot care and foot wear, minor OPD procedures for callus and corn removal, anti-fungal drug for Dermatophytosis, moisturizing lotions for cracks and fissures, advice regarding customized preventive footwear for foot with structural deformity and foot at risk (foot with LOPS).
• If mild infection is present, then empirical antibiotics like: Moxifloxacine (400 mg OD for 7 days); Cefdinir (300mg BD for 5-7 days); Linezolid (600mg BD for 5-7 days); Cephalexin (500mg TDS for 5-7 days); Azithromycin (500mg OD for 5-7 days) can be used.
• Limb threatening and life-threatening diabetic foot conditions needs indoor admission and help of surgeon for proper management. So, identification of such condition is important for early referral but before sending to a surgeon a physician must talk to the surgeon and discuss the modality of management regarding correction of dehydration by appropriate intra-venous fluid, insulin infusion for correction of hyperglycemia, selection of empirical antibiotics in consideration to renal status before the results of culture sensitivity comes.

• In limb- threatening conditions preferred intra-venous antibiotics are–Cefeperozone/ Sulbactam (2g 12 hrly) + Metronidazole (500mg 8hrly) or Moxifloxacin (400mg OD) + Metronidazole (500mg 8 hrly). For life threatening-Pipperacillin / Tazobactam (4.5g 8hrly) + Amikacin (15mg per kg OD) or Meropenem (1g 8hrly) or Clindamycin (600mg 8hrly) + Amikacin ((15mg per kg OD).
• A physician must discuss with the surgeon that the best dressing material for diabetic foot is normal saline and use of savlon, betadine, H2O2, Eusol is not suitable for diabetic wound because they have direct cyto-toxic effect to fibroblast and Keratinocytes.
• Use of Topical antibiotics is good for keeping the wound moist because moist environment is ideal for healing of diabetic wound. oint. of Metrozyl, Silver Sulphadiaze, Mupirocine (gram positive cocci MRSA), Nadifloxacin (gram positive cocci, anaerobes, gram negative bacteria), Ensamycine (pseudomonas).
• Always remember the final choice of antibiotics depends on the results of culture sensitivity. Clindamycin, Azithromycin and Moxifloxacin can be safely used for patients with impaired renal function, but for rest mentioned antibiotics dose adjustment is necessary.
• Wound off-loading is very important for proper management. So, to conclude tight metabolic control, extensive debridement, appropriate antibiotics and off-loading of wound are the principle of management of diabetic foot.
• Preventive care is most important daily inspection of foot, use of appropriate foot wear, use of moisturizing lotion all are important. And not only this every patient should follow the rule of DOS &DON’TS as advised by doctor.

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