CME INDIA Presentation by Prof (Dr.) L. Sreenivasamurth, MD, FRCP (Edinburgh), FRCP (Glasgow) FRCP (London), FACP (USA), FICP, FRSSDI, PDCR, ACCR, Senior Consultant Physician & Diabetologist, Life Care Hospital and Research Centre, Sahakaranagara, Bangalore. Former consultant at Fortis hospitals, Gleneagles Global & Apollo hospitals.

Diabetic Foot Ulcer
Shocking facts
- 75% of amputations are preventable.
- The estimated annual cost to treat diabetes related chronic complications such as DPN is $58 Billion (US).
- DPN is the most common type of neuropathy.
- It is estimated that someone loses a leg every 18 minutes as an ultimate
complication from neuropathy. - Average cost for a below-knee amputation (BKA) is $45,000. There are 80,000 BKA performed/year.
- Usually, the opposite limb develops an ulcer within 18 months 58% go on to have a BKA of the residual limb within 3-5 years.
Why Diabetic foot to be treated?
- 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.
- The Diabetic Foot may be defined as a syndrome in which neuropathy, angiopathy, and infection will lead to tissue breakdown resulting in morbidity and possible amputation (WHO 1995).
- Any foot pathology that results from diabetes or its long – term results (Boulton 2002).
- It’s unwise to consider that major diabetic foot problem occurs all of sudden.
Know 3-pointed Agenda
- Predisposing factors (Neuro- and angiopathy)
- Precipitating factors (Trauma and tinea)
- Perpetuating factors (Pt’s factors & delay healing
CPR of Diabetic Foot

Why We Need to Treat This?
Peripheral neuropathies are reported to be the most common complication of diabetes mellitus (DM).
Statistics of DPN:
- Half of all limb amputations are caused by diabetes.
- Risk of limb amputations is increased 40 times in diabetes.
- 70% of people die five years following an amputation.
- All amputations begin with an ulcer.
- 49-85% of amputations can be prevented.
Anything and everything need to be done to combat this progressive nerve disorder
Neuropathic pain of PDN (Painful diabetic neuropathy) negatively affects quality of life
- Pain may significantly interfere with a patient’s ability to exercise or walk. Walking has been shown to improve HbA 1C in patients with diabetes regardless of change in body mass.
- Pain often intensifies at night and may significantly interfere with sleep. Sleep debt has been shown to have a negative impact on metabolic and endocrine control.
- Pain is significantly correlated with depression in diabetic patients.
PDN is a complication of diabetes that often is undertreated.
- 83% of people with diabetic neuropathy report experiencing pain, but HCPs estimate that fewer than half (41%) of their diabetic neuropathy patients experience pain.
- Fewer than half of those with PDN say they speak about it with their HCP.
- More than half of patients (56%) report that PDN symptoms can be difficult to describe.
High risk for diabetic foot
- Long duration and uncontrolled Diabetes Plus
- One or more:
• Peripheral neuropathy
• Peripheral vascular disease
• Trauma
• Previous ulcers
• Diabetic nephropathy or retinopathy
• Obesity
• Lack of education
• Male gender
Other risks for ulcer/amputation
- Failure to adequately care for the feet:
• Inadequate patient education
• Inadequate patient motivation
• Depression, anxiety, anger more common in diabetes
• Physical disability
• Cannot see feet 2° to retinopathy
• Cannot reach feet 2° to obesity, age (50% of patients)
• Limited access to podiatry services
Precipitate 85% of amputations: “Rule of 15”

Tragic: “Rule of 50”

- Autonomic Neuropathy
- Regulates sweating and perfusion to the limb
- Loss of autonomic control inhibits thermoregulatory function and sweating
- Result is dry, scaly and stiff skin that is prone to cracking and allows a portal of entry for bacteria
- Motor Neuropathy
- Mostly affects forefoot ulceration
- Intrinsic muscle wasting – claw toes
- Equinous contracture
- Sensory Neuropathy
- Loss of protective sensation
- Starts distally and migrates proximally in “stocking” distribution
- Large fibre loss – light touch and proprioception
- Small fibre loss – pain and temperature
- Usually a combination of the two
- Two mechanisms of Ulceration
- Unacceptable stress few times
- Rock in shoe, glass, burn
- Acceptable or moderate stress repeatedly
- Improper shoe ware
- Deformity

Detecting Feet-at-Risk
- History:
• Prior amputation
• Prior foot ulcer
• PAD: known or claudication at < 1 block - Exam:
• Insensitive to 5.07/10g monofilament
• Major foot deformities
• PAD
• Absent DP and PT pulses
• Prolonged venous filling time
• Reduced Ankle-Brachial Index (ABI)
• pre-ulcerative cutaneous pathology
Patient Evaluation
Medical
- Optimized glucose control
- Decreases by 50% chance of foot problems
Vascular
- Assessment of peripheral pulses of paramount importance
- If any concern, vascular assessment
- Sclerotic vessels
- Toe pressures (n>40-50mmHg)
- pO 2 >30 mmHg
- Expensive but helpful in amputation level
Orthopaedic
- Ulceration
- Deformity and prominences
- X-ray
- Lead pipe arteries
- Bony destruction (Charcot or osteomyelitis)
- Gas, Foreign bodies Contractures
- CT can be helpful in visualizing bony anatomy for abscess, extent of disease.
- MRI has a role instead of nuclear medicine scans in uncertain cases of osteomyelitis.
Ulcer Classification
University of Texas Wound Classification System of Diabetic Foot Ulcers |
Grade I-A: non-infected, non-ischemic superficial ulceration Grade I-B: infected, non-ischemic superficial ulceration Grade I-C: ischemic, non-infected superficial ulceration Grade I-D: ischemic and infected superficial ulceration Grade II-A: non-infected, non-ischemic ulcer that penetrates to capsule or bone Grade II-B: infected, non-ischemic ulcer that penetrates to capsule or bone Grade II-C: ischemic, non-infected ulcer that penetrates to capsule or bone Grade II-D: ischemic and infected ulcer that penetrates to capsule or bone Grade III-A: non-infected, non-ischemic ulcer that penetrates to bone or a deep abscess Grade III-B: infected, non-ischemic ulcer that penetrates to bone or a deep abscess Grade III-C: ischemic, non-infected ulcer that penetrates to bone or a deep abscess Grade III-D: ischemic and infected ulcer that penetrates to bone or a deep abscess |

Wagner’s Classification
Grade-0 High risk foot and no ulceration.
Grade-1 Superficial Ulcer
Grade-2 Deep Ulcer (cellulitis)
Grade-3 Osteomyelitis with Ulceration or abscess.
Grade-4 Gangrenous Patches. Partial foot gangrene.
Grade-5 Gangrene of entire foot

Patient education
- Ambulation
- Shoe ware
- Skin and nail care
- Avoiding injury
- Hot water
- F. B’s
Manage Intelligently
Wagner 0: Prevention
1: Antibiotics and good glycaemic control
2: Needs hospital admission, as they need
Total contact cast (Distributes pressure and allows patients to continue ambulation)
Principles of application (Changes, Padding, removal)
Antibiotics if infected:
- Aminoglycosides, Clindamycin, new Penicillin derivatives and Cephalosporins are commonly used.
Wagner 0-2
- Surgical if deformity present that will re-ulcerate
- Correct deformity
- Exostectomy
Wagner 3
- Excision of infected bone
- Wound allowed to granulate
- Grafting (skin or bone) not generally effective
Wagner 4:
- Wide debridement and
- Amputation
Wagner 5:
- Preferred treatment is below knee amputation

Treatment-Bilayered Cellular Matrix (BCM)
- Diabetic neuropathic foot ulcers treated with BCM showed a faster rate of wound healing than those treated with standard care alone (moist saline gauze).
- Is made of human dermal cells cultured in bovine collagen sponge.
- The absorbable matrix is used as a wound dressing.
- The collagen framework provide strength to the skin and contains no cells that can cause rejection or irritation

Basic Foot Care Concepts
Daily foot inspection
- May require mirror, magnification, or caregiver
- Educate patient to recognize/report ASAP:
- Persistent erythema
- Enlarging callus
- Pre-ulcer (callus with haemorrhage)

Commitment to self-care:
- Wash/dry daily
- Avoid hot water; dry thoroughly between toes
- Lubricate daily (not between toes)
- Debride callus/corn to reduce plantar pressure 25%
- Avoid sharp instruments, corn plasters
- No self-cutting of nails if:
- Neuropathy, PAD, poor vision

- Protective behaviours:
- Avoid temperature extremes
- No walking barefoot/stocking-footed
- Appropriate exercise if sensory neuropathy
- Bicycle/swim > walking/treadmill
- Inspect shoes for foreign objects
- Optimal footwear at all times



Quick Take Aways
- Multi-disciplinary approach needed
- Going to be an increasing problem
- High morbidity and cost
- Solution is probably in prevention
- Most feet can be spared, at least for a while

CME INDIA Tail Piece
Diabetic foot pneumonic shared by Dr. A.K. Virmani, Jamshedpur:
IDIOOT
I – Immediate treatment
D- Debridement
I- Ischemia Treatment
O- Off Loading
T- Treat Infection
Dr. A. K. Tiwary, Lucknow
- Add Glycaemic control
Dr. N. K. Singh:
- Then it becomes IDIOT G😊

References:
- Novak P, et al. J Rehabil Med 2004; 36:249–252. 5. Zelman DC, et al. Clin J Pain 2006;22:681–685.
- Boule NG, et al. JAMA 2001;286:1218–1227. 6. Spiegel K, et al. Lancet 1999;354:1435–1339.
- American Diabetes Association. Diabetes Care 2011;34(Suppl1):S11–S61. 7. Åkerstedt T, Nilsson PM. J Intern Med 2003;254
- Spiegel K, et al. Lancet 1999;354:1435–1339.
- Quattrini C, et al. Diabetes Metab Res Rev 2003;19:S2–S8.
- Åkerstedt T, Nilsson PM. J Intern Med 2003;254:6–12.
- Age Ageing 1992; 21:333 Diabetes Care 2003; 29:495 Diab Metab Res Rev 2004; 20(Suppl 1):S13

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