Principles of management of diabetic foot lesions and its Prevention Dr AK Verma Department of Endocrine Surgery Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow

Introduction Foot lesions- 7% of people with Diabetes mellitus Costly to- both patients and state Factors delaying wound healing –Impaired wound healing in DM –Barrier to early referral and assessment Amputations due to Peripheral vascular disease, Neuropathy and severe infection

Introduction Cont. Common in- Older patients and those with longer duration Treatment options-limited, but coordinated care is needed Infection- mostly secondary to ulcer Nature and severity of infection varies Of all amputations – 80% done in diabetics

Predisposing factors Old Age, Atherosclerosis Long standing/ brittle diabetes, poor control Associated disease states and immunosuppressive states Post transplantation Hypoproteinemia and prolonged diseases

Causative factors Foreign bodies Improper nail pairing Nail infections Sensory and motor loss Corns, callosities Foot deformities Trauma, burns Bare foot walking and improper shoe wear

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Clinical presentation Wide clinical spectrum Localised cellulitis Nonhealing ulcer Ulcer with minimal discoloration Gangrene of the toe/toes Gangrene of forefoot/whole foot(dry/wet) Deformities Deformities with ulcerations

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Principles of management-1 A multidisciplany Approach I.Resuscitation first, diagnosis later (biochemistry/haematology/radiology/microbiology) II.General supportive measures -Correction of Anaemia/ hypoproteinemia/renal failure/dehydration -switching over to IV Insulin therapy -high calorie/protein diet -IV broadspectrum poly antimicrobial therapy( covering aerobes and anaerobes) -monitoring of polymicrobial infections by frequent microbial studies

Principles of management-2 III. Local care Guiding principle: Limb saving attitude Assesment of vascularity: Clinical: skin colour, temperature, hairs, nail colour and circulation, pulses. Poor pulse: best assessed by doppler A/B Index: N=0.8, if <0.5 chances of tissue survival is poor

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Principles of management-3 Localisation of abscess Clinical, Ultrasound, CT/ MRI Assessment of neuropathy touch, temperature, position and joint senses (cotton,blunt,pin, biosthesiometer) Look for other diabetic complications renal, opthalmic, cardiac, neurologic etc

Surgical management-1 Guiding principle- Limb saving attitude –Minimum but adequate surgery –Quick/Emergency debridement under whatever anaesthesia possible –All dead and necrotic tissue must be removed –Don’t do primary closure –Frequent daily minor debridements are a must –Limb elevation if edematous

Surgical management-2 Open tendon sheaths liberally Excise tendons if necessary Explore all possible pus pockets Institute double drainage for larger and deeper pus pockets Have lots of patience Frequent OT debridements may be required

Revascularisation procedures Angioplasty Angioplasty with stenting Arterial bypass Insitu Saphenous vein bypass

Role of orthotics Pressure of loading-significance Devices- –Casts –Insoles –Custom made shoes –Artificial limbs

Newer aids for wound healing Platelet derived growth factors( regranex) Granulocyte stimulating factors(cGSF) Electrical stimulation-magnetotherapy etc Plantar pressure measurement and recording systems

Prevention-I An ounce of prevention is better than a pound of cure Foot rehydration especially at night Proper foot wear –Well fitting, pressure offloading,washable,soft, no shoe laces. –No bare foot walking –Socks-cotton, wash daily,wear reversed, change frequently

Prevention-2 Foot care –Examination at bed time: cut, abrasion, foreign body, redness, blister, callosity/corn and local rise of temperature at any point. Must be done by some one with good vision in good light –Pairing of nails –Interdigital web cleaning and examination, use of antiseptic powder

Prevention-3 –Must examine shoe before wearing –Must be treated like a small newborn child –Foot examination should be a part of every clinical visit –Must contact the doctor at the slightest problem

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