1. THE DIABETIC FOOT DR.SEIF I M ELMAHI MD, FRCSI University of Khartoum, Sudan

2. CONTENT  Definition  Epidemiology  Social & Economic factors  Pathophysiology of foot ulceration  Diabetic Neuropathy  Peripheral Vascular Disease & Diabetes  Biomechanics of Foot Wear  The Diabetic Foot Ulcer Outcome & Management  Neuro-osteoarthropathy  Amputation in Diabetic Patient  Prevention of Foot Problem

3. Diabetic Foot  Definition: Infection, ulceration or destruction of deep tissues associated with neurological abnormalities & various degrees of peripheral vascular diseases in the lower limb Infection, ulceration or destruction of deep tissues associated with neurological abnormalities & various degrees of peripheral vascular diseases in the lower limb ( based on WHO definition) ( based on WHO definition)

4. Epidemiology  40% - 60% of all non traumatic lower limb amputation  85% of diabetic related foot amputation are preceded by foot ulcer  4 out of 5 ulcer in diabetics are precipitated by trauma  4% -10% is the prevalence of foot ulcer in diabetics

5. Epidemiology In Sudan:  Prevalence of DM ? 6 – 12 %  DSF inpatient KTH : 30% - 40% risk of major amputation 30% - 40% risk of major amputation 8% - 20% mortality 8% - 20% mortality

7. Social & Economic Factors  Diabetic foot complications are expensive : ( cost of healing 7000-10000 USD) ( healing with amp. 43000-63000USD) ( healing with amp. 43000-63000USD) In Khartoum : (4 weeks dressing cost 110000SD)  Intervention of foot care is cost effective in most societies  Scarce information regarding long term prognosis

8. Pathophsiology of Foot Ulceration  Neuropathic  Ischemic  Neuro -ischemic

10. STAGES OF ULCER DEVELOPMENT

12. Diabetic Neuropathy  Sensorimotor & peripheral sympathatic neuropathy are major risk factors for ulcer  History & careful foot examination are mandatory to diagnose neuropathy examination  Up to 50%of type2 diabetic patient have significant neuropathy & at risk of foot ulcer

13. Periphral vascular disease& diabetic PVD  PVD is the most important factors related to outcome of diabetic foot ulcer PVD  PVD is diagnosed by simple clinical examination  non invasive vascular test determines probability of healing probability probability  Symptoms of ischemia may be masked by neuropathy  Microangiopathy shouldn't be accepted as primary cause of ulcer  Conservative approach for treatment  Outcome of revascularization is similar to that in non-diabetic revascularization revascularization

14. Biomechanics of foot wear  Biomechanical abnormalities are consequence of neuropathy, they lead to abnormal foot pressure pressure pressure  Foot deformity & neuropathy increase the risk of ulcer ulcer  Pressure relief is essential for ulcer healing and/or prevention Pressure  Frequent inspection of shoes & insoles is mandatory  Appropriate foot wear significantly reduce ulcer recurrence

15. Diabetic Foot Infection  Infection in diabetic foot is limb threatening  Signs of infection may be absent in diabetic pt. with foot ulcer  Superficial infection is usually caused by gram +ve cocci, deep infection is poly microbial  Surgical debridment is essential in acute deep infection  Osteomylitis( diagnoses & treatment) Osteomylitis

16. Neuro-osteoarthropathy  Non- infective pathology  Should be suspected in any swollen hot erythematous foot swollen  Differentiation from infection is important to prevent misdiagnosis & possible amputation  Treatment should aim at preventing severe deformity

17. Diabetic Foot Ulcer Treatment  Multidisciplenary approach approach  Staging dictate the treatment option Staging  Continuity of care & life long observation

18. Amputation in Diabetic Patient  Increased minor\major amputation increased the no. of deformed feet deformed feetdeformed feet  Minor amputation is needed : *Gangrene *Gangrene *As part of debriment *As part of debriment *for correction of foot deformities *for correction of foot deformities  Minor amputation doesn’t significantly compromise walking ability

19. Major Amputation  Risk of loss walking ability  Mortality  Risk of contra-lateral amputation  Strict indication  Careful choice of the level

20. How To Prevent Foot Problems 5 corner stones 5 corner stones  Regular inspection & examination of foot & foot wear  Identification of high risk patient  Education of patient, family & health care providers  Appropriate foot wear  Treatment of non ulcerative pathology

23. SENSORY NEUROPATHY

24. Diabetic Neuropathy Diabetic Neuropathy

27. PERIPHRAL VASCULAR DISEASE

29. Biomechanics of foot wearBiomechanics of foot wearAREAS AT RISK OF ULCERATION Biomechanics of foot wear

30. FOOTFOOT WEAR FOOT

33. FOOT WEAR

35. OSTEOMYLITIS

36. Diabetic Foot Ulcer Treatment Diabetic Foot Ulcer Treatment Modalities Diabetic Foot Ulcer Treatment  Microbiological control  Wound control  Vascular control  Mechanical control  Metabolic control  Educational control

37. Staging of Diabetic Foot Stage Clinical condition Stage Clinical condition 1 Normal 1 Normal 2 High risk 2 High risk 3 Ulcerated 3 Ulcerated 4 cellulitic 4 cellulitic 5 Necrotic 5 Necrotic 6 Major amputation 6 Major amputation

38. AssessmentAssessment of Diabetic Foot Assessment  Neuropathy  Ischemia  Deformity  Callus  Swelling  Skin breakdown  Infection  Necrosis

39. NEURO-OSTEOARTHROPATHY( CHARCOT FOOT)

40. NEURO-OSTEOARTHROPATHY( CHARCOT NEURO-OSTEOARTHROPATHY( CHARCOT FOOT)Neuro-osteoarthropathy Neuro-osteoarthropathy NEURO-OSTEOARTHROPATHY( CHARCOTNeuro-osteoarthropathy

41. PODIATRY