1. Diabetic Foot Ulcers Sonja Lichtenstein, MD, FACS, UHM Zone Medical Director, National Healing Corporation

2. Objectives Review the risk factors for development of diabetic foot ulcers Methods to use to help prevent diabetic foot ulcers Basic management of diabetic foot ulcers

3. Diabetes epidemic Incidence of diabetes in the world in 2000 was 171,000,000 Projected incidence in 2030 is 366,000,000 In 2010, 12.3% of adults in the United States had diabetes

4. Incidence by Country

5. Society in Transition

6. Cost in Developed Countries 25% of diabetic patients develop a foot problem in their lifetime 2008: estimated 20.8 million with DM in USA Total of $19bn spent on diabetic foot ulcers $11bn spent on amputation Up to $21bn could be saved annually with practical and effective preventative foot-care education Rogers et al, JAPMA, 2008;98:166 Rogers et al, JAPMA, 2008;98:166

7. Cost in Undeveloped Countries 2010: estimated 51 million with DM in India Population-based study from Chennai Cost of illness study: 4677 subjects screened: 1050 with DM, 718 agreed to take part Median direct cost for DM $526, indirect $103 Costs increased according to complications Extrapolated to all India – annual cost of Diabetes in India – US$32bn. Tharkar et al, DRCP 2010;89:334 Tharkar et al, DRCP 2010;89:334

8. Who is at Risk for Ulceration? Neuropathy Peripheral Vascular Disease Past history of foot ulceration Foot deformity AmputationSmoking Poor glycemic control Callouses

9. Diabetic Foot Ulcers 63% of all diabetic ulcers are due to a combination of: NeuropathyTraumaDeformity Many are further complicated by Peripheral Arterial Disease (PAD) and infectin

10. How do we screen patients? Comprehensive foot exam HgA1C History reviewing risk factor

11. Neuropathy Incorporates metabolic and vascular defects Results in neuronal demyelination and atrophy Motor – muscle atrophy Autonomic – decrease in perspiration Sensory – loss of protective sensation

12. Trauma Resulting from Neuropathic Changes Motor neuropathy Altered gait and foot deformities Autonomic neuropathy Dry skin and fissures Sensory neuropathy Unrecognized trauma Ill fitting shoes Stepping on pins, pebbles, etc

13. Deformity Resulting from Neuropathic Changes Includes:BunionsHammer-toes Prominent metatarsal heads Charcot joint

14. Deformity Resulting from Neuropathic Changes Cause high compressive & frictional forces around area of deformity = skin breakdown Directly related to ill fitting footwear

15. Prevention in Patients with Neuropathy Need to screen patient for neuropathy Test with Semmes-Weinstein Monofilament Uses touch pressure sensation by utilizing a 10 gram monofilament Defines level of loss-of-protective sensation Failed monofilament test defined as inability to sense 4 of 10 locations per plantar aspect of the foot

16. Peripheral Arterial Disease Diabetes Mellitus increases the risk of lower extremity PADDiabetes Mellitus increases the risk of lower extremity PAD PAD leads to additional healing complications and increased risk for infectionPAD leads to additional healing complications and increased risk for infection One in three patients with diabetes over the age of 50 has PADOne in three patients with diabetes over the age of 50 has PAD The American Diabetes Association recommends screening for PAD in all diabetic patients older than 50 yearsThe American Diabetes Association recommends screening for PAD in all diabetic patients older than 50 years

17. Screening for PAD Feeling for pulses at all levels in the lower extremity ADA/ACC recommend that all those patients >50 years old should have an annual ABI Ankle-brachial index Less than 0.80: abnormal Less than 0.45: severe, limb-threatening Absolute toe systolic pressure - less than 45 mmHg is abnormal

18. Handheld Doppler Every patient with a lower extremity ulcer receives Hand Held Doppler assessments Assesses macro- circulation Used to auscultate flow velocity T.K. Carlson

19. Structural Deformity Leads for focal area of high pressure Due to atrophy of the intrinsic musculature responsible for stabilizing the toes

20. Other Factors Glycemic control Obesity Impaired vision SmokingCallous

21. Physician Responsibilities Inspect patient’s shoes for areas of inadequate support or improper Most patients are okay with athletic shoes and thick absorbent socks Patients with deformities or special support needs benefit from custom shoes Provide education about proper care and follow up Control blood sugars

22. Patient Education Daily foot inspection by the patient or caregiver Gentle cleansing with soap and water, followed by topical moisturizers Minor foot injuries and infections can be unintentionally exacerbated by home remedies that impede healing Avoid hot soaks, heating pads, hydrogen peroxide, betadine Cleanse minor wound and apply topical antibiotic to maintain a moist wound environment

23. Development of Ulcers Typically painless, even with severe infection Often just report soiled socks

24. A diabetic foot ulcer should heal if: There is adequate arterial inflow Any infection is appropriately managed Pressure is removed from the wound and its margins

25. Diabetic Lower Extremity Ulcers Cascade of Events: NeuropathyNeuropathy Ischemic changesIschemic changes InjuryInjury Massive tissue disruptionMassive tissue disruption (tunneling, undermining, cavity formation) Cellular dysfunction leukocytes / macrophagesCellular dysfunction leukocytes / macrophages InfectionInfection

26. How Should Diabetic Foot Ulcers Be Treated? Multidisciplinary Approach to Treatment May involve a number of the following: Podiatry Vascular surgery Dieticians Infectious disease Endocrinology Diabetes Educators Radiology Physical Therapy OrthotistNursing

27. Care Plan Objectives Determine and Manage Etiologies Comprehensive History and Physical Assessment Non-invasive studies Management of etiologies Laboratory Evaluation Nutrition status Glucose control Co-morbid disease management Ulcer management Off-loading Patient Education

28. Determine and Manage Etiologies History and Physical Patient and their family medical history History of the ulcer Thorough assessment of the patient Lower Extremity Assessment Semmes Weinstein and Tuning Fork - Assesses for neuropathy Hand-held Doppler - Dorsalis pedis and posterior tibial pulse signals Non-invasive studies Vascular studies Radiographic studies

29. Transcutaneous Oximetry (TcPO 2 ) – measures the oxygenation of the tissues around the ulcer Skin Perfusion Pressure (SPP) - measures the pressure at which blood flow first returns to the capillaries following a controlled release of occlusion from a blood pressure cuff. Arterial Duplex Ultrasound - Duplex ultrasonography of the arteries Ankle-Brachial Index (ABI)/Segmental Pressures/Toe Pressures - Assess pressure at multiple levels on the limb or digit Angiography – invasive study providing detailed imaging of the arteries Vascular Studies

30. Radiographic Studies X-ray – should be performed on all diabetic foot ulcerations to rule out foreign body presence MRI – recommended by ADA as best non- invasive diagnostic imaging for osteomyelitis Bone Biopsy - the definitive diagnostic study for osteomyelitis allowing for culture and sensitivity of the specimen

31. Management of Etiologies PAD and Osteomyelitis are two common secondary etiologies affecting healing of the diabetic ulcer Both must be identified and corrected/optimized for successful ulcer healing to occur Other etiologies also need to be identified and corrected/optimized for successful ulcer healing

32. Ulcer Management Diagnose and treat underlying etiologies Adequate debridement Dressing choice based on ulcer needs Treatments that stimulate healing Negative Pressure Wound Therapy (NPWT) Biologic products Bioengineered tissues Growth factors Hyperbaric Oxygen Therapy (HBOT) Offload!!!!

33. Adequate Debridement Serial sharp ulcer bed preparation Removes senescent cells, necrotic tissue, converts a chronic ulcer to an acute wound, re-initiates healing cascade Centers that utilize sharp debridement exhibit the highest degree of healing. T.K. Carlson

34. Approaches to ulcer Care For the Diabetic Patient Simple dressings that meet the needs of the ulcer Antimicrobial therapy – topically and systemically Advanced Treatment Modalities Growth Factors Bio-engineered Tissue Negative Pressure Wound Therapy Hyperbaric Oxygen Therapy Plastic surgery – skin grafts/flaps

35. Advanced dressings can reduce costs up to 50% particularly when you consider the cost of an infection Utilizing the wrong dressing can increase the cost of treating ulcers and cause further complications for the patient Thoroughly assess the “state of the ulcer bed” before prescribing treatment plan/dressings Nothing works well on the DFU without proper offloading Advanced Treatment Modalities

36. Off-Loading: A Standard of Care Proper off-loading: Reduces pressure Reduces shear Reduces shock Transfers weigh from sensitive or painful areas Corrects or supports flexible deformities Accommodates fixed deformities

37. Off-Loading: A Standard of Care Off-loading includes: Rest/elevationFelt/foam Multi- podus splint/boot Removable cast walker/walking boot Total contact casting (TCC) Wedge shoe Surgical shoe with pressure relief insole Other assistive devices used in addition CrutchesWheelchairsWalkers

38. Orthotic For Ulcers That Don’t Heal

39. Orthotics For Ulcers That Do Heal Therapeutic footwear should be placed upon healing Prevents recurrence Accommodates deformities Distributes the pressure equally throughout the foot (The image is a copyrighted product of AAWC (www.aawconline.org) and has been reproduced with permission)

40. Patient Education Must take an active role in their care Ulcer management Routine nail care Disease management Decreases the chance of reoccurrence Foot hygiene Daily inspection Proper footwear Prompt treatment of new lesions Elective surgery to correct structural deformities before ulcerations occur (The image is a copyrighted product of AAWC (www.aawconline.org) and has been reproduced with permission)

41. Summarizing the Information With the increase in diabetes in both the younger and aging population, we are at risk for greater complications Total National Annual Cost: $174 billion dollars.5 Common causes of Diabetic Foot Ulcers include: neuropathy, trauma, deformity, high plantar pressures Common secondary etiologies include: peripheral arterial disease (PAD) and osteomyelitis

42. Summarizing the Information Treatment Objectives of Diabetic foot ulcers Determine and manage the etiologies Establish blood supply Off-loading followed by therapeutic footwear upon healing Patient education Off-loading the pressure at the site of the ulcer is a standard of care

43. Summarizing the Information Treating the diabetic foot often includes: Debridement (clinical and/or surgical) Advanced treatment options HBONPWT Biologic products: Growth factors Bio-engineered tissues Diabetic patients must be active participants in their care to decrease the chance of reoccurrence

44. Thank You For Your Attention Any Questions?