1. Diabetic Foot: A Surgical Look Mohammed Al-Omran, MD, MSc, FRCSC Assistant Professor & Consultant Vascular Surgery King Saud University

2. Part I Diabetic Foot: The Basics What is a diabetic foot? What is the burden of diabetic foot? What is the etiology of diabetic foot? How does these patient present? How to evaluate and mange patients with diabetic foot?

3. Part II Diabetic Foot: The Role of Vascular Surgeons When to refer? What can we offer the patients with diabetic foot?

4. Diabetic Foot: The Basics

5. What is a diabetic foot? 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.

6. What is the burden of diabetic foot? International Diabetes Federation has chosen to focus on the global burden of diabetic foot disease in 2005 lifetime risk of a person with diabetes developing a foot ulcer could be as high as 25% resulting in more hospital stay days than all other diabetic complications combined Singh et al,. JAMA 2005; 293: 217–28.

7. What is the burden of diabetic foot? Foot ulcers cause Substantial morbidity Impair quality of life Engender high treatment costs ( US$ 17 500–27 987, UK£ 9533–15 246) Most important risk factor for lower-extremity amputation Every 30 seconds a lower limb is lost somewhere in the world as a consequence of diabetes Singh et al,. JAMA 2005; 293: 217–28.

8. What is the burden of diabetic foot? In the United States The cause of 50% of all the nontraumatic amputations 50,000 amputations / year 3 year mortality is 50%.

9. What is the burden of diabetic foot? In Saudi Arabia ??? DM prevalence 23.7% (in 30-70 yrs old) ?? 3% to 6% Diabetic foot prevalence AlNozha et al, Saudi med J 2004; 25: 1603-10.

10. What is the burden of diabetic foot? PAD is 4-6 folds more prevalent in diabetic between 45-75 years than non- diabetic

11. What is the etiology of diabetic foot? Multifactorial Neuropathy Ischemia Infection

12. Neuropathy affects more than 50% of diabetics Sensory loss Motor loss Autonomic neuropathy

13. Ischemia (PAD) More than 50% diabetics get significant atherosclerotic disease “Large vessel PAD” – often with tibial involvement with relative sparing of proximal and pedal vessels “Microcirculatory” disease – intimal and basement membrane thickening

14. Combination of PAD & Neuropathy

15.  Risk of injury Invasive soft tissue infection Osteomylitis Chronic ulceration Gangrene

16. Clinical presentation Evidence of PAD Intermittent Claudication Critical limb Ischemia / Ulcers Evidence of Neuropathy Deformities Ulcers Infection Cellulitis Invasive soft tissue infection Osteomylitis

17. How do patients with PAD present?

18. How do patients with neuropathy present?

19. How do patients with infection present?

20. Evaluation & Management Multi-displinary Approach –Diabetologists –Primary Care Physicians –Specialized Nurses –Social Workers –Diabetes Educators –Foot Care Specialists –Physiotherapists/ Occupational therapists –Radiologists –Vascular Surgeons

21. Evaluation & Management Clinical Assessment –History –Physical Examination

22. Evaluation & Management Investigation –Plain films / Nuclear Medicine –Non-invasive (Duplex / Digital pressures/ ABI, CTA, MRA) –Invasive test (Arteriography)

23. Investigations

25. Ankle Brachial Index ABI= Ankle SBP(PT or DP)/ Highest Arm SBP

26. Ankle Brachial Index ABI valueIndicates <0.9Abnormal 0.8- 0.9Mild PAD 0.5- 0.8Moderate PAD <0.5Severe PAD <0.25Very Severe PAD The ABI has limited use in evaluating calcified vessels that are not compressible as in Diabetics

27. Investigations Toe pressure Segmental pressure

28. Arterial duplex

29. Investigations

31. Evaluation & Management Goals of treating patients with Diabetic Foot Relief symptoms Improve quality of life Limb salvage Prolong survival

32. Evaluation & Management Treatment Preventive Measures Patient Education Local- footwear, cotton socks, nail care can reduce amputation rate by 40 to 80% Systemic- Risk factors modification

33. Patient Education Importance of risk factors control Avoidance of trauma and minor cuts Proper foot care Medical visit with early signs of infection or ulcer development

34. Local Foot Care

35. Risk Factors Modification AHA 2005 ACC 2003 Tobacco cessation. Physical Activity. Dietary modification. Weight reduction. BP control.  total chol & LDL. Anti-PLT therapy. ACE inhibitors. Glycemic control

36. Evaluation & Management Treatment Specific Measures –Eradication of infection- debride, drain, local amputation, metatarsal head reduction, Antimicrobial therapy –Revascularization- where possible –Major amputation – where all else fails or no alternative

37. Diabetic Foot: The Role of Vascular Surgeons

38. When to Seek Vascular Surgery Consultation? Evidence of PAD - Intermittent Claudication - Critical Limb Ischemia Rest Pain Impeding soft tissue compromise Tissue Loss Frank ulceration or gangrene.

39. Evaluation & Management Questions –Is there associated deeper infection? –Is this related to ischemia? –Will this heal?

41. What can we offer the patients with diabetic foot? Specific Measures –Eradication of infection- debride, drain, local amputation, metatarsal head reduction, Antimicrobial therapy –Revascularization- where possible –Major amputation – where all else fails or no alternative

42. Eradication of Infection DebridmentDebridment DrainageDrainage Minor amputationsMinor amputations Strategies in treating patients with diabetic foot

43. Improve Lower Limb Circulation Conservative (Exercise Program)Conservative (Exercise Program) Intervention ( Revascularization)Intervention ( Revascularization) - Angioplasty +/- Stenting - Angioplasty +/- Stenting - Surgical Bypass - Surgical Bypass Strategies in treating patients with diabetic foot

44. Percutanous Transluminal Angioplpasty PTA

45. Surgical Bypass

46. Major amputation Primary vs SecondaryPrimary vs Secondary BKA vs AKABKA vs AKA Strategies in treating patients with diabetic foot

47. Take home message Diabetic Foot is a major and an increasing public-health problem Etiology is Multifactorial Multi-displinary approach is the key for better outcomes

48. Thank You Mohammed Al-Omran, MD, MSc, FRCSC Assistant Professor & Consultant Vascular Surgery King Saud University