Multimodal approach of Foot & Ankle clinic on Diabetic Foot infections
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Multimodal approach of Foot & Ankle clinic on Diabetic Foot infections


Up until the last 5-8 years or so there was a little lack of attention to Diabetic Foot infections.  But, now the  entire scenario has changed dramatically. The diabetic foot care is a teamwork which aims at detecting signs that could bring the diabetic foot at risk of  Ulcerations' The elements that can be quantified are Pressure on feet, the planter blood flow, the sensitivity of feet.The role of this article is to bring to all about the recent update on the topic as the preventing efforts are well known to maintain an intact foot. There is evidence that appropriate footwear reduces planter pressure and can help healing the ulcer. The neuropathies are among the most common long term complications of diabetes mellitus ,affecting up to half of patients.The socio economic burden  the diabetic foot causes on the country’s resources is tremendous.

In India point prevalence of foot ulcers in diabetes in the clinic population is 3%,which is much lower than reported in the western world. Younger age and shorter duration of Diabetes may be possible reason for low prevalence here in our country. Peripheral  vascular disease has been reported to be low among  Asians ranging between 3 and 6 % as against 25 and 45 % in western patients.The prevalence also increases with increased duration of Diabetes ,15% at 10 years and 45% after 20 years. Although population based data are not available ,rough estimates indicate that in India approximately 45,000 legs are amputated every year,and the numbers are increasing each year.

Spectrum of disorders affecting the Diabetic Foot

1  Ischaemia

A Non –specific atherosclerosis.

B Specific diabetes microangiopathy

2 Neuropathy

A Motor

B Sensory

C Autonomic – Sudomotor and Vasomotor

3 Infection-Increased Susceptibility to infection.

Fungal infection of the foot is also more common in diabetes;where this occurs it must be controlled ,as the small epidermal erosions & fissures can provide a portal of entry to more virulent organisms leading to cellulitis and possible gangrene of the toes.

 

Classification of Diabetic Foot Ulcers

Many attempts have been made to classify diabetic foot ulcerations. Probably  the most commonly used system was introduced by Wagner.This system ,which originally addressed only the dysvascular foot,does not adequately address all diabetic foot ulcerations and infections. Most diabetic foot complication occur because of neuropathy not ischemia. Wagner  classification is based on the depth of ulcer.The university of Texas  classification is same as the depth-ischemia  classification with consideration of infection.

Stage A- Ulcer which is niether infected ulcer nor ischemic.

Stage B-  Infected ulcer but not ischemic.

Stage C- Ischemic but not infected.

Stage D-Both Ischemic and infected.

Actually the outcome of Ulcer mainly depend on Ischemia & infection not on Depth.

 

Wegeners Classification:

Grade 0: High risk foot with no ulceration/ Impending Ulcer

Grade 1:superficial Ulcer

Grade 2: Deep ulceration penetrating up to tendon, bone or even  joint.

Grade 3:Osteomyelitis

Grade 4: Localized Gangrene of Toes/Forefoot/Hindfoot.

Grade5: Gangrene of Entire Foot

 

Two types of Diabetic Foot can be seen:

A Neuropathic foot-Here neuropathy dominates which may lead to fissures, bullae, neuropathic/ charcot joint or even simple neuropathic Oedema

B Neuroischaemic foot- Here along with neuropathy, occlusive vascular disease is the main factor.

 

Management:

Multidisciplinary team of Diabetologist, Orthopaedic surgeon ,Podiatrist should be there for managing such cases.  A perfect Medical & surgical approach should be planned.

Infectious Diseases Society of America(IDSA) have proposed Guidelines for the Diagnosis and Treatment of Diabetic Foot infections that clearly define the clinical and Laboratory features that distinguish a mild infection from moderate /severe infection .This is a useful tool for grading foot infections.This classification is specially useful for predicting the organisms one can expect to find in a given situation thus allowing one to start appropriate empirical treatment before culture and sensitivity results are known.

Foot and Ankle Clinics are coming up very fast in our country .These clinics have Diabetic  Foot unit which comprises various subunit to take care of evaluation part.Vascular evaluation can be done by Digital colour Doppler. Neurological evaluation for early neuropathic changes can be done by Biothesiometer .It helps us to quantitate the vibration perception threshold and at same time can monitor the progressing neurological changes.Further for detecting changes in sensation of Heat,cold & Pain stimulus HCP sensitometer is used. Pressure point evaluation by Foot Scan can be done.Later according to the pressure points Off Loading Orthosis can be planned. Off LoadingDiabetic shoes are useful in treatment of Ulcerative or preulcerative conditions of Foot.It is good option when total contact casting isnot an option. These shoes have Tri-laminate IMPAX grid insole which is designed to redistribute load away from Ulcers.

 

 

 

  A.  Non Healing Diabetic ulcer

 

B.  Same patient with Calcification of Anterior & Posterior Tibial  Artery( Severe Peripheral Disease is the reason for nonhealing

 

Role of Pseudomonas aeruginosa and MRSA : In one of the largest studies of moderate  -to severe diabetic foot infections, the study of Infections in Diabetic Feet comparing Efficacy ,Safety,and Tolerability of Ertapenem versus Piperacillin/Tazobactum (SIDESTEP study) ,Lipsy and Colleagues recruited 576 patients to a randomized ,double-blinded,multicenter trial.289 patients were assigned to receive 1gm ofErtapenam and 287 patients received 3.375 g four times daily of pipercillin/tazobactum. The clinical success rate after the end of therapy were 94.2% in the Ertapenam group  and 92.2% for the piperacillin/tazobactum group.Based on this trial ,Ertapenem received an FDA indicationfor treatment of Diabetic foot infections.

Inadequately diagnosed or treated osteomyrlitis increases the risk for amputation.Thorough preoperative examination is necessary to maximize treatment outcome. Optimal medical  control of diabetes and associated comorbities is essential before foot& ankle surgery is undertaken.The treatment of diabetic patients who have large ulcers and underlyingosteomyelitis is not enough well described in the current Litrature.However currently there are only few reports describing salvage of diabetic foot with external fixationin the literature.  Surgeons  world wide have been using external fixators for all type of fracture management,arthrodesis,compex deformities. In addition,procedures such as repeated debridements,,skingrafting, dressing changes can be performed without disturbing the fixator. However the surgical technique differs in terms of anatomical location of the ulcer, soft tissue defect and osteomyetis for example a multiplaner  illizarov /JESS external fixation can decrease the soft tissue defect in equines posion of the ankle.Fixator is usually removed after between 6-8 weeks.Patients subsequently ambulate in a polypropylene splint with plastizote and foam filler in the region of heel defect.

 Diabetic Foot unit can handle clinical orthopaedic probles as Infetions, ulcerations, Charcot’s joint and worst to worst amputation if mandatory.Three factors must be considered while managing such neuropathic ulcers which are –How deep is the Ulcers? Is it ischemic.?  Is it infected? The most common operative procedure for neuropathic deformity is removal of bony prominence (Ostectomy)on the medial,lateral or planter aspect of the footthat is creating recurrent ulcerations and difficulty with Footwear. Management of the diabetic wound has impoved dramatically in the last decade .With the advent and clinical application of recombinant chemical and cellular  mediators of wound healing  most foot wounds can be healed with little morbidity.Newer dressings materials for particular type of wounds are required such as hydrogels,hydrocolloids,aliginate.

Newer therapies provide various growth factors topically,to promote and hasten wound healing.. Newer dressings materials for particular type of wounds are required such as hydrogels,hydrocolloids,aliginate.Often ,the primary impediments to healing include inadequate blood flow to the wound and impediments to healing include inadequate blood flow to the wound (as in above mentioned  radiograph) and an alteration in the local biologic milieu.For these patients ,advanced wound healing technologies, orthobiologics and bioengineered alternative tissues(BAT) may tilt the scales in the direction of definitive wound closure. BAT and topically applied platelet preparations are two of the newer technologies available.Both act to stimulate the conversion of a chronic wound to an acute wound and are used in the treatment of many problematic wound  types and locations.BAT products rely on an environment that has an adequate blood supply,therefore ,vascular studies examining the level of ischemia to the affected limb should always be considered when treating a chronic wound and applying BAT products.Optimization of the wound environment before the application of the BAT products will ensure a successful wound closure. The growth factors are most commonly involved in wound healing, angiogenesis. Inflammatory cells and cells that make up the skin contain these growth factors as  platelet-derived growth factor(PDGF),fibroblast growth actor(FGF),epidermal growth factor(EGF) and insulin like growth factor(IGF). Living cell-based BAT products generally stimulate wound healing process or can deliver growth factors extrinsically when applied to the wound. Some BAT contains contain living fibroblasts and keratinocytes in addition to growth factors. When selecting a particular BAT product,it is important to keep in mind the different layers of tissue and their architecture. 

 

Summary

Diabetic Foot should be managed using a multidisciplinary team approach which should comprises Diabetologist,Orthopaedic Surgeon,Podiatrist,Orthotist.Some time even help of Vascular surgeon is taken.The motto of the team is to save the Foot ,not to amputate it. A number of surgical techniques can maximize the success of wound healing. There is an urgent need to develop Diabetic foot care team working in Diabetic Foot clinics where an integrated approach in managing varied clinical presentations of diabetic foot should be made. A well organized Diabetic Foot clinic should provide consistent patient education as well as preventive and acute care of Diabetic Foot  lesions

 

References

1 Stokes IAF ,Faris IB Hutton WC: The neuropathic ulcer and the loads on the foot in diabetic patients.Acta orthop scand 46: 839-847,1975.

2 valente LA,Nelson MS: patient Education for diabetic Patients.An integral part of quality health care.J Am Podiatr Med Assoc 85:177,1975

3  Pendsey SP ,Epidemiological aspects of diabetic foot .Int j Diab. Dev Counteries  1994;14:37-8

4 International consensus on the Diabetic Foot,by international working on the Diabetic Foot,1999.

5 Mohan V, Premlatha G.Sastry N G .Peripheral vascular disease in Noninsulin dependent diabetes mellitus  in south India.Diab Res Clin Pract 1995 ;27:235-40.

6 Pensey Sharad .Diabetic Foot . A clinical atlas. Jaypee Brothers,N Delhi;2003

7 Wagner FW. The dysvascular foot: a system for diagnosis and treatment.foot Ankle 1981;2(2):64-122

8 Michael E,Edmonds,Alethea VM Foster(Eds).Managing the Diabetic Foot.Blackwell Science:2000;123-5

9 Lipsy BA,Armstrong DG ,Citron DM ,etal. Ertapenem versus Piperacillin/Tazobactum (SIDESTEP ).Lancet 2005;366(9498):1695-703.

10 Attinger CE ,Bulan EJ,Debridement:the Key initial step in wound healing.Foot Ankle Clinic 2001;6:627-60

11 Brem H ,Sheehan P,Boulton AJM,Protocal for treatment of diabetic foot ulcers.AM J Surg 2004;187(suppl):IS-10S

 

Corresponding Author

Dr.Manish Khanna (M.S.)

 Apley Clinic Orthopaedic Centre

1/9,Vastu Khand,Gomti Nagar,Lucknow-226010

Phone-9415167349 Email- manishvenus@rediffmail.com