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    Add as FriendThe Diabetic Foot

    by: Natalie

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    1 : Interventional Cardiology “The Diabetic Foot”
    2 : Collection of foot problems, which are not unique to, but occur more commonly in diabetic patients The Diabetic Foot
    3 : Facts Most common cause of hospitalization in DM 2/3rd of non traumatic amputations
    4 : Etiology of the Diabetic Foot Neuropathy Reduced response to infection Ischemia
    5 : Neuropathy Up to 50% of type 2 diabetic patients have significant neuropathy and at-risk feet International Consensus on the Management and the Prevention of the Diabetic Foot (2003)
    6 : Clawing/Retraction of minor digits Atrophy of plantar fatty pad Restricted ROM of joints Muscle wasting Warm feet Changes to joint alignment Skin anhidrosis Neuropathic Foot Changes
    7 : High Index of suspicion Diabetic Hot / red / swelling Trauma - minor / major Pain + / - Architectural Disruption Ulcer + / - Charcot Arthropathy
    8 : Neuropathic Pain Treatments Following are used for management of neuropathic pain: Duloxetine Pregabalin Others that are used for management of neuropathic pain: Amitriptyline Carbamazepine Gabapentin No option exists for restoration of sensory loss Surgical Nerve Release is controversial and evolving
    9 : Diabetic Foot Ulcer Treatments Off-Loading: Objective: Pressure normalization on affected areas Wound Care: Objective: to maintain moist wound bed, absorb exudate, prevent infection Antibiotic Treatment: Objective: to treat polymicrobial infection Vascular interventions: Objective: to restore vascular flow
    10 : Polymicrobial - gram (+) cocci, gram (-) bacilli and anaerobes Redness and swelling may not be present Suspect if deterioration in glycemic control Unusual foot pain with no fracture etc Diabetic Foot Infection
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    12 : Surgical principles Drain pus urgently / immediately Xray foot Assess perfusion Debride necrotic tissue Revascularize early if required MRI useful to assess soft tissues Diabetic Foot Sepsis
    13 : The Diabetic Foot
    14 : Ischemia The concept of small vessel disease is erroneous and has no place in management of diabetic foot Distribution similar to atherosclerosis Foot arteries almost always spared
    15 : Subjective palpation of pulses Objective Doppler pressures (ankle/brachial index) toe pressures Assessment of Foot Perfusion
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    17 : Low readings (ABI <0.5) confirm severe ischemia High readings (ABI >0.5) difficult to interpret if no pulses palpable Doppler Studies
    18 : Toe Pressures
    19 : Better predictors of wound healing Diabetics toe pressure <40mmHg ? skin perfusion pressure healing very unlikely 40 to 60mmHg ? healing likely Toe Pressures
    20 : Endovascular Balloon angioplasty +/- Stent Surgery Bypass Aorto-bifemoral Ileo-femoral Femoro-popliteal Axillo-bifemoral Femoro-femoral Management - Intervention
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    27 : Case Study 64 yrs male DM x 16 yrs HT x 2yrs Heavy smoker Painful non-healing ulcer left foot ABI R 0.7 L 0.43
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    32 : Management Underwent balloon angioplasty and stenting of left common iliac artery
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    34 : Followed by left Femoro-popliteal bypass using reversed GSV Patient did well Management
    35 : Case Study 69 yrs male DM + 12 yrs HT+ / Smoking + Rest pain left forefoot Left popliteal and pedal pulses absent ABI R – 0.93 L – 0.21
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    41 : Management Underwent fem-anterior tibial bypass using reversed GSV Required forefoot amputation
    42 : Vascular reconstruction For salvageable limbs where angioplasty will fail (long occlusions, multiple stenosis) Use autologous vein where possible The long-term results of the Bypass versus Angioplasty in Severe Ischemia of the Leg (BASIL) trial favour surgery rather than angioplasty if there is a good vein and the patient is fit. Some patients with critical lower limb ischemia are best treated by analgesia or primary amputation
    43 : Reconstruction Similar long term outcomes of revascularisation in patients with and without diabetes Karacagil S et al. Diabet Med 1995; 12: 537-541
    44 : Amputation Can be a very positive end point after months of hospitalization and chronic ill health. Do not try to salvage unsalvageable limbs. Level of amputation depends on degree of tissue disease, level of arterial occlusion, and expected postoperative mobility (general health and motivation). Discuss the possibility of amputation as early as possible.
    45 : Treatment of the Diabetic Foot Multi-disciplinary 1st line of defense: Podiatry Infectious Disease Percutaneous Intervention Vascular Surgery Orthopedic Surgery

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