Management

Aim

 

Stable, shoe-able plantigrade foot

 

Multidisciplinary approach

 

Multidisciplinary foot clinics (MDFC) 1st established UK 1980s

- shown to significantly reduce rate of diabetic amputations

- involve:

 

Endocrinologist +/- diabetic nurse

- glycaemic control crucial

 

Podiatrist

- non-surgical debridement

- orthoses

  

Orthotist / Plaster tech

 

Vascular surgeon

- referral if absent or asymmetrical pulses

 

Orthopaedic surgeon

- TCC

- foot reconstruction; amputations

 

Infectious Disease Consultant

- infected / nonhealing ulcers

 

Diabetic Foot Care

 

Foot Hygiene

- daily wash with mild soap & warm water

- powder between toes & moisturiser to ankle

- plain cotton socks inside out (2 socks ↓shear)

- minimum tds inspection

- report immediately all blisters / ulcers & unilateral warmth / swelling (Charcot’s fractures)

- no walking barefoot

 

Shoes / Orthoses

- custom made orthoses and shoes reduce DFU recurrence 1

- shoes should be

wide/ deep/ round toe box

soft leather (hard materials irritate)

adjustable

no/low heel

 

Issues

 

Infections

Ulcers

Charcot

Fractures

 

1.  Diabetic Foot Infections

(Therapeutic Guidelines; Version 15; 2015)

 

A.  Mild Cellulitis (+/- Ulcer)

 

Combination oral Abx

- Augmentin Duo Forte

OR Cephalexin PLUS Metronidazole 

OR Ciprofloxacin PLUS Clindamycin (Penicillin Allergy)

- offload ulcer (crutches, custom orthotics )

 

B.  Severe Cellulitis (+/- Ulcer)

 

IV Abs (Timentin or Pip-Taz; IV Cipro + Clind for Penicillin Allergy)

- Offload Ulcer

 

C.  Ulcer with Osteomyelitis

 

Diagnosis

- probe-to-bone test (Positive predictive value .57; Negative Predictive Value .98) 2

- plain films (low sensitivity; particularly early stage)

- MRI (high sensitivity and specificity; with plain films Ix of choice)

- Tc Bone Scan + Labelled WCC (if MRI contraindicated)

 

Management OM

- consider debridement & intra-operative deep MCS (more accurate)

 

Antibiotics

- broad spectrum initially / timentin or pip-taz

- adjust 2° to MCS

- ID consult

 

Diabetic Calcaneal Abscess

 

 

Diabetic Heel Abscess XrayDiabetic Heel Abscess MRIDiabetic Heel Abscess MRI 2

 

2. Neuropathic Ulcers

 

Diabetic Ulcer

 

 

Classification

 

1)Wagner Classification3

 

Most used classification for DFU in ortho literature

 

Grade 0      

 

Pressure area           

- Footwear Modification

 

Grade I      

 

Superficial Ulceration           

- local treatment, footwear modification

 

Grade II    

 

Deep Ulceration (probes to tendon / capsule)          

- TCC, footwear modification

 

Grade III   

 

Deep ulceration + secondary infection           

- debridement, antibiotics

 

Grade IV   

 

Partial foot gangrene

- Abx, amputation, hyperbaric O2

 

Stage V    

 

Whole foot Gangrene

- regional amputation, Abx

 

2) University of Texas4

 

Each wound has a grade and stage

- increasing stage, across all grades, more predictive of amputation & prolonged healing time

- UT better prognosticator than Wagner

 

Grade 1 Preulcerative

Grade 2 Superficial Wound

Grade 3 Deep wound penetrating to capsule or tendon

Grade 4 Deep penetrating to bone or joint

 

Stages A Clean

Stages B Nonischaemic Infected

Stages C Ischaemic Noninfected

Stages D Ischaemic Infected

 

Management

 

Nonoperative

 

1) Off-load 

TCC remains the gold standard

- other options: removable cast walkers; modified footwear

 

2) Increase healing rates

Hyperbaric O2 - short-term reduction ulcer size

Negative Pressure Wound Therapy (NPWT)

Biologic Therapy eg amniotic membrane (experimental)

 

Operative

1) Tendoachilles lengthening (TAL)

Aim to reduce forefoot pressures

 

Colen et al Plast Reconstr Surg 2013

- level 3 retrospective cohort

- 25% of patients with DFU & no TAL Vs 2% of DFU with TAL had recurrent ulcer

 

2) Gastrocnemius Recession

3) Toe Flexor Tenotomy

 

3.  Charcot Foot

 

See Charcot Foot

 

4.  Fractures in Neuropathic / Diabetic Feet

 

Principles

 

1.  Augment ankle ORIF

2.  Double time for sutures

3.  Double immobilisation period

- 12 weeks NWB

- 4-5 months in walking cast

4.  Brace for 1 year after surgery

- to prevent late Charcot arthropathy

- assume Charcot joint will develop

 

References 

1- http://www.ncbi.nlm.nih.gov/pubmed/22336901

2- http://www.ncbi.nlm.nih.gov/pubmed/17259493

3-  http://www.ncbi.nlm.nih.gov/pubmed/7319435

4- http://www.ncbi.nlm.nih.gov/pubmed/8986890