Chapter 113 - Diabetic foot ulcers Flashcards
Risk of diabetic foot ulcer resulting in amputation
85%
Mortality annually of a diabetic foot ulcer
10% 20% if amputated
Diabetic foot ulcer major amputation 5 year mortality
70%
Major amputation in contralateral limb in 3 years in diabetic
40%
Multifactorial etiology of diabetic foot pathology
1) vascular insufficiency: tibial disease, medial calcinosis 2) infection risk 3) neuropathy: decubitus, autonomic issues, sensory and motor
Diabetic neuropathy risk of foot ulceration increase
7x
Autonomic dysfunction causing diabetic foot ulcer
1) sympathetic nerve dysfunction = reduce sweating –> dry fragile skin 2) arterial-venous shunt and impaired microvascular regulation of skin
How often does contribution of arterial disease in DFU
50%
Diabetic endothelium
Elevated serologic concentration of adhesion molecules WBC and platelets clog up endothelium diminishing ability of antibiotics and other healing factors to get in
Classification system of diabetic foot infection by international working group on DFI PEDIS definition
TABLE 113.1 PEDIS = perfusion extent depth infection sensation
Pressure points of a diabetic foot
FIGURE 113.2
4 essential components of a diabetic foot exam
1) Vascular: palpate pulses, look for distal hair growth, cap refill 2) Neurologic: loss of protective sensation, biothesiometry, electronic tuning fork 128 mHz; muscle atrophy 3) Dermatologic: ulcer depth, wound bed, sign of infection, preulcerative lesions 4) Musculoskeletal: Charcot foot, dorsiflexion of ankle and great toe joint
Monofilament used to test diabetic foot sensory function
Semmes-Weinstein 10g more reliable than tuning fork
Charcot foot
1) Collapsed arch 2) Charcot neuropathic osteoarthropathy 3) red hot swollen foot 4) rocker bottom foot
Wagner classification system of DFU
TABLE 113.3
University of Texas method of DFU
TABLE 113.3
Scans to rule out osteomyelitis
XRAY CT MRI SPECT PET BONE SCAN
Benefit of wound debridement
1) remove dead and infected tissue 2) release plt growth factor, inhibit proteinases 3) limit action of bacterial biofilm
Number of debridements of a DFU before attempted closure on average
4
Dressing in between debridements of DFU
1) silver 2) cream 3) vac dressing - speeds closure
Offloading modalities
1) post-op shoes 2) wedge shoes 3) healing sandals 4) braces 5) boots 6) total contact casting
Double plantar rotation flaps limitation
only close < 2 cm central plantar forefoot ulcers
single stage debridement with closure healing rate
97% 54% without complication 88% without recurrence at 2.5 years
Achilles tendon lengthening goal
neutral or 5 degrees of dorsiflexion
Achilles tendon lengthening vs not in diabetic foot ulcer recurrence
2% vs 25% without at 3 years
TBI level that’s predictive of tissue healing
> 0.6
pulse volume recording cut off for healing
> 5 mm
Photoplethysmography above this level for healing
> 50 mmHg
Transcutaneous oxygen tension greater than this for healing
> 40 mmHg
TcPO2 index to heal wound
> 0.6 < 0.4 is non healing
skin perfusion pressure cutoff for healing
> 50 mmHg < 30 mmHg is non healing
Overall noninvasive vascular studies for DFU and cutoff interpretations
TABLE 113.4
Rate of amputation in DFU without a single tibial runoff
62% 1.7% if at least one patent
Pedal loop technique
1) traversing lesions in pedal arch to establish blood in prograde or retrograde manner
Infrapopliteal stenting outcome 1 year
Restenosis 20% primary patency 70%
PREVENT III trial
1) 1404 bypasses 2) 64% diabetic and 75% tissue loss 3) primary patency 61% 4) amputation free survival at 1 year improved
Percentage of diabetics that do not have adequate GSV
30% 50% if redo operation
Perioperative morbidity and incisional complication rate for diabetic getting vein bypass
20% morbidity 10% wound complication
Organization structure of a multidisciplinary team to optimize care of DFU
1) limb preservation program 2) physician team 3) physician champion 4) staff, space 5) imaging ability 6) endo vs open 7) wound care 8) rehab 9) education 10) research 11) marketing 12) financial analyst
