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 Diabetic Foot Problems

Frank W. LoGerfo , M.D., Jennifer Doyle, M.A.

Includes:

  • Pathophysiology of Ischemia, Neuropathy and Infection
  • Antibiotic Treatment
  • Amputation Types
  • Wound Management
  • Foot Care
  • Additional Important/Non-Core Cirriculum Topics:
  • Orthotic Management

I. Anatomy and Pathophysiology

1. To define the normal arterial and venous anatomy of the circulation of the foot.

2. To demonstrate an understanding of the etiology of three pathogenic mechanisms underlying problems of the diabetic foot:

a . ischemia.

b . neuropathy

c . infection ( polymicrobial nature)

3. To outline factors that can affect blood glucose levels in the peri - and postoperative period

II. Evaluation and Diagnosis

1. To demonstrate an understanding of the presenting signs and symptoms of three pathogenic mechanisms underlying problems of the diabetic foot:

a . ischemia: microvascular abnormalities, atherosclerosis, pattern of atherosclerosis, tibial vessel disease, mediocalcification .

b . neuropathy: motor, foot deformities, charcot foot, sensory neuropathy, neuroinflammatory response, manifestations of autonomic neuropathy

c . infection: altered clinical picture, metabolic consequences, polymicrobial nature

2. To understand the limitations of various non-invasive tests in the diagnosis of ischemia, the effect of calcified vessels, the role PVR, toe pressures

3. To understand the role of angiography

a . susceptibility to contrast induced ARF

b . role and techniques of hydration

c . need for visualization of foot arteries

4. To evaluate ulcer for ischemia, infection, neuropathy

a . use of sterile probe

b . role of foot films and interpretation, appearance of charcot changes

5. To accurately interpret clinical laboratory results, pathology reports, and radiographic studies

6. To synthesize historical findings, physical examination and laboratory data for diagnosis;

7. To identify inflow and outflow vessels on an arteriorgram

8. To assesses patient's ability to maintain level of activity (walk, drive motor vehicle, work, exercise, sexual activity)

III. Treatment

1. To understand priorities of management in diabetic patients with foot problems:

a . timing and methods of debridement in drainage for sepsis

b . metabolic control

c . evaluation of ulcer, depth, sepsis, involvement of bone, tendon

d . options for conservative management, role of foot gear, weight bearing

e . when to evaluate for ischemia

f . options in the management of the non-ischemic, purely neuropathic ulcer

2. To understand the role of distal bypass

a . role of dorsalis pedis bypass

b . alternative inflow sights

c . outcome as a function of inflow and outflow site

3. To understand the principles and techniques of wound care, dressing changes, debridement

4. To understand the timing and methods of soft tissue closure

5. To understand the long term importance of glycemic control, weight

6. To recognize the need for careful follow-up and patient education for diabetic patients with foot problems

7. To specify proper dressings and foot care for prevention of problems in diabetic patients, e.g., the role of orthotics , foot gear, nail care

8. To categorize the prevention and management of operative and postoperativecomplications , including graft infections, graft thrombosis and extremity ischemia

9. To develop familiarity with all techniques of arterial reconstruction including dorsalis pedis bypass and describe the specific role these operations have in management of the diabetic foot

10. To outline the indications for and illustrate the techniques of distal reconstruction, major and minor amputations

11. To outline indications for, and illustrate techniques of:

- debridement and drainage;

- arterial reconstruction;

- vascular bypass grafting;

- amputation

12. To maintain appropriate control of diabetes peri -operatively, in:

- NIDDM patient

- IDDM patient

13. To present an appropriate management plan for the severely septic foot

14. To describe the general outcomes of the diabetes control and complications trial (DCCT) for the purpose of counseling patients

15. To develop appropriate plans for management

16. To manage postoperative surgery and anesthesia complications

17. To delineate and select appropriate postoperative care of patients with diabetes

18. To communicate to patients instructions and expectations for follow-up, such as:

- pain level and location

- possible side-effects of medications

- level of activity and return to work

- wound care and potential problems

- timing of follow-up appointment

19. To arrange for home health and other outpatient services using institutional and community resources

20. To understand the role of the surgeon in taking the lead in management of the diabetic foot problem

21. To understand that care of the diabetic foot must necessarily go beyond the vascular reconstruction

22. To appreciate the importance of the team to provide maximum benefit for the patient

23. To demonstrate an understanding of, and sensitivity to, patient socioeconomic concerns regarding such issues as insurance and the ability to pay for physician services, hospitalization, and prescribed medications loss of work time and wages

24. To demonstrate sensitivity and appropriate flexibility regarding patient fears and concerns, including:

a . preoperatively - anxiety about pain

b . postoperatively - ability to care for self, drugs, level of function, prognosis

References

1. Bergman M, Sicard GA [ eds .]. Surgical Management of the Diabetic Patient. New York : Raven Press, 1991.

2. Caputo AN, Cavanough PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and Management of Foot Disease in Patients with Diabetes. NEJM 1994, 331:854 - 860.

3. Cooppan R. General approach to the treatment of diabetes. In: Joslin's Diabetes Mellitus, 13th edition. Lea & Febiger , 1994; pp. 197 - 403.

4. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes mellitus on the development and progression of long term complications in insulin dependent diabetes mellitus. NEJM 1993; 329:977 - 986.

5. Edmonds ME. The Neuropathic Foot in Diabetes. Part I: Blood Flow. Diabetic Medicine 1986; 3:111 - 115.

6. Gibbons GW. Vascular Surgery of the Lower Extremity. In: Frykberg RG, ed . The High Risk Foot in Diabetes Mellitus. New York : Churchill Livingstone, 1991, pp. 273 - 296.

7. Levy LA. Epidemiology and Prevention of Diabetic Foot Disease. In: Frykberg RG, ed.: The High Risk Foot in Diabetes Mellitus. New York : Churchill Livingstone, 1991., pp.. 23 - 30.

8. LoGerfo , Frank W. The Diabetic Foot. In: Richard H. Dean, James S.T. Yao and David C. Brewster, eds., Current Diagnosis & Treatment in Vascular Surgery. Norwalk , Connecticut : Appleton & Lange, 1995. Pp. 297 - 302.

9. LoGerfo FW, Coffman JD. Vascular and microvascular disease in the diabetic foot: Implications for foot care. NEJM 1984; 311:1615 - 19.

10. Maser RE, Wolfson SK Jr , Ellis D, Stein EA, Drash AL, Becker DJ, Dorman JS, Orchard TJ. Cardiovascular disease and arterial calcification in insulin - dependent diabetes mellitus: Interrelations and risk factor profiles. Arteriosclerosis and Thrombosis, 1991; 11:958 - 65.

11. Rosenblum BI, Pomposelli FB Jr , Giurini JM, Gibbons GW, Freeman DV, Chrzan JS, Campbell DR, Habershaw GM, LoGerfo FW. Maximizing foot salvage by a combined approach to foot ischemia and neuropathic ulceration in patients with diabetes mellitus: A five year experience. Diabetes Care 1994:17:983 - 7.

12. Thorne CJM, Siebert JW, et . al . Reconstructive surgery of the lower extremity. In: McCarthy JG, ed. Plastic Surgery. Philadelphia : WB Saunders 1990: vol.6:4081 - 4088.

13. Tooke JE. Microvascular function in human diabetes, a physiological perspective. Diabetes 1995; 44:721 - 725.

Posted June 2010