Lecture on Diabetic foot problems with overview of problem,evaluation and treatment from an orthopedic surgeon's standpoint

1. The foot in Diabetes M.
“How Sweet it is!!!!”
J. Gleason/Honeymooners
Rev. Steven C. Sheskier,M.D.
Presiding

2. Prevalence of Impaired Fasting Glucose in People
Ages 20 Years or Older, United States, 2007
25.9 percent of U.S. adults ages 20 years or older had IFG
35.4 percent of adults ages 60 years or older.
at least 57 million American adults had pre-diabetes in 2007
IFG prevalence among U.S. adults ages 20 years or older in 2003 to 2006 was
21.1 percent for non-Hispanic blacks, 25.1 percent for non-Hispanic whites
26.1 percent for Mexican Americans.
(After adjusting for population age and sex differences)

3. Prevalence of Diagnosed and Undiagnosed
Diabetes in the United States, All Ages, 2007
Total: 23.6 million people—7.8 percent of the population—have diabetes.
Diagnosed: 17.9 million people
Undiagnosed: 5.7 million people

4. Growing Problem
Estimated Diabetes Costs in the United States in 2007
Total—direct and indirect: $174 billion
Direct medical costs: $116 billion

5. After adjusting for population age and sex
differences, average medical expenditures
among people with diagnosed diabetes were 2.3
times higher than what expenditures would be in
the absence of diabetes

6. Complications of DM
Heart Disease/Stroke
HBP
Blindness
Renal Disease
Nervous System
Amputations

7. Circulatory System
large vessel
> 10% absent pedal pulse
progressive with time
infra-popiteal vessels
small vessel/micro

8. Peripheral arterial disease in diabetic and nondiabetic Patients: A
comparison of severity and outcome:Diabetes care 2001, vol. 24, no8
Diabetic Patients had greater severity of arterial
disease in the profunda femoris and all arterial
segments below the knee (P = 0.02). A greater
number of amputations occurred in the diabetic
group: diabetic patients were five times more likely
to have an amputation (41.4 vs. 11.5%, odds ratio
[OR] 5.4, P < 0.0001). Mortality was higher in DM

9. Nervous System Disease
• About 60 to 70 percent of people with diabetes have mild to
severe forms of nervous system damage. The results of such
damage include impaired sensation or pain in the feet or
hands, slowed digestion of food in the stomach, carpal tunnel
syndrome, erectile dysfunction, or other nerve problems.
• Almost 30 percent of people with diabetes ages 40 years or
older have impaired sensation in the feet—for example, at
least one area that lacks feeling.
• Severe forms of diabetic nerve disease are a major
contributing cause of lower-extremity amputations

10. Neuropathy
Peripheral neuropathy affects
• toes
• feet
• legs
• hands
• arms
Autonomic neuropathy affects
• heart and blood vessels
• digestive system
• urinary tract
• sex organs
• sweat glands
• eyes
• lungs
Proximal neuropathy affects
• thighs
• hips
• buttocks
• legs
Focal neuropathy affects
• eyes
• facial muscles
• ears
• pelvis and lower back
• chest
• abdomen
• thighs
• legs
• feet

11. DIABETES AS A MODEL of
DSPN*
Autonomic nerves
Small fiber
Large fiber
*Distal symetrical polyneuropathy versus OTHER presentations

12. Epidemiology
40-45% diabetics have DSPN1
No difference between Type 1 and 2 DM
Increased with years of disease and glycemic control2
1.Rochester Diabetic Neuropathy Study
2.Pirart,J. Prospective study of 4,400 patients

13. Autonomic Dysfunction
Increased blood flow
??Factor in Charcot???
Dry skin
Fissuring = increased risk of infection

14. Autonomic Neuropathy
• Orthostatic hypotension, leg edema
• Loss of sympathetic tone, arteriovenous shunting
• Distended dorsal foot veins
• Denervation of sweat glands, dry, atrophic skin with
severe cracking

15. Deformity due to:
Muscle imbalance
Claw toes
Tight achilles (increased forefoot pressure)
Charcot Neuroarthropathy

16. Charcot Arthropathy
inciting factors:
- peripheral neuropathy
- unrecognized injury
- continued repetitive stress on injured structures
- increased local blood flow;
- excessive osteoclastic activity w/o a concomitant increase in osteoblastic
function;
- pathoanatomy:
- includes cartilaginous fibrillation and destruction and subchondral/enchondral
bone formation;
- charcot joint can result in fragmentation of periarticular areas & subluxations:
- usually affects midtarsal joints and can lead to prolapse of the arch or valgus
deviation of the forefoot

17. Temporal Stages of Charcot
Arthropathy (Eichenholtz)
Stage I: Acute
Inflammation, redness, swelling, bony fracture
Stage II: Coalescence
Improved joint integrity, consolidation of bone
Stage III: Resolution
Reduced bony fragmentation, joint stability,

18. Charcot (con’t)
- Radiographic Studies:
- early changes:
- may present as a low energy fracture with joint subluxation;
- bone fragmentation may be seen in early stages;
- wt bearing radiographs help accentuate joint subluxation if it present;
- mid stage changes:
- resorption and coalescence of fragments (large fragments may fuse together);
- bone surrounding the joint becomes sclerotic
- absorption of the fine debris occurs
- late changes:
- reconstruction and reconstitution phase;
- osteolysis may be present w/ both Charcot joints and osteomyelitis;
- hypertrophic changes can accompany joint destruction;
- remodeling occurs with reduction of the sclerosis;
- there is rounding of the major fragments;
- there is an attempt at reformation of the joint architecture;

19. Patterns of Charcot*
I. IPJ/MTP and
metatarsals
II.Tarsometatarsal joints
III. Midfoot (Navicular-
cuneiform,TN,CC)
IV. Ankle
V. Calcaneus

20. Other
• People with diabetes are more susceptible to many other
illnesses and, once they acquire these illnesses, often have
worse prognoses. For example, they are more likely to die
with pneumonia or influenza than people who do not have
diabetes.
• People with diabetes ages 60 years or older are two to
three times more likely to report an inability to walk a
quarter of a mile, climb stairs, do housework, or use a
mobility aid compared with people without diabetes in the
same age group

21. Diabetes, Neuropathy, and
Gait
Sensory and proprioceptive loss
Postural instability
Gait abnormalities
Velocity
Stride length
Stride width and double support
Center of pressure (COP) trajectory
Van Deursen, Simoneau, JOSPT, 1999;29:718-726

22. EVALUATION OF FOOT

23. PagePage

24. Inspection
Skin (dry.hair,callosities,ulcers,scars)
Deformities
Fixed vs. Flexible
Shoes

25. Palpation
Pulses
edema
prominences

26. Assess gastrosoleus
complex!!!

27. INTERPRETATION OF THE ABI
ABI
Normal 0.91-1.30
Mild obstruction 0.71-0.90
*Moderate obstruction0.41-0.70
*Severe obstruction  0.40
**Poorly compressible >1.30
2° to medial Ca++
*Poor ulcer healing with ABI  0.50©2006. American College of Physicians. All Rights Reserved.

28. Neurologic Exam
Semmes-Weinstein 5.07 (10 gm.) monofilament
(loss of protective sensation)
Vibratory perception threshold > 25 V
Neuropathy Disability Score
Single stance test
Proprioception testing

30. USING THE 5.07/10gm MF (Tool-Kit)
• Demonstrate sensation on the
forearm or hand
• Place monofilament perpendicular to
test site
• Bow into C-shape for one second
• Test four sites/foot: Predicts 95% of
ulcer formers vs. 8 sites
• Heel testing does not discriminate
ulcer formers
• Avoid calluses, scars, and

31. Testing
EMG/NCV
Vibratory Perception Threshold
QSART (sweat test/autonomic function)

32. 2 degrees C

33. ULCERS

34. Ulcer prevalence
15% history of ulceration(s)
<30 y/o higher prevalance
men slightly> women
increase with age
3% diabetes related admissions were for “ulcer”

35. PRE-ULCER CUTANEOUS PATHOLOGY
Neuropathy  inappropriate footwear:
– Persistent erythema after shoe removal
– Callus
– Callus with subcutaneous hemorrhage: “pre-ulcer”
Autonomic neuropathy and secondary dry skin:
– Fissure  ulceration
– Augment callus formation
Poor self-care of the feet:
– Interdigital maceration with fungal infection
– Nail pathology

36. Wagner Grading System for
Ulcers- 0 - Intact Skin
- 1 - Superficial ulcer of skin or subcutaneous
tissue
- 2 - Ulcers extend into tendon, bone, or capsule
- 3 - Deep ulcer with osteomyelitis, or abscess
- 4 - Gangrene of toes or forefoot
- 5 - Midfoot or hindfoot gangrene

37. This is what I am talking
about!

38. Etiology of Ulceration
Neuropathy
Increased pressure
poor circulation
DORSAL ULCER=Arterial Insufficency

39. Causal Pathways for Foot Ulcers
Neuropathy
Deformity
ULCER
% Causal Pathways
Neuropathy: 78%
Minor trauma: 79%
Deformity: 63%
Behavioral ?


Poor self-foot care
Minor Trauma
- Mechanical (shoes)
- Thermal
- Chemical

40. Risk Factors for Diabetic Foot
Male Sex
DM > 10 years duration
Peripheral neuropathy
Abnormal foot structure
Peripheral arterial disease
Smoking
H/O previous ulceration / amputation
Poor glycemic control

41. Risk stratification for ulcer risk
Risk Level
Foot Ulcer
%/yr
3: Prior amputation
Prior ulcer
28.1%
18.6%
2: Insensate and
foot deformity or
absent pedal
pulses
6.3%
1: Insensate 4.8%
0: All normal 1.7%

43. TREATMENT

44. Treatment
Offloading
Debridement
Wound dressing
Antibiotics
Revascularisation
Amputation

45. Early Management
immobilization and off loading
tendon “balancing”
Achilles tendon
Multiple tendon (Ach+peroneals+PTT)
ORIF of Unstable fractures

46. Off-loading Appliances

47. Off-loading Appliances

48. Total Contact Cast:
Indications
Neuropathic Foot Ulcers
Wagner grade 1 and 2
? Wagner grade 3
Neuroarthropathy (Charcot’s Foot)
Forefoot
Midfoot
Ankle

49. Total Contact Cast: Basic
Protocol
Initial cast application: 3-7 days
Repeat, serial casting every 1-2 weeks
Wound and/or Charcot evaluation at each cast
change
Limit ambulation, use of assistive device
Therapeutic shoe ware at completion of casting

50. Contraindications
Grossly infected wounds
Uncontrolled osteomyelitis
Deep infection or abscess
Poor skin integrity
Excessive edema

52. Total Contact Cast Studies
AUTHOR HEALED MEAN HEALING TIME
Myerson 64/71(90%) 30 days forefoot/ 63 rear
Helm 16/22(75%) 38.8 days
Mueller 19/21(95%) 42 days
Sinacore 27/33(82%) 43.6 days
Walker 55/55(100%) 31 days forefoot/ 42 rear
Armstrong 25/25(100%) 38.8 days
Lavery 22/22(100%) 28.4 days midfoot ulcers

53. Problem:Tight Achilles
tendon

55. Good Literature Support for
Tendon Lengthening for Forefoot
UlcersInt. J. Leprosy,1971,Yosipovitch et al,39:631-2
Orthopaedics,1996,Lin et al,19(5):465-74
J.B.J.S,1999,Armstrong et al,81A(4):535-8
J. S. Ortho. Assoc.,2003,Laborde,12(2):60-5
J.B.J.S.,2003,Mueller et al,85A(8):1436-45
Surg. Clin. N. Am.,2003,Nishimoto et al,83:707-
26
Foot & Ankle Int.,2005,Strauss;26(1):5-14
Wounds,2005,Laborde,17(5):122-130

56. Vulpius Procedure
Intramuscular
Lengthening(recession) of
Gastroc-Soleus
No Wound Problems
No Over-Correction
Immediate Full Weight
Outpatient

57. Tenotomy

58. Ulcer Tendon
Lengthening
Met. Head 1-5 Gastroc-Soleus
1st Met. Head Peroneus Longus
5th Met.Head Posterior Tibial

59. Charcot Meta-analysis
301 patients from 15 outcome studies
Average healing time with immobilization: was 5.7 +/-
3.5 months, range 3-18 months
Failed non-surgical management: 21%
Prolonged or permanent bracing:28%
Partial or complete amputation: 6.6%
Sinacore and Withrington, JoOrth&SportsPT, 1999;29:736-746

60. EARLY CHARCOT
VS.INFECTION

61. Late Management
orthotics/bracing
exostectomies
arthrodesis
reconstruction
amputations

62. Assess clinical probabilities, including
history, exam and X-ray
“Probes-to-Bone” assessment
MRI most helpful to evaluate infection
May require deep debridement or percutaneous
sampling for diagnosis

63. General indications for
Reconstruction
Unshoeable deformity
Recurrent ulceration
Instability
PAIN
Cosmesis (make xray
look better) BEWARE!!!!!

64. Not unreasonable to tell the
patient that reconstructive
surgery is an alternative to a
amputation and that be very
well be the ULTIMATE
outcome…

65. When to operate
Failure of conservative
Rx
Eichenholtz stage
(Stage 3)
Medical condition
optimal
DO NOT FORGET
=Nutritional status
Non-smoking
Skin/ulcer status

66. Midfoot

67. Problem: Rocker bottom
foot
• midfoot ulceration

69. Ankle
Indicatons
Instability
Unbraceable
Ulceration
Patterns
Varus
Valgus

70. Internal Fixation

72. OOPS!?!

73. Wedge resection

75. BEAUTIFUL!!!!

76. Subtalar / peritalar
dislocation
Most common area to
come to treatment

77. hindfoot

78. Hindfoot

79. FOREFOOT

80. “By any means necessary”
Malcolm X

81. Simple exostectomy

82. Amputations
• More than 60 percent of nontraumatic lower-
limb amputations occur in people with
diabetes.
• In 2004, about 71,000 nontraumatic lower-
limb amputations were performed in people
with diabetes.

83. FOOT ULCERS IN DIABETES
(85% all amputations)
“Rule of 15”
• 15% of diabetes patients Foot ulcer in lifetime
• 15% of foot ulcers Osteomyelitis
• 15% of foot ulcers Amputation
Clinical Care of the Diabetic Foot, 2005

84. AMPUTATIONS IN DIABETES
Tragic: “Rule of 50”
• 50% of amputations transfemoral/transtibial level
• 50% of patients 2nd amputation in  5y
• 50% of patients Die in  5y
Clinical Care of the Diabetic Foot, 2005

85. ANKLE FRACTURES

86. Acute complications in the operative treatment of isolated
ankle fractures in patients with diabetes mellitus (Foot and
ANkle Int. 1999
Using a computer database, we conducted a retrospective review of all ankle fractures treated at our institution from March 1985 to
October 1996. Twenty-one patients with diabetes mellitus and isolated ankle fractures that were treated operatively met all inclusion
criteria. Seven had insulin-dependent diabetes, and 14 had non-insulin-dependent diabetes. A randomly selected control group of 46
patients without diabetes who also underwent operative treatment of ankle fractures during this same time period were matched for age,
sex, and fracture severity. The complication rate was 43% with 13 complications in nine patients with diabetes. There were seven
(15.5%) complications in the control group. Complications in the diabetic group included seven infections (five deep, two superficial) and
three losses of fixation. The complications were more severe in our diabetic population, requiring seven additional procedures including
two below-knee amputations; a third patient refused an amputation. No additional procedures were required in our control group. All
complications in our control group resolved with treatment. The relative risk for postoperative complications in patients with diabetes who
sustained ankle fractures that were treated operatively was 2.76 times greater than the control group's (95% confidence interval, 1.57-
3.97)

87. Operative management of ankle fractures in
patients with diabetes mellitus Foot Ankle Int 2007
Abstract
BACKGROUND: Multiple studies have documented increased risks associated with treatment of ankle
fractures in patients with diabetes mellitus. We reviewed our results in the largest series to date of this
complex patient group to determine the frequency of complications. METHODS: Eighty-four patients with
diabetes had open reduction and internal fixation using standard fixation techniques for acute, closed ankle
fractures. The 51 men and 33 women had an average age was 49.3 (22 to 77) years. The average followup
was 4.1 years (11 to 97 months). Seventy-five fractures were closed and nine were open. Thirty-nine
patients used insulin and 45 used oral hypoglycemics or diet for control of their diabetes. Diabetic
complications, including nephropathy, hypertension, peripheral vascular disease, and neuropathy were
evaluated. The management of diabetes, fracture classification, and presence of diabetic complications
were assessed with chi-square, ANOVA, and univariate logistic regression to determine the presence of
statistical significance for these factors. RESULTS: Twelve of the 84 patients developed postoperative
complications. Ten patients developed infections (eight deep and two superficial). Four of 12 patients with
preoperative evidence of peripheral neuropathy developed Charcot arthropathy. Ten of 12 patients who had
absent pedal pulses preoperatively developed complications (p<0.0001) and 11 of 12 patients with
peripheral neuropathy had complications (p<0.0001). A trend towards complications was noted with
nephropathy (two of five patients) and hypertension (nine of 12 patients). Open fractures, insulin
dependence, patient age, and fracture classification had no significant effect on outcome. CONCLUSIONS:
Most patients with diabetes can undergo open reduction and internal fixation of acute ankle fractures
without complications. Patients with absent pedal pulses or peripheral neuropathy are at increased risk for

88. Why such a high non-union rate?
Decreased platelet derived growth factor
expression during fracture healing in diabetic
animals. Clin Orthop 2003 Mar;(408):319-
30 (ISSN: 0009-921X)
The effects of blood glucose control upon
fracture healing in the BB Wistar rat with
diabetes mellitus. J Orthop Res 2002
Nov;20(6):1210-6 (ISSN: 0736-0266)
Alterations of cartilage and collagen expression
during fracture healing in experimental
diabetes. Connect Tissue Res 2000;41(2):81-
91 (ISSN: 0300-8207)

89. Sound familiar???
Decreased platelet derived growth factor expression during
fracture healing in diabetic animals. Clin Orthop 2003
Mar;(408):319-30
• Fracture healing as a post-natal developmental process:
molecular, spatial, and temporal aspects of its regulation. J Cell
Biochem 2003 Apr 1;88(5):873-84 (the role of three key groups
of soluble factors, pro-inflammatory cytokines, the TGF-beta
superfamily, and angiogenic factors, during repair )
Nitric oxide regulates alkaline phosphatase activity in rat fracture
callus explant cultures. Redox Rep 2000;5(2-3):126-7 (ISSN:
1351-0002)
Expression of cathepsins B, H, K, L, and S and matrix
metalloproteinases 9 and 13 during chondrocyte hypertrophy and
endochondral ossification in mouse fracture callus. Calcif Tissue
Int 2000 Nov;67(5):382-90 (ISSN: 0171-967X)

90. Bottom Line:
Regardless of the specifics of treatment,
adherence to the basic principles of
preoperative planning, meticulous soft-tissue
management, and attention to stable, rigid
fixation with prolonged, protected
immobilization are paramount in minimizing
problems and yielding good functional
outcomes.

91. Non-limb threatening
Infection
Oral therapy
cephalexin,
clindamycin
amoxicillin/clavulonate
quinalone
Topical: no evidence, ? pexiganin
Antiseptic agents: cytotoxic

92. Limb-threatening Infection
Debridement
Deep wound and blood cultures
Broad spectrum intravenous therapy
Imipenem/cilastin
Vancomycin/aztreonam/metronidazole
Lactam/lactamase inhibitor
Clindamycin plus quinalone

93. WAKE UP!!!
The lecture is over...