Diabetic foot

Clinical image

Charcot neuroarthropathy with Lisfranc disruption in a patient with diabetes. Source: Wikimedia Commons — J. Terrence Jose Jerome; CC BY 3.0. Image binary is embedded locally in this package; original source and licence are retained.

Foot ulcers

• precedes 80% amputations
• 1st amputation makes further amputation risk 23 times
• 70% death in 5 years after amputation
• 50% death after ulceration in 5 years

10% all hospital admission of DM

• 1/3 neuropathic
• 1/3 vascular ischemic
• 1/3 mixed
• MDT approach

Neuropathy

• Sensory:
  • stocking destribution of sensory loss
  • 10g Sammes-weinstein monofilament test: protective sensation
  • Loss of vibration with 128hz early sign of neuropathy
• Motor
  • Claw due to intrinsic weakness
  • Equinous: weak Tib Ant
• Autonomic
  • Dry skin
  • altered nail growth
  • reduced vascular response to injury

Assessment

• Diabetic control
• NV status
• Ulcers
• Deformity

Sammes Weinstein Monofilament

• ABPI

• Transcut oxygen pressure and angiography

• NV status

Ulcers

• Neuropathic
  • Painless under MT head
  • Punched out with surrounding hyperkeratosis
  • Good granulation
  • Loss of protective sensation
  • Normal pulses
• Ischemic
  • Anywhere
  • Painful

Deformity

• Claw toes
• Equinous
• Plantar keratosis
• Charcot asso deformities
  • Cavus
  • rocker bottom

Management

• Diabetes: control
• Ulcer
  • Neuropathic
    • accommodative foot wear
    • Total contact cast
  • Vascular
    • MDT approach (angioplasty/bypass)
  • Infected ulcer
    • Step ladder approach from Ab to Amputation
• Deformity management

Deformity management Charcot

Goal of management

• Reduce deformity
• Provide stability
• Prevent ulceration

Charcot Deformity treatment principles

• DM control
• Accomodative foot wear
• TCC
• Avoid operations in destruction phase unless a/c deformity
• Arthrodesis preferred over ORIF
• Treat Equinous
• Long term non wt bearing (2-4months) followed by protective wt bearing for 1 year
• a/c deformity: surgery
• c/c deformity: non surgical

Operative indications

• a/c deformity
  • Medial dislocation of navicular and cuniforms with foot in abduction, causing medial ulcerations: Osteotomy
  • Dorsal dislocation of N and Cu causing lateral rocker bottom : Arthrodesis
• c/c progressive deformity

Emergencies

• a/c infection that does not require drainage
• a/c infection requiring drainage
  • with out circulation compromise: drain by local facility
  • with circulation compromise: Drain by vascular team
• Ischemic foot
  • MDFS with in 24 hours
  • Vascular input with in 48 hours
  • revascularisation with in 8 days

Key points

• Summary of indications for conservative surgical approach or primary amputation