National Health Service Trust

Fig. 6.5 (a) The foot has developed spreading necrosis, (b) Close-up view of foot, (c) The patient had fever whilst the necrosis was spreading and this resolved when ceftazidime as antipseudomonal treatment was started. After an episode of acute ischaemia patients may develop areas of necrosis even following successful revascularization Such necrosis is related to the markedly reduced perfusion during the acute ischaemic episode These areas of necrosis are usually dry but may become wet if they...

Adaptation of a Zimmer frame

A 54-year-old lady with type 2 diabetes of 2 years' known duration, developed a plantar ulcer over a rockerbottom deformity resulting from a mid-foot Charcot's osteoarthropathy and was admitted to hospital for surgical debridement. The resulting defect measured 6 by 4 cm. She was very anxious to return home without delay. She was given a Zimmer frame and a wheelchair, and discharged home with strict instructions to rest the foot. She arrived at the diabetic foot clinic for her first...

Angioplasty

When non-invasive angiography has identified the areas of occlusive disease, then angioplasty can be carried out as an invasive procedure. Angioplasty is indicated in the treatment of single or multiple stenoses or short segment occlusions of less than 10 cm. The aim is to improve the arterial circulation, achieve straight-line flow to the foot and bring about an increased blood supply to the site of ulceration and infection (Fig. 5.26a-c). Although the foot pulses may not be restored, there is...

Angioplasty in the elderly

A 90-year-old woman with type 2 diabetes of 20 years' duration developed a small painful ulcer on the lateral border of her right heel (Fig. 4.19). The foot was pulseless with a pressure index of 0.5. Pain kept her awake at night. She underwent angioplasty of a short stenosis of the Fig. 4.19 This small painful ischaemic ulcer on the heel of a 90-year-old woman healed in 9 weeks following angioplasty. superficial femoral artery, the pain improved and the foot healed in 9 weeks. Advanced age is...

Ankle arthrodesis

Arthrodesis for severe ankle deformity and instability has traditionally been reported to have a high incidence of non-union and pseudoarthrosis in patients with neuroarthropathy. Recent reports however, are more encouraging, with authors reporting success rates ranging from 66 to 100 . In cases where solid ankle fusion is not achieved, there may still be an acceptable outcome with fibrous ankylosis, when the foot is satisfactorily aligned beneath the leg. Failure to obtain fusion maybe due to...

Case Study

A 47-year-old man with type 2 diabetes of 9 years' duration and previous history of neuropathic ulcer, attended the orthotist for review 1 month after receiving new shoes because he was developing new callus in his mid-tarsal area where he had never previously had a problem. When the orthotist removed the ethyl vinyl acetate insole he found that a large nail had punctured the sole of the shoe (Fig. 3.2). Fortunately the insole was thick enough to prevent penetration of the skin, but the...

Complicated leg wounds following distal bypass surgery

A 76-year-old lady with type 2 diabetes of 30 years' duration underwent a distal bypass for critical ischaemia. Three days later the proximal area of her leg wound developed bluish discolouration (Fig. 6.28a). The next day it began to break down (Fig. 6.28b) and then dehisced, revealing an area of yellow slough (Fig. 6.28c). Wide-spectrum antibiotics were prescribed. The area dried out and formed a dark brown eschar which stood proud of the area of skin. The vascular surgeon agreed that if...

Diabetic foot infection and MRI

A 62-year-old patient with type 2 diabetes of 3 years' duration developed an ulcer of the right 1st toe which had been present for 6 months when first seen in the foot clinic. He then had cellulitis and a markedly swollen 1st (Fig. 5.14a,b). This indicated osteomyelitis of the metatarsal head. There was a small collection of fluid between the extensor hallucis longus tendon and the metatarsophalangeal joint proximal phalanx of the big toe (Fig. 5.15a-c). The decision to debride the foot and...

Distal bypass for ischaemic ulcer

A 62-year-old lady with type 1 diabetes of 12 years' duration wore tight shoes and developed an ulcer on the plantar surface of her forefoot after a nail penetrated her shoe. Despite regular podiatry, special shoes and antibiotics the ulcer failed to heal for 7 weeks and became larger (Fig. 4.20a). Her feet were pulseless and her pressure index was 0.4. She did not suffer from intermittent claudication or rest pain. Angiography showed a 10-cm occlusion of the superficial femoral artery and...

Dressings and postoperative care

Dressings consist of non-adherent fine mesh gauze (petrolatum, 3 Xeroform or Adaptic ), and a fluffy dry sterile compression gauze bandage. A surgical shoe is dispensed. The patient is instructed to rest at home, remain non-weightbearing and to elevate his feet for 48 h. He is then allowed partial weightbearing in a surgical shoe with crutches or a walker. The first postoperative dressing change is scheduled within 1 week. Dressings are changed weekly for 3-4 weeks postoperatively. Sutures are...

Dry necrosis

When dry necrosis develops secondary to severe ischaemia, antibiotics should be prescribed if discharge develops, or the deep wound swab or tissue culture is positive, and continued until there is no evidence of clinical or microbiological infection. When toes have gone from wet to dry necrosis and are allowed to autoamputate, antibiotics should only be stopped if the necrosis is dry and mummified, the foot is entirely pain free, there is no discharge exuding from the demarcation line, and...

Education for patients with Charcots osteoarthropathy

Patients should be warned of the dangers of unprotected walking. Even one step without cast or brace can injure the foot irrevocably. They should be told always to wear the cast or walker, even in bed at night, otherwise the temptation to go to the lavatory in the middle of the night without bothering to don it may be too great. Patients should walk as little as possible the more the foot is rested and elevated the sooner it will recover. Patients should be advised to borrow or hire a folding...

Elective surgical procedures

Elective surgery includes procedures that are advantageous to the patient but not urgent. For example, correction of a painful bunion or hammer toe in a stage 1 patient (with protective pain sensation, adequate perfusion and well-controlled diabetes) is considered elective. Yet, surgical correction of these same deformities is considered prophylactic surgery when the patient is neuropathic or neuroischaemic and the condition places the foot at risk for ulceration, infection and amputation. The...

Emboli minimal neuropathy and severe localized pain

A 51-year-old woman with type 2 diabetes of 7 years' duration was referred to the diabetic foot clinic by the vascular surgeon who had diagnosed peripheral embolic disease. She had very discrete areas of non-blanching blue discolouration on the tips of her right 3rd and 5th toes (Fig. 6.8). Her pressure index was 0.5 and her vibration perception threshold was 20 volts. Angiography had shown multiple stenoses of the right superficial femoral artery and she was due for angioplasty. Aspirin and...

Emergent surgical procedures

Emergent surgery includes conditions that require immediate surgical intervention. These patients generally present to the emergency room casualty department with serious foot infections. It is important to emphasize that signs of systemic toxicity are not always present and clinical findings may be subtle. Patients may or may not be febrile they may or may not have an elevated white blood cell count however, their diabetes is most often out of control. These patients require immediate...

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Factitial (artefactual) ulcers 62,96-8 amputees 176-7,181 education 31-2,157 family history 3 fasciitis, necrotizing 157-9 felt padding 39-40,71 femoral neuropathy 50 fever, in cellulitis 108-9,125-7 fibrofatty padding depletion (FFPD) 6-7,39 fibula, neuropathic fractures 51 fifth metatarsal head resection 195-6,197 fifth ray amputation 203-4 film dressings 76 first aid 33 first ray amputation 203 first toe see hallux fissures 3,4,25 management 41,42 flucloxacillin 81,115,116 in local...

Followup

Patients need follow-up in a multidisciplinary diabetic foot service. Occasionally there may be a relapse in an already established but stabilized foot with Charcot's osteoarthropathy. This will present with erythema, swelling and warmth. The patient should be treated as if he was again in the acute phase. Many patients will eventually develop Charcot's osteoarthropathy in both feet. All patients with Charcot's osteoarthropathy should therefore be taught to check their feet and ankles regularly...

Great toe ulceration

Neuropathic foot ulcer prevention in diabetic American Indians with hallux limitus. J Am Podiatr Med Assoc 1989 79 447-50. Downs DM, lacobs RL. Treatment of resistant ulcers on the plantar surface of the great toe in diabetics. Bone Joint Surg AM 1982 64A 930-3. Lin SS, Bono CM, Lee TH. Total contact casting and Keller arthroplasty for diabetic great toe ulceration under the inter-phalangeal joint. Foot Ankle Int 2000 21 588-93. Rosenblum BI, Giurini IM, Chrzan JS, Habershaw GM....

Hammertoe

A hammer toe is characterized by hyperextension of the toe at the metatarsophalangeal joint, and flexion contracture of the toe at the proximal interphalangeal joint. The resulting deformity, like a swan's neck, results in retrograde force on the metatarsal head, causing increased plantar pressure, metatarsalgia, callus formation and eventually ulceration. Friction and pressure caused by the shoe on a prominent proximal interphalangeal joint, results in the development of a corn and,...

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Iatrogenic lesions 96 imipenem 116 imipramine 49 incision and drainage 184-7 independence, of amputees 180-1 infected foot (stage 4) 13,14,102-40 differential diagnosis 110 11 educational control 135-9 investigations 111-13 management 15,113-39 mechanical control 135 metabolic control 135 microbiological control 114-28 necrosis developing in 142-3,144 presentation and diagnosis 102-13 spectrum of clinical presentations 102-10 surgical management 184 vascular control 133 5 wound control 128-33...

Image Not Available

Fig. 4.17 Magnetic resonance angiography (MRA) showing multiple areas of stenosis and occlusion through the right and left superficial femoral arteries and in the left popliteal artery. Courtesy of Dr Paul Sidhu. It is slow, lasting up to 2 h, to cover the area from the bifurcation of the aorta to the distal lower extremity Gadolinium-enhanced MRA involves an intravenous injection of gadolinium contrast and a fast imaging that follows the passage of the contrast bolus through the arteries. It...

Info

Fig. 4.2 This healing ulcer is surrounded by an area of shiny new pink and white epithelium. discharge. A purplish colour indicates reduced oxygen supply to the tissues this may result from ischaemia or severe infection or both. Healing ulcers are surrounded by an area of shiny new pink and white epithelium (Fig. 4.2). Purulent discharge is indicative of infection. Clear or yellow-tinged viscous bubbly discharge from an ulcer which probes to bone may be synovial fluid indicating involvement of...

Investigation of patients with emboli

When dry necrosis is secondary to emboli, a possible source should be investigated, and therefore the following investigations should be performed ECG to detect atrial fibrillation or recent myocardial infarct Echocardiogram to detect the presence of valvular disease or thrombus in the left ventricle Ultrasound of abdomen to detect aortic aneurysm Duplex angiography of the lower limbs to detect atherosclerotic plaque in iliac or femoral arteries. Having located the source of the emboli,...

Isbn

A catalogue record for this title is available from the British Library Set in 9.25 11.5pt Minion by Graphicraft Limited, Hong Kong Printed and bound in Denmark, by Narayana Press, Odder Commissioning Editor Alison Brown Editorial Assistant Elizabeth Callaghan Production Editor Rebecca Huxley Production Controller Kate Charman For further information on Blackwell Publishing, visit our website http www.blackwellpublishing.com

Ischaemic foot complicated by extensive deep soft tissue infection needing a wide excision

A 73-year-old Afro-Caribbean patient with type 2 diabetes of 7 years' duration, attended the diabetic foot clinic at 2-monthly intervals for nail care. He had no excessive callus formation requiring debridement. His daughter brought him to the clinic as an emergency he was unable to put his shoe on because his foot was swollen. He felt no pain in the foot and was apyrexial. We found an ischaemic ulcer on his 5th toe which had not been present at his previous visit to the diabetic foot clinic,...

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Flucloxacillin 500 mg qds Sodium fusidate 500 mg tds Clindamycin 300 mg tds Rifampicin 300 mg tds Flucloxacillin 500 mg qds Gentamicin 5 mg kg day (according to levels) Clindamycin 150-600 mg qds Methicillin-resistant Staphylococcus aureus (MRSA) Sodium fusidate 500 mg tds Trimethoprim 200 mg bd Rifampicin 300 mg tds Doxycycline 100 mg daily Linezolid 600 mg bd (according to levels) Teicoplanin 400 mg daily Amoxicillin 500 mg tds Flucloxacillin 500 mg qds Clindamycin 300 mg tds Erythromycin 500...

Lesser metatarsal osteotomies

Weil's metatarsal osteotomy in the treatment of metatarsalgia. Orthopade 1996 25 338-44. Fleischli IE, Anderson RB, Davis WH. Dorsiflexion metatarsal osteotomy for treatment of recalcitrant diabetic neuropathic ulcers. Foot Ankle Int 1999 20 80-5. O'Kane C, Kilmartin TE. The surgical management of central metatarsalgia. Foot Ankle Int 2002 23 415-19. Vandeputte G, Dereymaeker G, Steenwerckx A, Peeraer L. The Weil osteotomy of the lesser metatarsals a clinical and pedo-barographic...

Mechanical control

Ideally, ulcers must be managed with rest and avoidance of all pressure. However, total non-weightbearing is rarely practical and is difficult to achieve. For these reasons, ambulatory methods of achieving mechanical control are best. In the neuropathic foot, the overall aim is to redistribute plantar pressures evenly, thus avoiding areas of high pressure which will prevent or delay healing. In the neuroischaemic foot, the aim is to protect the vulnerable margins of the foot. Thus, mechanical...

Microbiological control

Calhoun JH, Overgaard KA, Stevens CM, Dowling JP, Mader JT. Diabetic foot ulcers and infections current concepts. Adv Skin Wound Care 2002 Jan-Feb 15 31-42. Chantelau E, Tanudjaja T, Altenhofer F et al. Antibiotic treatment for uncomplicated neuropathic forefoot ulcers in diabetes a controlled trial. Diabetic Medicine 1996 13 156-9. Craig JG, Amin MB, Wu K et al. Osteomyelitis of the diabetic foot MR imaging pathological correlation. Radiology 1997 203 849-55. Cunha BA. Antibiotic selection for...

Microbiological investigations

We believe that it is important to make a microbiological diagnosis and ascertain the organisms that are responsible for the infection. This involves either taking a deep ulcer swab or curettings, or tissue scrapings after debridement. How to take a deep ulcer swab curettings The ulcer is debrided of surrounding callus and superficial slough The ulcer is washed out with sterile normal saline The base of the wound is then curetted (or scraped with a scalpel blade) and the curettings scrapings...

Necrosis in the neuropathic foot

In the neuropathic foot, the first presentation of necrosis is almost invariably of wet necrosis, and this is caused when infection complicates an ulcer, leading to a septic arteritis of the digital and small arteries of the foot. The walls of these arteries are infiltrated by polymorphonuclear leukocytes leading to occlusion of the lumen by septic thrombus. This leads to the so-called 'diabetic gangrene' where a toe become blue and subsequently black and necrosed, while a few centimetres...

Neuropathic avulsion fracture of the calcaneum

A 45-year-old woman with type 1 diabetes of 29 years' duration, developed a red, hot swollen foot 2 weeks after a fall. Acute Charcot's osteoarthropathy of the mid-foot was diagnosed and she wore a total-contact cast for 7 months. When the foot had settled down with resolution of redness, warmth and swelling she was given a removable cast and advised to limit her walking to a few steps a day. Christmas was coming, and she went out to do her Christmas present shopping without her cast. Next...

Neuropathic fractures and Charcots osteoarthropathy

Limb threatening neuropathic complications from ankle fractures in patients with diabetes. Clin Orthop 1998 348 212-19. Fabrin J, Larsen K, Holstein PE. Long-term follow-up in diabetic Charcot feet with spontaneous onset. Diabetes Care 2000 23 796-800. Jude EB, Selby PL, Burgess J et al. Bisphosphonates in the treatment of Charcot neuroarthropathy a double-blind randomised controlled trial. Diabetologia 2001 44 2032-7. McGill M, Molyneaux L, Bolton T et al. Response...

Neuropathic ulcers

Our approach to neuropathic ulcers is as follows. At the first visit, if there is no cellulitis, discharge or probing to bone, the foot is deemed to be at stage 3. Debridement, cleansing with saline, application of dressings and daily inspection will suffice. The patient is reviewed at, preferably, 1 week or less, together with the result of the deep ulcer swab or tissue culture. If the neuropathic ulcer shows no sign of infection and the swab is negative, treatment is continued without...

Perioperative care

A major amputation will put the remaining foot at great risk of ulceration. The heel of the surviving foot should be protected on the operating table and postoperatively. One of our surgeons always wrapped several layers of thick cotton wadding (Gamgee, Robinson) around the heel of the contralateral foot to avoid pressure on the heel during the amputation. Drains are advisable for amputations, as blood clots are a good culture medium for bacteria. A rigid dressing applied in below-knee...

Phantom limb phantom pain and residual pain

Phantom limb is sensation felt at the amputated site which is not painful. Phantom pain is pain felt at the amputated site. Residual pain is stump pain felt at the site of the surgical incision. Pain felt when wearing a prosthesis could be due to Inappropriate prosthetic device Postamputation pain is more likely if the patient has been in pain for a long time before the amputation.

Postgadolinium with fat suppression sequence

Gadolinium concentrates in areas of inflammation and results in a hyperintense signal on Tl images. As fat is hyperintense on Tl sequence, images are acquired using a fat suppression technique. Normal marrow in the foot is predominantly composed of fat. Thus it is hypointense on the fat-suppressed images. Any bright or high signal after injection of gadolinium with fat suppression technique applied represents a focus of inflammation. The main MRI finding in osteomyelitis is an abnormal marrow...

Postoperative care

Some patients return from theatre thinking that they still have their leg as they can still 'feel' it. Without reminders they may get out of bed and try to 'stand on two feet' resulting in a fall and possible injury to the stump or the other foot. Phantom sensation gradually decreases and may telescope so that the patient feels his foot at his thigh. During the postoperative period patients who have lost a limb often describe similar feelings to those described by people who have just had a...

Practice Points

The basic approach to the diabetic foot is assessment, classification, staging and multidisciplinary management Diabetic feet can be classified into neuropathic and neuroischaemic feet The natural history of the diabetic foot falls into six stages normal, high risk, ulcerated, infected, necrotic and unsalvageable Multidisciplinary management consists of mechanical, wound, microbiological, vascular, metabolic and educational control The multidisciplinary foot care service should include...

Preoperative care

The following points should be recognized Admission to hospital is always an anxious time, especially for patients fearing or facing a major amputation When patients are worried and anxious they may not retain information Information should be repeated several times and reinforced with the written word Patients like to feel that their limb is valuable, and that initial investigations and interventions are made in an effort to try and save the limb Patients want to know the reason why the leg...

Presentation And Diagnosis

When feet reach stage 4, they have developed infection. This is a highly significant staging post on the road to amputation. Although amputation may result from severe ischaemia or gross deformity of Charcot's osteoarthropathy, this is rare, and infection is usually the final common pathway to amputation. More people undergo major amputation because of combined diabetes and infection than for all other causes. In this chapter we describe how infected diabetic feet are managed at King's College...

Presentation And Management

Major amputation is sometimes inevitable, particularly in neuroischaemic patients. Rehabilitation of the diabetic amputee is extremely difficult and is characterized by long stays in hospital. Major amputation therefore must not be taken lightly. Morbidity and mortality associated with major amputation in diabetes are very high. Without optimal care, within 3 years half of diabetic major amputees will be dead and of the survivors, half will have lost their remaining leg. Survival of above-knee...

Probeability of the ulcer

The depth and dimensions of the ulcer are determined by probing, which is an important part of the examination. Probing reveals the presence of Undermined edges where the probe can be passed from the ulcer under surrounding intact skin (Fig. 4.3a,b) Sinuses when the probe can be inserted deeper than in other areas of the ulcer bed and may reach tendon or bone. A sinus may not be immediately apparent, but Fig. 4.3 (a) Ulcer with a probe placed over the skin to indicate position of sinus, (b)...

Prophylactic surgical procedures

Prophylactic surgery includes procedures which are necessary to prevent further compromise of the foot for example, a patient with chronic recurrent ulceration beneath the hallux, who has a limitation of motion at the 1st metatarsophalangeal joint. The pathomechanical aetiology of this lesion, in an insensate patient, is hallux limitus or rigidus. Unless this condition is corrected the ulcer will never be completely resolved. Another example is the patient with a stable Charcot foot, with...

Rigid hammer toe deformity

A 64-year-old man, a retired pilot, with type 2 diabetes of 16 years' duration, was followed regularly in the diabetic foot clinic for treatment of a rigid hammer toe deformity of his right 2nd toe, with recurrent ulceration over the proximal interphalangeal joint. The patient underwent an elective proximal interphalangeal joint arthroplasty, with lengthening of the extensor hallucis longus tendon and dorsal capsulotomy of the metatarsophalangeal joint. A Kirschner wire was not used in this...

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Saline, for wound cleansing 80 sandals 18 Sanders, Lee ix 'sausage toe' 109,127,128 scapegoating, after amputation 181 scope of problem vii-viii Scotchcastboot 69,73 screening, foot 17,35 screw fixation mid-foot arthrodesis 216 Weil shortening osteotomy 195 sensory neuropathy 9-10 sensory symptoms 2 sepsis, systemic 108-9,124 septic arteritis 144, 45,165, 67 Serratia 115,144 sesamoidectomy 192-3,194 shin spots 3 shoes advice on buying 18-19 bespoke 36,72 after total-contact casting 68 blisters...

Supplementary wound healing techniques

Several supplementary wound healing techniques have been used in diabetic foot ulcers including the following. To speed healing of large, clean ulcers with a granulating wound bed, a split-skin graft may be harvested from the patient and applied to the ulcer If the donor site is chosen from an area within the distribution of the neuropathy, local anaesthetic infiltration of the donor site with a spinal needle will provide sufficient analgesia A general anaesthetic can thus be avoided and a...

Surgical approach to the diabetic foot

This fester'd joint cut off, the rest rests sound This, let alone, will all the rest confound. (Richard II, V, iii, William Shakespeare) Diabetic gangrene is preventable in the overwhelming majority of cases . Hopefulness in the treatment of gangrene is possible. It comes first of all from the knowledge that the majority of the cases are needless and occur in those patients who have not been trained in the care of their feet or who have not followed training prompt treatment of the infection...

Surgical reconstruction of Charcots osteoarthropathy of the hindfoot

A 61 -year-old lady with type 1 diabetes of 40 years' duration developed a hot, red, swollen foot and ankle, and Charcot's osteoarthropathy was diagnosed. She was unwilling to wear a total-contact cast, but agreed to wear an Aircast. One month later she attended a wedding and discarded the Aircast for 1 day. She returned to the foot clinic the following week with an unstable flail ankle. She underwent surgical reconstruction (Fig. 3.26) and returned to the foot clinic in a non-weightbearing...

The aftermath of amputation advice to healthcare professionals

When catastrophes happen and patients lose a leg because of diabetic foot complications, then a storm of strong emotions, including fear and anger, is often aroused in the patient and his relatives. They may seek a scapegoat someone to blame for the amputation as if apportioning guilt makes them feel safer because they can then deny that a similar disaster could happen to the remaining leg. Unfortunately, it is often the last person who saw or treated the foot who is blamed for the catastrophe,...

The definitive prosthesis

The standard prosthesis contains a stump sheath worn inside a customized thermoplastic socket. This is then fitted onto a modular prosthesis. The shank of the prosthesis articulates with a prosthetic foot that is matched to the patient's physique and functional requirements. Putting the definitive prosthesis on and off may be difficult if hands are neuropathic and eyesight is poor, and visual inspection of the stump may be difficult. Velcro straps are useful in the patient with neuropathy and...

Treatment of bone destructiondeformity

The aim of treatment is immobilization in a plaster cast (see Chapter 4) until there is no longer evidence on X-ray of continuing bone destruction, and the foot temperature is within 2 C of the contralateral foot, which can be measured with an infrared thermometer. When this is achieved, the foot has reached the stabilization phase. Deformity in a Charcot's osteoarthropathy can predispose to ulceration, particularly on the plantar surface of the rockerbottom deformity. It may also occur on the...

Ulcer with extensive deep soft tissue infection

This involves the skin and subcutaneous tissues. This is a severe infection involving the deep soft tissues of the foot. In the presence of neuropathy, pain and throbbing may be absent, but if present this is a danger sign, usually indicating serious infection with pus within the tissues. Palpation may reveal fluctuance, suggesting abscess for mation. There may be bulging of the plantar surface of the foot. Discrete abscesses are relatively uncommon in the infected diabetic foot. Often there is...

Vascular control

Vascular imaging and intervention in peripheral arteries in the diabetic patient. Diabetes Metabolism Res Rev 2000 16 (Suppl 1) S16-22. Eagle KA, Brundage BH, Chaitman BR et al. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery an abridged version of the report of the American College of Cardiology American Heart Association Task Force on Practice Guidelines. Mayo Clin Proc 1997 72 524-31. Faglia E, Mantero M, Caminiti M et al....

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Barefoot 29,45,94 on infected foot 139 walking stick 71 warfarin 134 Warren, Grace ix, x warts 25 proprietary remedies 26 7 water, soaking foot in 138-9 weight-relief shoes 70-1 Weil shortening osteotomy 194-5 wheelchairs 71 amputees 180,181 in Charcot's osteoarthropathy 60 Whitfield's ointment 24 wound control infected foot 128-33 necrotic foot 151-62 ulcerated foot 73-80 wound healing blood glucose control and 85 criteria, for amputation 201 effects of infection 80 products, advanced...

Charcots osteoarthropathy

This is an acute osteoarthropathy, with bone and joint destruction, that occurs in the neuropathic foot. Rarely, in diabetes, it can also affect the knee. Patients who develop Charcot's osteoarthropathy usually have evidence of a peripheral neuropathy, autonomic neuropathy and a good blood supply to the lower limb. Patients may have symptoms of autonomic neuropathy such as gastro-paresis, diabetic diarrhoea, gustatory sweating or postural Fig. 3.14 (a) Spiral fracture of the tibia, (b) Charcot...

Overwhelming necrosis after patient lost to followup

A 73-year-old man with type 2 diabetes of 25 years' duration, peripheral neuropathy, peripheral vascular disease and previous amputation of his 2nd toe for osteomyelitis, failed to attend follow-up appointments in the diabetic foot clinic. He lived alone and turned away ambulance transport, despite frequent reminders and notification of his general practitioner, who arranged weekly visits by the district nurses. His forefoot changed colour it was initially blue and then became black but because...

Principles Of Surgical Management

A team approach to the medical care of patients with diabetes is necessary for successful surgical management. Prior to surgical intervention, patients require thorough preoperative medical assessment and aggressive management of their diabetes and comorbid conditions. Prompt attention must be directed to cardiovascular, renal, peripheral vascular and infectious disease issues. There is also a need to assess the patient's nutritional status and requirements for help from the dietitian. Wounds...

Problems with the good leg

A 39-year-old male with type 1 diabetes of 27 years' duration and end-stage renal failure treated by continuous Fig. 7.2 Necrosis spreading to the leg after a major arterial occlusion. Fig. 7.2 Necrosis spreading to the leg after a major arterial occlusion. ambulatory peritoneal dialysis had a history of bilateral neuropathic ulceration and underwent amputation of left 3rd, 4th and 5th toes. The foot healed and he was issued with an orthotic walker. The foot remained intact for most of the...

Volume fluctuation

It is in the early stages that the greatest changes in the stump will occur, and the size and shape of the stump can be expected to change markedly for around 1 year. During the amputee's life, his body weight and the amount he walks are likely to fluctuate, and this results in alteration of the stump volume. Cardiac and renal disease can lead to stump oedema. Fluctuating stump volume is a particular problem in diabetic amputees, and patients with neuropathic stumps may have difficulty in...

What must I do to heal my foot quickly

You should ask for help (the same day) from your doctor, hospital or diabetic foot service Clean the ulcer with saline Cover the ulcer with a sterile dressing held in place with a light bandage Ask for help dressing the ulcer from your community nurse if you or your family have difficulty with this Keep right off the ulcer. Use crutches or a wheelchair and try not to put your foot to the ground Keep your foot up on a stool and cushion, sofa or bed Stay home from work or work from home if...

Choice of level of amputation

The level of amputation should be carefully considered to ensure that there is sufficient perfusion to achieve wound healing. When possible, a below-knee amputation should be carried out to conserve the knee joint and aid the fitting of a prosthesis. Preserving the knee joint lowers the energy expenditure necessary for walking. The cardiovascular cost for walking and foot plantar pressures in the opposite limb both increase in direct proportion as the amputation becomes more proximal. The aims...

Removal of sesamoids

A 69-year-old man with type 2 diabetes of 22 years' duration and peripheral neuropathy had a history of chronic full-thickness ulceration beneath his left 1st metatarsal head. The ulcer did not probe to bone (Fig. 8.11). Radiographs revealed a hypertrophic tibial sesamoid (Fig. 8.12). Conservative treatment was employed for 4 months with no improvement in his condition. The patient was offered the option of surgical treatment and he consented. In this case, the plantar ulcer was excised and...

Relapse of Charcots osteoarthropathy or infection

A 60-year-old type 1 diabetic of 42 years' duration who had bilateral Charcot's osteoarthropathy affecting both feet and 12 years' previous history of ulcers and infections, was referred to the foot clinic with a hot, swollen left ankle and erythema over the medial malleolus. Both her feet were intact. The left foot was very painful on weightbearing. A provisional diagnosis of infection was made although we could not be sure that this was not a relapse of Charcot's osteoarthropathy. She was...

Angiography

Initially, non-invasive angiography should be carried out. This is either duplex angiography or magnetic reson ance angiography (MRA), which should be carried out urgently to detect the presence of stenoses or occlusions which may be amenable to angioplasty or bypass. Duplex angiography is proficient at looking at the femoral and popliteal arteries but it is sometimes difficult to obtain good views of the infrapopliteal arteries and foot arteries because of the excessive calcification in the...

Sesamoidectomy

Sesamoidectomy is indicated for the treatment of a discrete intractable lesion, beneath the 1st metatarsal head, that fails to heal or remain healed with a conservative approach to treatment local wound care, total-contact casting or attempts to off-load the forefoot with orthoses and custom footwear . Sesamoidectomy is also indicated for the curative treatment of osteomyelitis of the sesamoid bone. This procedure is appropriate for the treatment of neuropathic patients with evidence of...

Outcomes of transmetatarsal and midfoot amputations

Of the three levels of amputation discussed in this chapter, the transmetatarsal amputation is the most successful with respect to functional outcomes, patient satisfaction and long-term results. Transmetatarsal amputation preserves foot function, is cosmetically acceptable, does not require a prosthesis and enables fitting with commercially available footwear. Amputations performed at the tarsometatarsal and mid-tarsal joint levels frequently result in deformity and difficulty fitting shoes....

Percutaneous lengthening of Achilles tendon

A 55-year-old African-American male with poorly controlled type 2 diabetes HbA c 10.6 of 8 years' duration, and dense peripheral neuropathy was seen regularly in the diabetic foot clinic for treatment of a chronic nonhealing full-thickness ulcer located beneath the 2nd and 3rd metatarsal heads of his left foot. The ulcer did not probe to bone. Treatment consisted of surgical wound debridement, total-contact casting, walking brace and a variety of topical wound healing agents. Serial X-rays were...

Fall in an Aircast

A 40-year-old male with type 1 diabetes of 30 years' duration, proliferative retinopathy treated with laser photocoagulation, sensory neuropathy and autonomic neuropathy including postural hypotension, developed an acute right mid-foot Charcot's osteoarthropathy. Because of a previous episode of severe sepsis he was reluctant to wear a total-contact cast, but agreed to wear a removable Aircast. He suffered a fall in his home where the kitchen floor was covered with shiny linoleum and X-ray...

The Scope Of The Problem

Gangrene Diabetic Toe

Diabetic foot complications are a major global public health problem. Amputation rates vary throughout the world but are always increased in people with diabetes compared to those without diabetes. Amputations are increasing in diabetic patients. Throughout the world, health-care systems, both public and private, have been unsuccessful in managing the overwhelming problems of patients suffering with diabetic foot complications. The results of this failure are shown in the following case...

Transcutaneous oxygen tension TcPo

This measurement is a non-invasive method for monitoring arterial oxygen tension and reflects local arterial perfusion pressure. A heated oxygen sensitive probe is placed on the dorsum of the foot. Normal TcPo, is greater than 40 mmHg. A level below 30 mmHg indicates severe ischaemia and indicates the need for further vascular assessment such as non-invasive angiography. However, levels can be falsely lowered by oedema and cellulitis. Values in the foot can also be compared with those on the...

Management of the five presentations of infection

Treatment is discussed for the five presentations of infection, in neuropathic feet and in neuroischaemic feet, both as initial treatment and follow-up. Infection in the neuroischaemic foot is often more serious than in the neuropathic foot which has a good arterial blood supply. We regard a positive ulcer swab in a neu roischaemic foot as having serious implications, and this influences antibiotic policy. We give amoxicillin 500 mg tds, flucloxacillin 500 mg qds and metronidazole 400 mg tds...

Reasons for major amputation

Diabetic patients who present with extensive ulcers on their feet are sometimes offered early amputation as 'the one sure way of sorting out the problem permanently', on the basis that such an operation is likely to be inevitable at some time in the future. This approach may be useful for young, otherwise healthy, non-diabetic patients incapacitated by pain or a useless limb, whose other limb is normal. However, major amputation does not guarantee an ulcer-free existence for the diabetic...

Amputations Of The Foot

Amputations of the foot can be divided into nonemergency and emergency procedures. Non-emergency amputations allow some flexibility in the creation of skin flaps, selection of level and wound closure. These cases generally include neuropathic feet that are structurally or functionally impaired, with satisfactory circulation and controlled infection. They are characterized by moderate to severe forefoot deformities with associated chronic non-healing ulcers that are recalcitrant to conservative...

Management

Charcot Crutches

All neuropathic fractures should be treated promptly in conjunction with orthopaedic surgeons. Fractures that develop Charcot changes are associated with the greatest overall delay in diagnosis and management. Fractures should be treated with non-weightbearing and plaster Fig. 3.12 Fractured styloid process at base of 5th metatarsal. Fig. 3.12 Fractured styloid process at base of 5th metatarsal. immobilization, supported by crutches and or wheelchair. Fractures do not heal at the same rate as...

Neuropathic foot

Scotchcast Bnt

The most efficient way to redistribute plantar pressure is by the immediate application of some form of cast. If casting techniques are not available, temporary ready-made shoes with a cushioning insole can be supplied to off-load the site of ulceration. Alternatively, weight-relief shoes can be supplied, and felt padding can also be used. Additional off-loading measures are crutches, wheelchairs and Zimmer frames. Moulded insoles in bespoke shoes are sometimes used to treat ulcers. However,...

Feckless patient with endstage renal failure

Stub Toe Nail

A 44-year-old woman with type 1 diabetes of 26 years' duration, proliferative retinopathy, profound neuropathy and end-stage renal failure treated by renal transplant had her feet checked at monthly intervals at the renal unit as part of a research protocol. Her foot pulses were palpable. She was educated in foot care, foot inspections and early reporting of any problems. However, during a 3-year period she suffered nine separate episodes of foot trauma, none of which she reported early they...

Introduction

The discovery and commercial production of insulin in the early 1920s were seminal developments in the treatment of diabetes that allowed people affected by this disease to live an almost normal life. Although insulin commuted the death sentence attributed to diabetes, it was soon recognized that it was not a cure. As people affected by this disease lived longer, they began to experience serious complications including blindness, kidney failure, heart disease, stroke and amputations. In 1934,...

Extensive deep soft tissue infection secondary to interdigital tinea

A 43-year-old man with type 2 diabetes of 2 years' duration was admitted via casualty with an infected neuropathic left foot with cellulitis, oedema and a purple patch on the dorsum of the foot. He was apyrexial. The dorsum of his foot was fluctuant and he was taken to theatre and underwent incision and drainage of an abscess. The pus from the abscess grew Staphylococcus aureus and he was treated with flucloxacillin 500 mg qds. The wound was not sutured but left open to heal by secondary...

Conservative management of Charcots osteoarthropathy of the hindfoot

Amputation First Ray

A 46-year-old male with type 1 diabetes of 40 years' duration presented with bilateral Charcot's osteoarthropathy. He was referred from a clinic 80 miles away and had been advised to have a right below-knee amputation. The left foot had stable mid-foot Charcot's osteoarthropathy with rockerbottom deformity the right foot was hot with unstable hindfoot Charcot's osteoarthropathy with lateral talotibiofibular displacement. The Charcot's osteoarthropathy was diagnosed 3 years previously following...

Further Reading Presentation and diagnosis

Zondervan Publishing House. Grand Rapids, Michigan, USA, 1997. Jacobs AM, Appleman KK. Foot-ulcer prevention in the elderly diabetic patient. Clin GeriatrMed 1999 15 351-69. Lavery LA, Lavery DC, Quebedeax-Farnham TL. Increased foot pressures after great toe amputation in diabetes. Diabetes Care 1995 18 1460-2. Litzelman DK, Marriott DJ, Vinicor F. Independent physiological predictors of foot lesions in patients with NIDDM. Diabetes Care 1997 20 1273-8....

Choparts amputation

A 54-year-old man with type 2 diabetes of 17 years' duration and Charcot's arthropathy had chronic ulceration beneath the calcaneocuboid joint of his left foot. He also had nephropathy, peripheral vascular disease, retinopathy, neuropathy, congestive heart failure, hypertension and cardiovascular disease. He presented at accident and emergency with fever, rigors and a grossly infected left foot. Radiographs and clinical examination confirmed gas in the soft tissues on the dorsum of his foot,...

Principles of antibiotic treatment

The microbiology of the diabetic foot is unique. Infection can be caused by Gram-positive aerobic, and Gram-negative aerobic and anaerobic bacteria, singly or in combination Table 5.1 As there may be a poor immune response of the diabetic patient, even bacteria normally regarded as skin commensals may cause severe tissue damage. This includes Gram-negative organisms such as Citrobacter, Serratia, Pseudomonas and Acinetobacter. When Gram-negative Table 5.1 Bacteria isolated from the diabetic...

Technique

Diabetic Foot Care

The procedure is performed in the operating theatre under local anaesthesia, with a Penrose drain applied as a tendon and joint capsule are identified overlying the proximal interphalangeal joint, c Removal of the head of the proximal phalanx with a double action bone cutting forceps, d Immediate postoperative appearance. tendon and joint capsule are identified overlying the proximal interphalangeal joint, c Removal of the head of the proximal phalanx with a double action bone cutting forceps,...

Investigations

These should include neurological, vascular, laboratory and radiological investigations as described in Chapter 1. Fig. 4.4 This deep sinus has a slit-shaped aperture. Fig. 4.4 This deep sinus has a slit-shaped aperture. While it is not necessary to X-ray every stage 3 foot with a presenting ulcer, it may be advisable to do so in the following circumstances When the history suggests that the patient may have trodden on a foreign body When the ulcer probes to bone, clinically suggesting...

Ischaemia and cellulitis

In the neuroischaemic foot it may be difficult to differentiate between the erythema of cellulitis and the redness of ischaemia. It is helpful to elevate the leg. The redness of ischaemia is usually cold and is most marked on dependency it will disappear upon elevation of the limb, whereas cellulitis will remain. The erythema associated with inflammation is warm, although a very ischaemic foot may become deceptively warm when it is infected. Erythema also occurs secondary to traumas, including...

Hidden depthsunsuspected soft tissue infection complicating apparently superficial heel ulceration under callus

A 56-year-old man with type 2 diabetes of 12 years' duration and peripheral neuropathy trod on a nail while walking barefoot. The wound healed after 6 days, but the heel developed a callus which became painful after 2 weeks so he sought advice from the diabetic foot service. The callus was debrided and the underlying skin appeared to show superficial ulceration only Fig. 5.10a . However, when the heel was palpated the patient complained of pain, and careful inspection revealed a deep sinus from...

Neuroischaemic ulcers

We prescribe antibiotics more readily for the neuroischaemic foot because untreated infections in neuroischaemic feet lead rapidly to extensive necrosis, destruction of the foot and major amputation. At the first visit, if the ulcer is superficial, we prescribe oral amoxicillin 500 mg tds and flucloxacillin 500 mg qds. If the patient is penicillin allergic, we prescribe erythromycin 500 mg qds or cefadroxil 1 g bd. If the ulcer is deep, extending to subcutaneous tissues, we add trimethoprim 200...

Indications for surgery

Antibiotics alone may be unable to control infection and it is necessary to decide whether adjunctive surgery is necessary. In severe episodes of cellulitis, the ulcer may be complicated by extensive infected subcutaneous soft tissue. At this point, the tissue is not frankly necrotic but has started to break down and liquefy. It is best for this tissue to be removed operatively. The definite indications for urgent surgical intervention are A large area of infected sloughy tissue Localized...

Early discharge without accepting treatment by a young diabetic patient addicted to crack cocaine

Crack Cocaine Necrose Feet

A 28-year-old man with type 1 diabetes mellitus for 18 years attended the casualty department complaining of a painful foot. He was well known to the hospital and was addicted to crack cocaine. He had severe infection of the left hallux, and deep, infected ulcers over both 1st metatarsal heads Fig. 5.27 . He was admitted to the ward for intravenous antibiotics and possible surgical debridement but walked off the ward 2 h later before treatment was started and was lost to follow-up. Three weeks...

Improper use of a rubber band

A 25-year-old man with type 1 diabetes of 15 years' duration presented with a painful nail sulcus and underwent removal of a spike of nail. The toe was dressed with Fig. 4.12 A ring of superficial necrosis around the toe following use of a tight rubber band to hold a dressing on the toe. Fig. 4.12 A ring of superficial necrosis around the toe following use of a tight rubber band to hold a dressing on the toe. Melolin and Tubegauz and he was advised to attend his practice nurse for dressings and...

Mobility aids

Amputation Stump

Before the definitive prosthesis is issued, some patients may be suitable for mobility aids. The amputee mobility aid AMA is suitable for below-knee and through-knee amputees only. The stump is supported and stabilized by an inflatable bag, which also assists in reducing oedema. It is a physical and psychological boost to get the patient on his feet early. It has a knee joint. The pneumatic postamputation mobility aid PPAM aid has an inflatable socket and is suitable for above-knee,...

Advances In Diabetic Foot Care

The diabetic foot has become a major area of interest, and insight has been gained into the reasons why diabetic feet go wrong and the ways in which patients can be helped. Of all the complications of diabetes, the diabetic foot is probably the easiest to prevent and treat. The groundswell of interest in the diabetic foot surged in the 1980s, and developments in foot care included the setting up of multidisciplinary diabetic foot clinics Fig. 6 and the pioneering educational work of Jean...

Wet necrosis

The microbiological principles of managing wet necrosis are similar to those for the management of infection of the foot with extensive soft tissue infection or the foot with blue discolouration as described in Chapter 5. When the patient initially presents, deep wound swabs and tissue specimens are sent off for microbiology. Deep tissue taken at operative debridement must also go for culture. Intravenous antibiotic therapy Both neuropathic and neuroischaemic patients need parenteral therapy....

Pressure index

Dopplerwaveform From Normal Foot

The pressure index is widely criticized because, when the arteries are calcified, it may be artificially raised. However, we feel that it is very relevant to the investigation of the diabetic foot as long as the potential difficulties of its interpretation are understood. If the pressure index is 0.5 then it is truly low, and indicates severe ischaemia whether the arteries are calcified or not. Indeed, if the artery is calcified the true pressure index may be even lower and even more urgent...

Prologue

Wet Gangrene

He's both their parent and he is their grave, And gives them what he will, not what they crave. Pericles, Prince of Tyre, II, iii, William Shakespeare Fig. 1 Foot from the UK. This 85-year-old man with type 2 diabetes of 8 years' duration received regular dressings of his ulcerated ischaemic foot for 9 months, but was not referred until extensive gangrene had developed. Fig. 2 Foot from Ukraine. This 48-year-old man with type 2 diabetes of 12 years' duration trod on a nail and developed severe...

Causes of necrosis

Necrosis can be due to infection, when it is usually wet, or to occlusive macrovascular disease of the arteries of the leg, when it is usually dry. Necrosis is not, as previously thought, due to a microangiopathic arteriolar occlusive disease, or so-called small vessel disease. Health-care professionals working with diabetic foot disease should avoid using this term, which is imprecise and may lead to therapeutic nihilism. Digital necrosis is common in patients with renal impairment,...

Historical Background

Plamen Kamenov

The last century made great inroads into improving the management of diabetes. The early work of pioneers such as Nicolas Paulesco in Rumania and Georg Zuelzer in Germany culminated in the work of Banting, Best, Collip and Macleod in Canada who produced a pancreatic extract which was used successfully in patients and ended the Fig. 6 International visitors at the King's Diabetic Foot Clinic left to right, Dr Kamenov Bulgaria , the Authors, Dr Harkless USA and Dr Plamen Bulgaria . Fig. 7 The...

Gas gangrene diagnosed from culture of tissue

Clostridium Perfringens Gangrene

A 65-year-old man with type 2 diabetes of 23 years' duration and chronic ischaemia developed four necrotic toes following an episode of infection which was treated in hospital with intravenous antibiotics. Vascular intervention was not feasible and the toes were treated conservatively, with treatment consisting of pain control with liberal analgesia, oedema control with diuretics, infection control with oral antibiotics, and wound control with Fig. 6.17 a The proximal portion of this necrotic...

Ulcer with local signs of infection

Diabetic Ulcer Bone Exposure Probe

Local signs that an ulcer has become infected include any or all of the following Base of the ulcer changes from healthy pink granulations to yellowish or grey tissue Increased friability of granulation tissue Fig. 5.4 Increased amount of exudate Fig. 5.5 Exudate changes from clear to purulent Fig. 5.6 A deep sinus has appeared in the base of this ulcer. Fig. 5.6 A deep sinus has appeared in the base of this ulcer. Sinuses develop in an ulcer Fig. 5.6 Edges may become undermined so that a probe...