DM Foot Dr Hussein Safar

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					Diabetic Foot
Dr Hussein Safar, MD, FRCS
Consultant Vascular Surgeon

Diabetic Foot: Risk Factors
Risk Factors for Atherosclerosis
Older age (> 40 years) Male gender

Smoking Diabetes Hypertension Hyperlipidaemia Homocysteinuria

Family History
When risk factors coexist, the risk increases several-fold
Am J Cardiol 2001; 87 (suppl): 3D-13D NEJM 2001; 344: 1608-1621

Murabito JM et al. Circulation 1997;96:44–49; Laurila A et al. Arterioscler Throm Vasc Biol 1997;17:2910–2913; Malinow MR et al. Circulation 1989;79:1180–1188; Brigden ML. Postgrad Med 1997;101:249–262.

Diabetic Foot: Presentation
Acute 6Ps [pulseless, paresthesia, paralysis, pain, pallor, parse cold ] Chronic Intermittent claudicating (typical or atypical)

Critical limb ischemia (rest pain or ulceration or gangrene)
Neuropathic ulcer / gangrene without ischemia

Diabetic Foot: Ulcer
Ischaemic Pulse Coldness Sensation    Necrotic   Delayed  Digits Neuropathic    Granulating   Normal  Pressure area

Ulcer Hyper-keratotic edges Atrophic appearing skin (shiny, thin, dry) capillary return time Pain Site

Diabetic Foot: Classification
0 A
Pre or postulcerative lesion completely epithelialized




Superficial wound, not Wound penetrating Wound involving tendon, penetrating to to tendon or capsule, or bone bone or joint capsule
Superficial wound, not involving tendon, capsule, or bone with infection Wound penetrating to tendon or capsule with infection Wound penetrating to bone or joint with infection


Pre or postulcerative lesion, completely epithelialized with



Pre or postulcerative lesion, completely epithelialized with

Superficial wound, not involving tendon, capsule, or bone with
ischemia Superficial wound, not involving tendon, capsule, or bone with infection and ischemia

Wound penetrating to tendon or capsule
with ischemia Wound penetrating to tendon or capsule with infection and ischemia

Wound penetrating to bone or joint with
ischemia Wound penetrating to bone or joint with infection and ischemia



Pre or postulcerative lesion, completely epithelialized with

infection and ischemia

The University of Texas Health Science Center San Antonio Diabetic Wound Classification System

Diabetic Foot: Investigations
Plain X-ray Hand-Held Doppler Vascular Lab (Arterial Doppler study) MRA Angiography

Plain X-ray

Hand-Held Doppler

Vascular Lab.
ABI Normal Claudication Rest Pain 1.0 0.5-1.0 0.3-0.5 Wave Form Tri-phasic Bi /Tri-phasic Mono-phasic
Exercise AP<50 Rest AP<40


Tissue Loss

< 0.3


TP<30 Rest AP<60 TP <40

ABI=Ankle-Brachial Index, AP=ankle pressure, TP=toe pressure (mmHg)

Arterial Doppler

ABI = 1

ABI = 0.4



Diabetic Foot: Management
• Goals in claudication
1. Relieve of symptoms
2. Improve their walking capacity 3. Improve their quality of life


Goals in critical leg ischemia
1. Relieving ischemic rest pain 2. Healing ischemic ulceration 3. Preventing limb loss

Diabetic Foot: Management
Modification of risk factors Medical Intervention radiologist Surgical

Diabetic Foot: Management Exercise
• Walking to near-maximal pain for least 6 months. • Should be part of the standard medical care for patients with intermittent claudication.
» Exercise rehabilitation programs for the treatment of claudication pain. A meta-analysis. JAMA. 274(12):975-80, 1995 Sep 27.

Diabetic Foot: Management Smoking Cessation
• Slows progression of the disease
• Reduces the risks of MI & death • Nicotine-replacement therapy & use antidepressant drugs.

»Daughton D, Susman J, Sitorius M, et al. Transdermal nicotine therapy and primary care. Importance of counseling, demographic, and participant selection factors on 1-year quit rates. The Nebraska Primary Practice Smoking Cessation Trial Group. Arch Fam Med 1998;7:425-30.

Diabetic Foot: Management
Antiplatelet & Anticoagulant Drug Therapy
• 25% reduction in all vascular events.
– – – – – ASA Clopidogrel Pentoxifylline Dipyridamole Cilostazol

Diabetic Foot: Management Prostaglandins
• Used in patients with critical leg ischemia (ulcer & gangrene).
• May reduces major amputation rate.

» Eur J Vasc Endovasc Surg. 2000 Oct;20(4):358-62. » Minerva Cardioangiol. 1998 Oct;46(10 Suppl 1):59-63. » Eur J Vasc Surg. 1991 Oct;5(5):511-6.

Diabetic Foot: Management
• • • Radiological Intervention PTA & Stenting Surgical 1. Embolectomy and thrombectomy 2. Endarterectomy 3. Patch angioplasty 4. Anatomical or extra anatomical bypass 5. Amputations

PTA & Stenting

Bypass Surgeries
Anatomical (Fem-Pop) & (Fem-Tib.)

Bypass Surgeries
Extra anatomical (Fem-Fem) & (Fem-Axill.)

Bypass Surgeries
Patch Angioplasty

Rest Pain & small ulcer ABI pre Rt 0.1 Lt 0.7 post Rt 0.7 Lt 0.7 Rx Iliac Artery PTA & Stent

Gangrene ABI pre Rt 0.7 Lt 0.7 post Rt 0.7 Lt 1.0 Rx Lt fem-Pop Bypass

pre Lt 0.7

post Lt 1.0


LVF & EF 35% Rest Pain & Gangrene ABI pre Rt 0.2 Lt 0.3 post Rt 0.7 Lt 0.3 Axillo-Rt Femoral Artery Bypass

Rest Pain & Gangrene ABI pre Rt 0.5 Lt 0.5 post Rt 1.0 Lt 1.0 Rx Aorto-Bi-Femoral Bypass

Gangrene ABI pre Rt 0.88 Lt 0.59 Rx No run off, conservative & amputation

Ulcer ABI pre Rt 1.6 Lt 1.5 Rx No arch conservative & amputation

• Gangrene • ABI pre Lt 0.3 post 1.0 • Rx after Pop-post tibial artery bypass

• infection and Gangrene • ABI pre Lt 0.8 • Angio only peroneal artery patent till the ankle joint • Rx only amputation

• • • •

DM foot ulceration ABI pre Lt 1.0 with palpable pulse X-ray bone osteomylitis Rx only debridment

• • • •

Bed-ridden Gangrene ABI Not done Rx Primary Amputation

 activity Diabetes  BP Lipid Homocyst.

Help Help

Diabetic foot

Management of DM Foot
Stop Smoking Exercise

Thrombolysis Angioplasty

Diet Control
Anti Lipid Anti HTN

Thrombectomy Bypass

ASA & Plavix
Folic Acid Vitamin „B‟ complex Vitamin „C‟ & „E‟


Thank you

Anti Coagulant

Diabetic Foot: Chronic Limb Ischaemia (Clinical Categories)
Grade Category Clinical description Objective Criteria
0 I II III 0 1 2 3 4 5 6 Asymptomatic Mild Claudication Moderate Severe Ischaemic Rest Pain Minor Tissue Loss Major Normal ABI Exercise AP >50 Category 1 & 3 Exercise AP <50 Resting AP <40 or TP < 30 Resting AP <60 or TP < 40
Rutherford 97

AP=ankle pressure, TP=toe pressure (in mmHg), ABI=Ankle-Brachial Index

Diabetic Foot: Classification
Stage I Non-blanchable erythema of intact skin, “ lesion of skin ulceration”.

Diabetic Foot: Classification
Stage II Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater

Diabetic Foot: Classification
Stage III
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.

Diabetic Foot: Classification
Stage IV
Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule).

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