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Current Issues in Diabetic Foot Disease

Current Issues in Diabetic Foot Disease. Gareth Griffiths Department of Vascular Surgery, Ninewells Hospital, Dundee, UK Chairman of the Specialty Advisory Committee in General Surgery. Multi-factorial Pathogenesis. Connective tissue changes Peripheral neuropathy Somatic sensory

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Current Issues in Diabetic Foot Disease

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  1. Current Issues in Diabetic Foot Disease Gareth Griffiths Department of Vascular Surgery, Ninewells Hospital, Dundee, UK Chairman of the Specialty Advisory Committee in General Surgery

  2. Multi-factorial Pathogenesis • Connective tissue changes • Peripheral neuropathy • Somatic sensory • Somatic motor • Autonomic • Pressure point development • Immunological dysfunction • Infection • Superadded ischaemia

  3. Eurodiale Study • Multicentre European cohort study • 1229 patients studied in 2003/2004 • Arterial disease 49% • Infection 58% • Non-plantar 52% Older Nonplantar Comorbidity Diabetologia 2008;50:18-25

  4. Treatment Plan • Connective tissue changes • Peripheral neuropathy • Pressure point development • Immunological dysfunction • Infection • Superadded ischaemia IdentifyProtectPrevent Antibiotics Debridement Wound care Endovascular Bypass

  5. Infection Gram +ve 32% Gram -ve 51% Anaerobes 15% Polymicrobial75% Gram +ve: vancomycin Gram -ve: piperacillin-tazobactam / amikacin Al Benwan et al J Inf Pub Health 2012;5:1-8 ESBL: 10% of E coli and Proteus Tascini et al Diab Res Clin Prac 2011;94:133-9

  6. Infection • Local debridement • Sharp • Autolytic • Fly larvae • Versajet • None better than sharp • Surgical debridement • As radical as needs be • Only get one chance in severe infection • Beware of leaving a metatarsal head

  7. Surgical Debridement

  8. Revascularisation Correct the correctableEndovascular techniques Surgical bypass If good - Bypass If mediocre - Bypass / endovascular If poor - Endovascular Patient fitness Vein quality Arterial target quality Life expectancy BASIL Trial, Lancet 2005;366:1925-34 • Bypass better for extensive tissue loss Neville et al Sem Vasc Surg 2012;25:102-7 • Aim for in line flow into the foot

  9. Angiosomes • Concept introduced in 1987 Taylor et al Br J Plast Surg 1987;40:113 • 3D zones • Supplied by specific source arteries • Drained by specific veins • Patent bypass but failed healing in 10-18% Simons et al J Vasc Surg 2010;51:1419-24

  10. Angiosomes anterior tibial posterior tibial peroneal 6. directvsindirect Alexandrescu et al J Endovasc Ther 2008;15:580-593

  11. Angiosomes • Factors influencing choice of target vessel • Length of available autogenous vein • Quality of tibial arteries and skin • ?angiosome affected • ? direct revacularisation better than indirect Neville et al Ann Vasc Surg 2009;23:367-373 Varela et al Vasc Endovasc Surg 2010;44:654-60 Iida et al J Vasc Surg 2012;55:363-70 • Indirect revascularisation better than none

  12. Wound Management • Simple dressings • No evidence that any are superior • Negative pressure wound dressings • Reduces oedema, ?stimulates angiogenesis • Accelerates healing of ulcers and debrided wounds Blume et al Diab Care 2008;31:631-6 Armstrong et al Lancet 2005;366:1704-10 Apelqvist Am J Surg 2008;195:782-8

  13. Adjunctive Wound Management • Cell derived growth factor treatment • Hyperbaric oxygen • Extracorporeal shock wave • None have been shown conclusively to be of value

  14. Adjunctive Wound Management Cell derived growth factor treatment • Fibroblast derived dermal substitute (Dermagraft) • Cultured human fibroblasts, bioabsorbable scaffold Marston et al (RCT) Diab Care 2003;26:1701-5 • Allogenic cultured skin (Apligraf) • Cultured human keratinocytes and fibroblasts with bovine collagen Edmonds et al (RCT) Int J Lower Ext Wounds 2009;8:11-18 Veves et al Diab Care 2001;24:290-5

  15. Adjunctive Wound ManagementHyperbaric Oxygen • Mechanism of action • Stimulates angiogenesis • Enhances fibroblast and leukocyte function • Normalises cutaneous microvascular reflexes • Small, underpowered studies • No conclusive evidence for improved healing Kranke et al Cochrane Database Syst Rev 2004(2):CD004123 • More recent randomised controlled trial • Suggested greater healing rate at 1 year Londahl Diab Care 2010;33:998-1003 • ?More effective if TCpO2 is >25mmHg • Expensive and difficult for daily treatment

  16. Adjunctive Wound ManagmentExtracorporeal Shock Wave Therapy • ?increased angiogenesis via growth factor stimulation • ?neolymphogenesis • ?improved wound perfusion, increased cell proliferation, reduced apoptosis • Mechanism of action uncertain • ?Improved healing over hyperbaric oxygen • Wang et al Diab Res Clin Prac 2011;92:187-93

  17. First Principles • Identify • Protect • Prevent • If ulcers develop, • Treat aggressively • Eradicate infection • Revascularise • Re-epithelialise • Pressure relief

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