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Foot and Leg Wound Management: Medical Issues

Foot and Leg Wound Management: Medical Issues. Dr. Todd Yip MSc MD FRCPC Dine and Learn Event Victoria Division of Family Practice January 28, 2014. Declaration. One Bracing is an orthotic, bracing, and splinting office within Rebalance MD clinic. Foot and Leg Ulcer Clinic.

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Foot and Leg Wound Management: Medical Issues

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  1. Foot and Leg Wound Management: Medical Issues Dr. Todd Yip MSc MD FRCPC Dine and Learn Event Victoria Division of Family Practice January 28, 2014

  2. Declaration • One Bracing is an orthotic, bracing, and splinting office within Rebalance MD clinic

  3. Foot and Leg Ulcer Clinic • RJH Memorial Pavilion • 40-50 new referrals per month • Nurses, Pedorthist, Orthotist, Physician, Surgeon • Not open Mondays, some Friday PM • Referrals must be via Central Intake • Recommend fax copy of referral to FLUC

  4. Peripheral Vascular Disease and Compression Dr. Todd Yip MSc MD FRCPC Victoria Division of Family Practice Dine and Learn Event January 28, 2014

  5. Edema • Lower limb edema control is vital to heal wounds and to prevent recurrent ulceration. • How much compression would be reasonable? • What is a reasonable to compression management?

  6. PVD Work-up • Arterial • **Renal function (eGFR >60) • **Resting arterial doppler U/S (includes ABI) • ABI (with doppler study • **CTA Abdo Aorta + runoff (preferred) • Conventional unilateral angiogram • MR Angiography • **key items • Venous • Reflux (valve competence) • Deep veins, Superficial veins, perforators

  7. Ankle Brachial Index/Doppler Ultrasound • Index • <0.4 Severe disease (rest pain) • 0.4-0.9 Mild to moderate disease • 0.9-1.2 Normal • >1.3 Poorly compressible vessels • Age and diabetes – main confounders • Doppler • Waveform (flattens with disease) • Triphasic Normal • Biphasic Mild disease • Monophasic Severe disease • Localizes occlusive disease • Eg. Monophasicpopliteal, dorsalispedis, posterior tibial = above knee stenosis • Toe pressure • >30 mmHg • Predicts healing in non-diabetic • >50 mmHg • Predicts healing in diabetic

  8. Ankle Brachial Index • Sensitivity: 70-90% • Lower in elderly or diabetics • Specificity: 65-95% • Khan TH et al. Critical Review of the Ankle Brachial Index. Current Cardiology Reviews, 2008, 4, 101-106

  9. ABI/Toe Pressure

  10. ABI/Toe Pressure

  11. Approach to Compression • Avoid compression (generally) • Severe PAD; ABI <0.4 • Low compression (8-15 mmHg) • ABI >0.5 • Pure venous + leg edema +/- significant drainage • Needs dressing, not socks • Mixed PVD • Medium compression (15-20 mmHg) • Mixed PVD, if edema control reasonable • If tolerating low compression • Try adding low compression sock to low compression dressing to graduate

  12. Approach to Compression • High compression • At least 20-30 mmHg compression • Strong, palpable pulses, normal ABI; No risk factors • Pure venous disease, mild edema • ?Local dressing + compression sock vs. compression dressing • Depends on clinical picture/practical options • Trial and (hopefully not) error approach • If dressings, change 2 to 3 x per week

  13. Practical Considerations • The application of compression dressings (or complex dressing) is highly variable • Socks must be hand-washed and hung to dry • Socks must be less than 6-8 months old (of total daily use) • Socks on in the AM, off in the PM, unless patient sleeps in chair • Dressing and sock costs are often not covered in community

  14. Some Compression Dressings • Modified Unna’s boot +/- tensor • Less than 10mmHg • Light options: local dressing + tubifast (blue- or yellow-line, or tubigrip) • Coban 2 lite – 20-30 mmHg • Coban 2 – 30-40 mmHg

  15. Some Compression Options • If no ulcer or nearly healed, then compression stockings: • 8-15 mmHg (e.g. “Diabetic sensifoot”) • 15-20 mmHg intermediate • 20-30 mmHg venous insufficiency, some PAD • 30-40 mmHg lymphedema • 40-50 mmHg young venous insufficiency • Some patients can use remarkably high compression safely

  16. Compression Stocking Practical Tips • Layered lower level compression stockings for increased compliance/ease of management and cost savings • 10 mmHg stocking liner • 10 mmHg ankle-high “socklet” • Open-toed or zippered socks • Sock donning gadgets • Home supports as required for dressing

  17. Infection Dr. Todd Yip MSc MD FRCPC Victoria Division of Family Practice Dine and Learn Event January 28, 2014

  18. Work-up - Foot • X-ray +/- x-ray in 3 weeks • CBC, CRP, renal function • Bone scan (debatable role – non-specific) • “add infection label if +” • WBC label if <3/12 • Gallium if >3/12 • Indicate duration of ulcer and if patient on antibiotics on requisition • MRI - ?debatable role • Wound cultures can be helpful or misleading

  19. Infection • Legs • Mostly clinical diagnosis • ?Cellulitis vs. ?Stasis dermatitis vs. ?Ostemyelitis • Essentially the same work up as feet

  20. Diabetic Foot Infections (DFI) • Mostly polymicrobial • Aerobic GPC, especially staphylococci • Aerobic GNB, if chronic • Anaerobes, if ischemic or necrotic • Foul odour of necrosis +/- pseudomonas

  21. Reasonable Empiric Antibiotics • 1st line • Keflex (500 mg BID-QID) • Clindamycin (300-600 mg TID) • 2nd line • Clindamycin + cipro (250-500 mg OD-BID) • Clavulin (500 mg TID/875 mg BID) • If MRSA • Clindamycin, Bactrim (1 DS tab BID), or Doxycycline (100 mg BID) • Note: clindamycin requires no adjustment for renal function and covers MRSA!

  22. Parenteral Antibiotics • Suggested Indications • Failed oral antibiotics • Abscess or ?abscess (surgical consult pending) • Sepsis • Dialysis • Side effects from oral antibiotics • Impaired immune response • Past response of frequent flyers • ?Non-adherence to oral medications? • “No data support the superiority of any specific antibiotic agent or treatment strategy, route, or duration of therapy” • Lipsky et. al., 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clinical Infectious Diseases 2012;54(12):132-173

  23. Imaging for Osteomyelitis Details Pineda  C, Vargas  A, Rodriguez  AV.  Imaging of osteomyelitis: current concepts.  Infect DisClin North Am.  2006;20(4):789–825. Termaat  MF, Raijmakers  PG, Scholten  HJ, Bakker  FC, Patka  P, Haarman  HJ.  The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis.  J Bone Joint Surg Am.  2005;87(11):2464–2471. Kapoor  A, Page  S, Lavalley  M, Gale  DR, Felson  DT.  Magnetic resonance imaging for diagnosing foot osteomyelitis: a meta-analysis.  Arch Intern Med.  2007;167(2):125–132

  24. Dermatology and Diabetes: Something Different? Dr. Todd Yip MSc MD FRCPC Victoria Division of Family Practice Dine and Learn Event January 28, 2014

  25. Skin Manifestations of Diabetes • Type 1 • Periungaltelangiectasia • Necrobiosislipoidicadiabetacorum • Bullosisdiabeticorum • Vitiligo • Lichen ruberplanus • Type 2 • Yellow nails • Diabetic thick skin • Acrochordons (skin tags) • Diabetic dermopathy • Skin spots and pigmented pretibial papules • Acanthosisnigricans • Acquired perforating dermatosis • Calciphylaxis • Eruptive xanthoma • Granulomaannulare

  26. Skin Manifestations of Drugs • A number of reactions, too many to list • Van hattem, Bootsma AH, Thio HB. Cleveland Clinic Journal of Medicine: 75(11): 772-787

  27. Three Recent Cases

  28. My Main Differential Diagnosis • Dry skin (autonomic) • Fungus/tinea • ??Psoriasis • ??Something else that responds to topical steroid • If psoriasis, then it is recommended not to debride • So, confirming a diagnosis will affect the treatment approach (i.e. it affects management)

  29. ?Psoriasis • Usually 2-3 referrals per to Dr. Telford, RJH Psoriasis Clinic dermatologist for “?Psoriasis not previously diagnosed?” • For estimated >95% of referrals, Dr. Telford agrees psoriasis – may or may agree with foot involvement • Prevalence = 2-4% general population • Prevalence among patients with diabetes? • Disclaimer: Dr. Telford’s consultation is pending for these cases.

  30. Recent Literature: Psoriasis-Diabetes Link • Independent risk factor in the development of T2DM • Population-based cohort study (n=108132) • HR 1.14 (mild psoriasis); 1.30 (severe psoriasis) • Arch Dermatol. 2012;148(9):995-1000. • Associated with an increased prevalence and incidence of diabetes • Systematic review and meta-analysis • 27 Cohort, case-control, and cross-sectional studies from 1980-2012 • Prevalence OR 1.59 (1.97 if severe psoriasis); Incidence RR 1.27 • JAMA Dermatol. 2013; 149(1)84-91.

  31. Questions • Is the reverse true? • That is, • Is the incidence and prevalence of psoriasis higher amongst those with diabetes? • Is diabetes and independent risk factor for psoriasis? • Is psoriasis more prevalent among those with “severe” diabetes? Or, those who have or at high risk of foot ulcers?

  32. Three Recent Cases

  33. Simple Treatment Approach • If unsure, consider treat with least potentially harmful agent first • Moisturizer • Hydrophilic petrolatum • Atrac-Tain • Anti-fungal • Anti-dandruff shampoo foot wash • Lamisil 1% OD • Steroid ointment • Clobetasol0.05% OD (affected areas only) • Dermatology referral

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