THE DIABETIC

FOOT
DR.SEIF I M ELMAHI
MD, FRCSI
University of Khartoum,
Sudan

CONTENT

Definition
Epidemiology
Social & Economic factors
Pathophysiology of foot ulceration
Diabetic Neuropathy
Peripheral Vascular Disease & Diabetes
Biomechanics of Foot Wear
The Diabetic Foot Ulcer Outcome & Management
Neuro-osteoarthropathy
Amputation in Diabetic Patient
Prevention of Foot Problem

Diabetic Foot
Definition:
Infection, ulceration or
destruction of deep tissues associated
with neurological abnormalities &
various degrees of peripheral vascular
diseases in the lower limb

definition)

(based on WHO

Epidemiology
40%

- 60% of all non traumatic lower

limb amputation
85% of diabetic related foot
amputation are preceded by foot ulcer
4 out of 5 ulcer in diabetics are
precipitated by trauma
4% -10% is the prevalence of foot
ulcer in diabetics

Epidemiology
In Sudan:
Prevalence of DM ? 6 12 %
DSF inpatient KTH :
30% - 40% risk of major
amputation
8% - 20% mortality

Social & Economic Factors

Diabetic

foot complications are

expensive :
(cost of healing 7000-10000 USD)
(healing with amp. 43000In Khartoum :

Intervention

63000USD)
(4 weeks dressing cost 110000SD)

of foot care is cost

effective in most societies
Scarce information regarding long
term prognosis

Pathophsiology of Foot Ulceration

Neuropathic
Ischemic
Neuro -ischemic

STAGES OF ULCER DEVELOPMENT

STAGES OF ULCER DEVELOPMENT

Diabetic Neuropathy
Sensorimotor

& peripheral
sympathatic neuropathy are major
risk factors for ulcer
History & careful foot examination are
mandatory to diagnose neuropathy
Up to 50%of type2 diabetic patient
have significant neuropathy & at risk
of foot ulcer

Periphral vascular disease&

diabetic PVD

PVD is the most important factors related to

outcome of diabetic foot ulcer
PVD is diagnosed by simple clinical examination
non invasive vascular test determines probability
of healing
Symptoms of ischemia may be masked by
neuropathy
Microangiopathy shouldn't be accepted as primary
cause of ulcer
Conservative approach for treatment
Outcome of revascularization is similar to that in
non-diabetic

Biomechanics of foot wear

Biomechanical abnormalities are
consequence of neuropathy, they lead to
abnormal foot pressure
Foot deformity & neuropathy increase the
risk of ulcer
Pressure relief is essential for ulcer healing
and/or prevention
Frequent inspection of shoes & insoles is
mandatory
Appropriate foot wear significantly reduce
ulcer recurrence

Diabetic Foot Infection

Infection in diabetic foot is limb threatening
Signs of infection may be absent in diabetic
pt. with foot ulcer
Superficial infection is usually caused by
gram +ve cocci, deep infection is poly
microbial
Surgical debridment is essential in acute
deep infection
Osteomylitis( diagnoses & treatment)

Neuro-osteoarthropathy
Non-

infective pathology
Should be suspected in any swollen
hot erythematous foot
Differentiation from infection is
important to prevent misdiagnosis &
possible amputation
Treatment should aim at preventing
severe deformity

Diabetic Foot Ulcer Treatment

Multidisciplenary

approach
Staging dictate the treatment
option
Continuity of care & life long
observation

Amputation in Diabetic Patient

Increased

minor\major amputation
increased the no. of deformed feet
Minor amputation is needed :
*Gangrene
*As part of debriment
*for correction of foot deformities
Minor

amputation doesnt
significantly compromise walking
ability

Major Amputation

Risk of loss walking ability

Mortality
Risk of contra-lateral amputation
Strict indication
Careful choice of the level

How To Prevent Foot Problems

5 corner stones
Regular

inspection & examination of

foot & foot wear
Identification of high risk patient
Education of patient, family & health
care providers
Appropriate foot wear
Treatment of non ulcerative pathology

SENSORY NEUROPATHY

Diabetic Neuropathy

PERIPHRAL VASCULAR DISEASE

Biomechanics of foot wearAREAS AT

RISK OF ULCERATION

FOOT WEAR

FOOT WEAR

OSTEOMYLITIS

Diabetic Foot Ulcer Treatment

Modalities
Microbiological
Wound

control

control
Vascular control
Mechanical control
Metabolic control
Educational control

Staging of Diabetic Foot

Stage
1
2
3
4
5
6
amputation

Clinical condition
Normal
High risk
Ulcerated
cellulitic
Necrotic
Major

Assessment of Diabetic Foot

Neuropathy
Ischemia
Deformity
Callus
Swelling
Skin

breakdown
Infection
Necrosis

NEURO-OSTEOARTHROPATHY(CHARCOT
FOOT)

NEURO-OSTEOARTHROPATHY(CHARCOT
FOOT)Neuro-osteoarthropathy

PODIATRY