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
– Somatic motor
– Autonomic
•
•
•
•
Pressure point development
Immunological dysfunction
Infection
Superadded ischaemia
Eurodiale Study
• Multicentre European cohort study
• 1229 patients studied in 2003/2004
• Arterial disease
• Infection
• Non-plantar
49%
58%
52%
PAD - PAD +
Infection -
24%
18%
Infection + 27%
31%
Older
Nonplantar
Comorbidity
Diabetologia 2008;50:18-25
Treatment Plan
• Connective tissue changes
• Peripheral neuropathy
• Pressure point development
Identify
Protect
Prevent
• Immunological dysfunction
• Infection
Antibiotics
Debridement
Wound care
• Superadded ischaemia
Endovascular
Bypass
Infection
Gram +ve
32%
Gram -ve Anaerobes
51%
15%
Polymicrobial
75%
Enterobacteriaceae 28% Anaerobic gram –ve 11%
Pseudomonas
17% MRSA
8%
Staph Aureus
12% Enterococcus
7%
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
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
Surgical Debridement
Revascularisation
Correct the correctable
Endovascular techniques
Surgical bypass
Patient fitness
Vein quality
Arterial target quality
Life expectancy
If good
- Bypass
If mediocre
- Bypass / endovascular
If poor
- Endovascular
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
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
Angiosomes
anterior tibial
posterior tibial
peroneal
6.
direct
vs
indirect
Alexandrescu et al J Endovasc Ther 2008;15:580-593
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
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
Adjunctive Wound Management
• Cell derived growth factor treatment
• Hyperbaric oxygen
• Extracorporeal shock wave
• None have been shown conclusively
to be of value
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
Adjunctive Wound Management
Hyperbaric 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
Adjunctive Wound Managment
Extracorporeal Shock Wave Therapy
• Mechanism of action uncertain
– ?increased angiogenesis via
growth factor stimulation
– ?neolymphogenesis
– ?improved wound perfusion,
increased cell proliferation,
reduced apoptosis
•?Improved healing over hyperbaric oxygen
Wang et al Diab Res Clin Prac 2011;92:187-93
First Principles
• Identify
• Protect
• Prevent
• If ulcers develop,
– Treat aggressively
•
•
•
•
Eradicate infection
Revascularise
Re-epithelialise
Pressure relief