Strategies For Complex Foot Affections In Diabetes

Sherif El-Sarky
Professor of Surgery, Faculty of Medicine, Cairo University (Kasr Al-Ainy)

Strategies For Complex Foot Affections In Diabetes

Sherif El-Sarky

Diagnostic challenges
1) 2) 3) 4) 5) Vascularity and viability of foot tissues. Extent of bony affection. Localization of deep collections. Decision for intervention. Assessment of progress.

Objectives

Disease control
1) Infection eradication. 2) Dead tissue extirpation. 3) Healing promoting.

Limb salvage
1) Anatomical integrity. 2) Function.

1) In the shortest possible time. 2) At the least possible costs.

Strategies
1) Precise initial evaluation, for: foot vascularity, extent of infection and tissue viability.

2) Precise therapeutic decision making for intervention and RVP.

3) Continuous monitoring for progress: infection, viability and healing.

Initial evaluation

Diagnostic challenges
1) 2) 3) 4) Vascularity and viability of foot tissues. Extent of bony affection. Localization of deep collections. Assessment of progress.

Foot vascularity is assessed by: 1) Clinical evaluation. 2) Doppler study and Duplex scan for any major vascular insufficiency above the ankle. 3) MRA for vascularity below the ankle (when suspected to be compromised).

Extent of infection is assessed by: 1) Clinical evaluation (differential pressure). 2) Bacteriological study (C&S). 3) Imaging for deep collections: contrast study (sinography) and MRI. 4) Osteomyelitis is detected by: probing test, plain X-ray and MRI.

Tissue viability is assessed clinically (bleeding, color, reaction ..).

Therapeutic Decision

Locally, therapy, consists of:

1) Dressing. 2) Intervention (drainage, debridement). 3) RVP.

Facts
1. Pedal infections occur in up to 25% of diabetic patients (Lipsky et al, 1990). 2. They are the most common cause of hospital admission in diabetics (Eckman et al, 1995). 3. Diabetic foot is behind25% of total expenses of hospital treatment in diabetics (Stiegler, 1989). 4. It is the most common cause of amputation (after trauma) in USA (Newman et al, 1991).

Facts !

The Principle

Principle

Bier's principle (direct administration of agents to tissues by retrograde venous perfusion with arterial blockade) was introduced in 1908. Since then, it was limited to regional anesthesia (local intravenous anesthesia). Eighty years later (1988), it was re-discovered as a potential approach for therapy in foot disorders, by the Latin American investigators Acevedo and Schoop from Chile.

RVP results in high tissue concentration of administered drugs. RVP results in high tissue concentration of
administered drugs.
Tissue concentration of 99 mTc labelled human 1. Tissue concentration of 99 mTc labelled human serum albumin after was: :RVP serum albumin after RVP was: .3. times higher than after intra-arterial 3 times higher than after intra-arterial . 7 times higher after systemic i.v. injection . 7 times higher thanthan after systemic i.v. injection

Pharmacologically, tissue concentration of 2. Pharmacologically, tissue concentration Netilmycin after RVP was 2.5 times higherof than 2.5 times higher than after systemic i.v.i.v. injection (Seidel et al, 1995). after systemic

Previous Applications Recent Applications

author(s) Partsch et al, 1993 indication trophic lesions agent buflomedil frequency 3/week duration 3 weeks Acevedo et al, foot ulcer 1993 Seidel et al, 1994 Buhler-Singer et al, 1995 DNPU

Cefotaxime

once

once

Netilmycin combinatio n

daily

10 days

DNPU

daily

10 days

Patient Groups Patients

group
disorder
diabetic foot: acute infection diabetic foot: trophic ulcer diabetic foot: pedal ischemia nondiabetic traumatic ulcer nondiabetic pedal ischemia

number

A B C D E

8 4 3 4 5

Assessment of the patient and the lesion

Assessment of the patient Diabetic patients: grou

1. 1. Diabetic Diabetic history: history: duration duration of of diabetes, diabetes, control control of of diabetes, isease, diabetes,history history of of neuropathy, neuropathy, vascular vascular d d isease, coronary .. coronary artery arterydisease, disease, hypertension hypertension 2. 2. Pedal Pedal history: history: previous previous diabetic diabetic foot foot affection, affection, its its duration, duration,prior prior surgical surgical intervention, intervention, amputations. amputations. 3. 3. General General examination examination 4. 4. Local Local examination: examination: ..lesions lesions were were defined. defined. .. neurological neurological examination examination .. Doppler Doppler study study of of the the lower lower extremities extremities .. culture culture and and sensitivity sensitivity of of any any discharge discharge .. assessment assessment of of underlying underlying bone bone involvement involvement

Group C Patients Examination of pedal ulcer

Examination of diabetic ulcer
1. 1. site, site, shape shape and and ulcer ulcer area. area. 2. 2. ulcer ulcer depth: depth: visually visually and and by by bone bone probing, probing, .. grade-I: grade-I: exposing exposing bone bone (visually) (visually) .. grade-II: grade-II: reaching reaching bone bone (by (by probing) probing) .. grade-III: grade-III: deep deep (> (> 3 3 mm, mm, not not reaching reaching bone) bone) .. grade-IV: grade-IV: shallow shallow (< (< 3 3 mm) mm) 3. 3. severity severity of of infection infection and and surrounding surrounding inflammation. inflammation. 4. 4. presence presence of of gangrene gangrene and and its its extent extent 5. 5. clinical clinical signs signs suggesting suggesting bone bone involvement involvement

Method

Method Technic
1. 1. A A dorsal dorsal foot foot vein, vein, or or a a vein vein in in the the lower lower leg leg is is punctured. punctured. 2. veins. 2. The The leg leg is is elevated elevated for for 5 5 minutes minutes to to empty empty veins. 3. 3. A A sphygmomanometer sphygmomanometer cuff cuff is is applied applied to to the the lower lowerthigh thigh and and inflated, inflated, while while elevated, elevated, to to a a level level higher higherthan than systolic systolic pressure pressure of of the the patient. patient. 4. 4. The The agent(s) agent(s) employed employed is is slowly slowly injected injected into into the thevein vein diluted diluted in in 120 120 ml ml of of saline. saline. 5. 5. After After 20 20 minutes, minutes, the the pressure pressure is is released. released.

Clip 1

Clip 2 Clip 3

Agents Agents
group agent(s)
antibiotic (Gentamycin or otherwise) DSE/G/H/X DSE/G/H/X DSE/G/X/P DSE/PGE/G/X

A B C D E

Frequency

Frequency
group frequency
once to 3 times 3 / week 3 / week 3 / week 3 / week

A B C D E

Value of RVP
Good when arterial perfusion to the limb is inadequate...
as systemic therapy is not expected to reach therapeutic level in the target tissue.

Value of RVP
Good when a wound or an ulcer is the target
as the concentration of the therapeutic agents in wounds and ulcers reaches 3 times higher than intact skin. the "rinsing effect"

Value of RVP
Good for diabetics in particular
as it is associated with improvement in the impaired microcirculation of skin in these patients.

Value of RVP
Good when the agent is toxic
as smaller doses are required to reach the same therapeutic concentration in target tissue, and blood level after fixation in tissue is less than following systemic injection.

Value of RVP
Good when the agent is given systemically by infusion and the patient is cardiac
as this avoids volume overload hazards.

Value of RVP
Good when the agent is either expensive or not always available
as smaller doses and shorter courses are required.

Value of RVP
Good when surgery: has failed, is contraindicated or is required locally
as it can be considered as an alternative or adjunctive therapy

Value of RVP
Good Good when when time time is is a a critical critical factor factor
as as it it can can be be used used as as a a temporizing temporizing therapy therapy for for rapidly rapidly progressing progressing lesions lesions due due to to its its rapid rapid effects. effects.

Value of RVP
Good for patients patient with poor compliance to long-term therapy

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Value of RVP

Good as a last ditch therapy !!