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 49%• Infection 58%• Non-plantar 52%

PAD - PAD +Infection - 24% 18%

Infection + 27% 31%

OlderNonplantar

Comorbidity

Diabetologia 2008;50:18-25

Treatment Plan

Antibiotics DebridementWound care

IdentifyProtect

Prevent

Endovascular

Bypass

• Connective tissue changes• Peripheral neuropathy• Pressure point development

• Immunological dysfunction• Infection

• Superadded ischaemia

InfectionGram +ve

32%Gram -ve

51%Anaerobes

15%Polymicrobial

75%

Gram +ve: vancomycin

Gram -ve: piperacillin-tazobactam / amikacin

ESBL: 10% of E coli and ProteusTascini et al Diab Res Clin Prac 2011;94:133-9

Enterobacteriaceae 28% Anaerobic gram –ve 11%

Pseudomonas 17% MRSA 8%

Staph Aureus 12% Enterococcus 7%

Al Benwan et al J Inf Pub Health 2012;5:1-8

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

If good- Bypass

If mediocre - Bypass / endovascular

If poor- Endovascular

Patient fitnessVein qualityArterial target qualityLife expectancy

BASIL Trial, Lancet 2005;366:1925-34

• Bypass better for extensive tissue lossNeville et al Sem Vasc Surg 2012;25:102-7

• Aim for in line flow into the foot

Correct the correctableEndovascular techniques

Surgical bypass

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

posterior tibial

peroneal

anterior tibial

6.

Alexandrescu et al J Endovasc Ther 2008;15:580-593

directvs

indirect

Angiosomes

• Factors influencing choice of target vessel– Length of available autogenous vein– Quality of tibial arteries and skin– ?angiosome affected

• ? direct revacularisation better than indirectNeville et al Ann Vasc Surg 2009;23:367-373

Varela et al Vasc Endovasc Surg 2010;44:654-60Iida 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;31:631-6Armstrong 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 scaffoldMarston et al (RCT) Diab Care

2003;26:1701-5

• Allogenic cultured skin (Apligraf)– Cultured human keratinocytes and

fibroblasts with bovine collagenEdmonds et al (RCT) Int J Lower Ext Wounds

2009;8:11-18Veves 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

– ?increased angiogenesis via growth factor stimulation

– ?neolymphogenesis– ?improved wound perfusion,

increased cell proliferation, reduced apoptosis

•?Improved healing over hyperbaric oxygenWang et al Diab Res Clin Prac 2011;92:187-93

• Mechanism of action uncertain

First Principles

• Identify• Protect• Prevent

• If ulcers develop, – Treat aggressively• Eradicate infection• Revascularise• Re-epithelialise• Pressure relief