FOOT ULCERS

Dr.B.BALAGOBIRegistrar/Surgery

Chronic Foot ulcers

• Diabetic ulcer• Vascular– Arterial– Venous

• Infection:COM• Malignant

Arterial ulcers

Pulse evaluations

Neuropathic ulcers

Neuropathic ulcers

OSTEOMYLITIS

Pathogenesis

Venous Arterial Neuropathic

Treatment:Venous ulcer

VV Treatment

Surgical• V Vs surgery:– High tie– Stripping– Perforators ligation– Multiple avulsions

Treatment:Arterial ulcer

• Arterial bypass.• Debridment.• Skin Graft.

Arterial Bypass

Skin graft

Treatment:Neuropathic ulcers

Off load the pressure !

Wound dressing

BASICS

• Treat the aetiology– Hb– FBS control– Vit C,Zn– Protein– Respect VIP• Vascular• Infection• Pressure

Methodes of Debridement

• Surgery• Hydro therapy• Biological:Maggots• Enzymatic:Proteolytic enzyme• Autolytic:Hydrogel

Surgical debridement

Bedside procedure

Mechanical

Debridement

Maggots

Reduce bacterial load

Moisture

VAC therapy

VAC

VAC

VERY TASTY!!!!!!

Diabetic Foot ulcer

Latest Figures • Prevalence for Sri Lankans aged ≥20 years –

10.3%• Prevalence of pre-diabetes in urban and rural

population was 11.5% • Overall prevalence of some form of dysglycaemia

(sugar problems) was 21.8%

2008*- Katulanda P. Constantine G.R. , Mahesh J. G. etal., Prevalence and projections of diabetes and pre-diabetes in adults in Sri Lanka- Sri Lanka Diabetes , Cardiovascular Study (SLDCS)

Epidemiology• DM largest cause of neuropathy• Half don’t know• Foot ulcerations is most common cause of hospital

admissions for Diabetics.• Expensive to treat• may lead to amputation.

Pathophysiology• Vascular disease• Neuropathy– Sensory– Motor Foot deformities– Autonomic

• Hyperglycaemia• Immune deficiency

STAGES OF ULCER DEVELOPMENT

STAGES OF ULCER DEVELOPMENT

RISK STRATIFICATION

• Previous ulceration/Amputation• Sensory neuropathy• Foot deformities/Callous• PVD

RISK STRATIFICATION

• Low risk– no risk factors and no previous ulceration

• High risk – one risk factor and no previous ulceration

• Foot emergencies – ulcerated, injured or infected foot

10g Monofilament-Sensory Examination

Corns

Callous

HALLUX

HAMMERTOES

Footwear

• Match to the shape of the foot– Room for breathing & movement– Accommodate foot deformities

• Modification of foot wear– Insert cushioned insoles

• Offload pressure areas

Evidence-based decisions for local & systemic wound care

Paper accepted 12 April 2012Published online 6 July 2012 in Wiley Online Library (www.bjs.co.uk)

Background

• CommonQOL, pain and cost.• Decisions vary among surgeons and are

frequently based on expert opinion. • literature on wound care, often showing

conflicting results.• The aim of this review was to compile best

available evidence from systematic reviews.

Methods

• For this review, All systematic reviews in the Cochrane Database up to June 2011 on local and systemic wound care were included.

systematic review

• is a literature review focused on a research question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question.

Methods

• For this review, All systematic reviews in the Cochrane Database up to June 2011 on local and systemic wound care were included.

• 109 evidence based conclusions: – 30 on venous ulcers– 30 on acute wounds(Traumatic and surgical wounds)

– 15 on pressure ulcers– 14 on diabetic ulcers– 12 on arterial ulcers– 8 on miscellaneous chronic wounds.

• Systemic reviews were retrieved and screened independently by two researchers, and by a third in case of any disagreement.

RESULTS• Findings were placed into five categories,

based on – Strong evidence of effect– Strong evidence of no effect– limited evidence of effect– limited evidence of no effect – no evidence either way

• A total of 33 conclusions with strong evidence of effect and 18 conclusions with fairly strong evidence of effect could be drawn from the CSR.

Acute wounds: conclusions with strong evidence of effect

Acute wounds

• Using antibiotics to prevent infections after dog bites is ineffective unless the bites are on the hands.

• Cleansing pin site orthopaedic fixators wounds using saline, alcohol, hydrogen peroxide or antibacterial soap to prevent infections is no more effective than no cleansing.

• Systemic treatment with therapeutic touch does not have any additional effect on wound healing compared to placebo or non-treatment after minor surgery.

Acute wounds

• Topical honey reduces wound healing time when compared to film or gauze-based dressings for burns.

Healing Wounds and other Health Conditions with Honey

• produced hydrogen peroxide that is responsible for the antimicrobial activity of all honey.

• effective against antibiotic-resistant strains of bacteria.

• Unlike other topical antimicrobial agents used on wounds, Manuka honey does not slow the healing.

Acute wounds

• Silver sulfadiazine should not be used for burns as trials show this can delay wound healing and increase pain and infection rates.

• Drinking quality tap water is better for cleansing lacerations and acute soft tissue wounds than sterile saline solutions.

Acute wounds• No difference between sutures, adhesive

tape and tissue adhesives for wound healing.

• Less erythema and pain when using tissue adhesives compared with standard wound care

• Tissue adhesives are a reasonable alternative to close traumatic lacerations, despite a slightly increased rate of wound dehiscence

Venous ulcer: conclusions with strong evidence of effect

Venous ulcers

• Pentoxifylline was strongly effective in promoting wound healing compared with placebo, in combination with compression therapy.

Pentoxifylline

•It is used to treat intermittent claudication.•is a competitive nonselective phosphodiesterase inhibitor.•Which raises intracellular cAMP, activates PKA, inhibits TNF and leukotriene synthesis.•Improves red blood cell deformability,reduces blood viscosity and decreases the potential for platelet aggregation and thrombus formation.

Venous ulcers

• Oral zinc was strongly ineffective for ulcer healing compared with placebo.

• no antimicrobial drug should be used without evidence of colonization or infection.

Venous ulcers• Strong evidence of effect was shown for high

compression versus low compression, whereas elastic bandages were more effective than inelastic bandages.

• Limited evidence of effect is available for the following local antimicrobial therapies in addition to compression therapy to increase healing rates.(iodine, hydrocolloid)

High compression elastic bandages.

Venous ulcer

• Type of wound dressing beneath compression does not influence healing (trials included hydrocolloids, foam dressings, alginates,low-adherent dressings and hydrogels)

• Lidocaine–prilocaine cream decreases pain during ulcer dressings (not clear whether this affects healing)

Diabetic ulcer: conclusions with strong evidence of effect

Diabetic ulcers

• Using hyperbaric oxygen therapy decreases major amputations in diabetic.

hyperbaric oxygen therapy

Diabetic ulcers

• There is strong evidence of benefit for the local application of hydrogels after debridement compared with standard treatment after debridement, gauze-based dressings or standard care to promote wound healing.

Hydrogel dressing

• is designed to hold moisture in the surface of the wound,.

• providing the ideal environment for both cleaning the wound, and allowing the body to rid itself of necrotic tissue.

• The moisture in the wound is also essential in pain management for the patient, and these dressings are very soothing and cooling.

Hydrogels dressing

Diabetic ulcer

• Surgical or larval debridement may decrease healing time comparedwith conventional treatment or hydrogel(Small study)

• No eligible studies identified so no evidence for effectiveness of silver-based wound dressings

Arterial ulcer: conclusions with strong evidence of effect

Arterial ulcers

• Systemic prostanoids should be used to relieve rest pain and improve ulcer healing in patients with critical leg ischaemia.

• Oral iloprost reduces amputation.

Prostanoids

•Iloprost is a synthetic analogue of prostacyclin PGI2.• Iloprost dilates systemic and pulmonary arterial vascular beds.• It also affects platelet aggregation

Arterial ulcers

• Spinal cord stimulation improves limb salvage.

Arterial ulcer

• Primary graft patency was higher compared with PTA after 1 year.

Pressure ulcer: conclusions with strong evidence of effect

Pressure ulcers

• Using high-specification foam mattresses and low air loss mattresses can prevent pressure ulcers on the ward and pressure-relieving overlays are recommended on operation tables.

• Using local therapeutic ultrasound is not recommended for healing pressure ulcers.

Foam mattresses

• The Memory Mattress is made from unique upper layer of high density visco-elastic polymer gel.

• Originally designed for NASA missions, it is soft and pliable following the outline of your body perfectly.

Foam mattresses

Foam mattresses

CONCLUSION

• "Ideally wound treatment decisions should be based on the best available evidence, integrated with patients' concerns and priorities and fine-tuned by the local resources and skills”

THANK YOU