The Diabetic Foot: Medical and Surgical Management

Front Cover......Page 1
Title Page......Page 4
Copyright......Page 5
Preface......Page 6
Contents......Page 8
Contributors......Page 10
Color Plates......Page 14
Epidemiology......Page 15
Diagnosis......Page 16
Classification......Page 17
Type 1 Diabetes......Page 18
Type 2 Diabetes......Page 19
Insulin Secretion......Page 20
Metabolic Abnormalities......Page 21
Diabetic Ketoacidosis......Page 23
Hyperosmolar Hyperglycemic Nonketotic Syndrome......Page 24
Microvascular Complications......Page 25
Retinopathy......Page 26
Nephropathy......Page 27
Macrovascular Complications......Page 28
Cardiovascular Disease And Diabetes......Page 29
Rationale And Goals Of Treatment......Page 31
Pharmacologic Treatment Of Type 1 Diabetes......Page 32
Insulin......Page 33
Oral Agents......Page 34
Approach To The Surgical Patient With Diabetes......Page 36
Cardiovascular Risk: Assessment And Management......Page 37
Glycemic Control In The Surgical Patient: Rationale......Page 39
Insulin Infusion......Page 40
The Glucose Balancing Act......Page 41
Subcutaneous Insulin Regimens......Page 42
Conclusions......Page 43
References......Page 44
Epidemiology Of Foot Ulcers......Page 49
Epidemiology Of Lower Limb Amputation......Page 54
Subsequent Amputations And Mortality......Page 63
Economic Considerations......Page 65
References......Page 69
Platelets......Page 73
Coagulation......Page 74
Proliferation And Tissue Formation (phase 2)......Page 75
Migration......Page 76
Fibroplasia......Page 79
Angiogenesis......Page 80
Fibronectin......Page 82
Collagen......Page 83
References......Page 84
Classification......Page 89
Distal Symmetrical Neuropathy......Page 90
Small-fiber Neuropathy......Page 92
Natural History......Page 93
Are Painful And Painless Neuropathies Distinct Entities?......Page 94
Acute Painful Neuropathy Of Poor Glycemic Control......Page 95
Asymmetrical Neuropathies......Page 96
Proximal Motor Neuropathy (femoral Neuropathy, Amyotrophy, Plexopathy)......Page 97
Truncal Radiculopathy......Page 98
Pathogenesis Of Distal Symmetrical Neuropathy......Page 99
Unknown......Page 0
Chronic Hyperglycemia......Page 100
Neurotrophic Factors......Page 101
Vascular Factors......Page 102
Autonomic Neuropathy......Page 103
Changes In Peripheral Blood Flow......Page 104
Gastroparesis......Page 105
Management Of Diabetic Neuropathy......Page 106
Intravenous Lignocaine And Oral Mexiletine......Page 107
References......Page 108
Overview Of Diabetic Microvascular Disease......Page 113
Morphologic Changes In The Microcirculation Of The Diabetic Foot......Page 114
Hyperglycemia, Hyperinsulinemia, And Diabetes......Page 116
Microvascular Disease And Neuropathy In The Diabetic Foot......Page 118
Conclusions......Page 122
References......Page 123
Pathology Of Atherosclerosis In Diabetes......Page 127
Clinical Presentation......Page 129
Diagnosis And Evaluation......Page 132
Treatment Protocol......Page 138
References......Page 139
Out-of-shoe Methods......Page 141
Podotrack......Page 142
In-shoe Methods......Page 143
Fscan System......Page 144
Natural History Of Foot Pressure Abnormalities In Diabetes Mellitus......Page 146
Foot Pressures And Foot Ulceration......Page 147
The Role Of Foot Pressures As A Screening Method To Identify At-risk Patients......Page 149
Off-loading The Diabetic Foot: The Role Of Footwear......Page 151
Hosiery......Page 152
Shoewear......Page 153
Insoles And Orthotics......Page 157
References......Page 158
Foot Function......Page 161
Changes In The Foot Caused By Diabetes......Page 162
Limited Joint Mobility......Page 163
Development Of Diabetic Foot Ulceration......Page 164
Biomechanical Aspects Of Foot Ulceration......Page 165
Plantar Tissue Thickness In Relation To Foot Ulceration......Page 166
Foot Type And Foot Ulceration......Page 167
Surgical Interventions And Foot Ulceration......Page 168
Off-loading The Diabetic Foot Ulcer......Page 170
References......Page 172
1. Is There Loss Of Protective Sensation?......Page 177
Use Of A Vibration Perception Threshold Meter......Page 178
2. Is There Deformity Or Limited Joint Mobility?......Page 180
3. Is There A Previous History Of Ulceration Or Amputation?......Page 182
Cumulative Risk......Page 183
Vascular Evaluation......Page 184
2. How Large Is It?......Page 185
4. What Do The Margins Look Like?......Page 186
6. Is It Infected?......Page 187
Summary......Page 188
References......Page 190
Risk Factors......Page 197
Soft Tissue Abnormalities......Page 198
Osteomyelitis......Page 199
Radiography......Page 200
Three-phase Technetium Bone Scan......Page 203
Gallium Scan......Page 204
Labeled Leukocyte Scan......Page 205
Computed Tomography......Page 206
Ultrasound......Page 207
Pulse Sequences......Page 208
Gadolinium......Page 209
Optimization Of Technique......Page 210
Imaging Features......Page 211
Angiography......Page 212
Osteomyelitis Versus Neuroarthropathy......Page 215
Approaches To Diagnosis Of Pedal Osteomyelitis In The Diabetic Patient......Page 218
Summary......Page 220
References......Page 221
Diagnosis......Page 225
Severity......Page 226
Microbiology......Page 227
Microbiologic Assessment......Page 230
Antibiotic Therapy......Page 231
References......Page 235
Introduction......Page 239
Etiology......Page 240
Classification Of Charcot Arthropathy......Page 243
Radiographic Findings......Page 244
Pattern Ii: Tarsometatarsal (lisfranc’s) Joint......Page 245
Pattern Iii: Midtarsal And Naviculocuneiform Joints......Page 246
Pattern Iv: Ankle And Subtalar Joint......Page 247
Clinical Presentation......Page 248
Clinical Diagnosis Of Acute Charcot Arthropathy......Page 252
Conservative Management......Page 253
Surgical Therapy......Page 256
Indications And Criteria......Page 257
Complications......Page 260
References......Page 262
The Interdisciplinary Approach......Page 265
Wound Dressings......Page 267
Properties Of The Ideal Dressing......Page 268
Types Of Dressing......Page 269
Predressing Wound Preparation......Page 270
Techniques Of Debridement......Page 271
Sharp And Surgical Debridement......Page 272
Enzymatic Debridement......Page 273
Mechanical Debridement......Page 274
Hydrocolloid Dressings......Page 275
Infection And Hydrocolloids......Page 277
Frequency Of Change Of Hydrocolloids......Page 278
Attributes......Page 279
Biodegradability......Page 281
Alginates And Infection......Page 282
Hydrogel Dressings......Page 283
Hydrogels And Infection......Page 284
Cadexomer-iodine......Page 285
Growth Factors......Page 287
Bioengineering......Page 288
References......Page 289
Classification Of Diabetic Foot Ulcers......Page 297
Grade 0 Foot......Page 298
Grade 1 Foot......Page 299
Grade 2 Foot......Page 302
Grade 3 Foot......Page 305
Grade 4 Foot......Page 306
References......Page 307
Goals Of Surgery......Page 311
Anesthesia Techniques......Page 312
First Ray......Page 313
Lesser Digits......Page 317
Lesser Metatarsal Procedures......Page 318
Ostectomy......Page 323
Medial Column Fusion......Page 324
Exostectomy With Fasciocutanous Flap......Page 325
Rearfoot Procedures......Page 327
Triple Arthrodesis......Page 328
Pantalar Arthrodesis......Page 330
References......Page 332
Introduction......Page 335
Load Transfer And Weight Bearing......Page 336
Nutrition And Immunocompetence......Page 339
Indications......Page 340
Postoperative Care......Page 341
Indications......Page 342
Technique......Page 344
Postoperative Care......Page 346
Long-term Follow-up Needs......Page 347
Indications......Page 348
Technique......Page 349
Indications......Page 351
Indications......Page 352
Procedure......Page 354
Indications......Page 355
Postoperative Care......Page 357
Rehabilitation......Page 358
Conclusions......Page 359
References......Page 360
Introduction......Page 363
Definitions: Grafts And Flaps......Page 364
Free Tissue Transfer: General Considerations......Page 365
Preoperative Management......Page 369
Intraoperative Management......Page 372
Postoperative Management......Page 373
Dorsum Of The Foot......Page 374
Distal Plantar Area......Page 378
The Plantar Midfoot: Special Considerations In The Treatment Of Charcot Ulcers......Page 379
Proximal Plantar Area/weight-bearing Heel......Page 384
Non-weight-bearing Heel, Achilles Region, And Malleoli......Page 387
References......Page 400
Additional Reading......Page 402
Principles Of Wound Healing And Growth Factor Therapy......Page 403
Growth Factors......Page 405
Platelet-derived Growth Factor......Page 406
Transforming Growth Factor......Page 408
Fibroblast Growth Factor......Page 409
Platelet Releasates......Page 410
References......Page 412
Wound Healing In Diabetes......Page 415
Dfus And Skin Grafting......Page 416
Epidermal Replacements......Page 417
Dermagraft......Page 418
Graftskin (apligraf)......Page 421
References......Page 426
Vascular Disease In Diabetics......Page 429
Patient Selection......Page 430
Evaluation And Diagnostic Studies......Page 436
Vascular Reconstruction......Page 439
References......Page 443
Percutaneous Transluminal Angioplasty And Stenting......Page 447
Indications......Page 448
Technique And Evaluation Of Technical Outcome......Page 449
Complications......Page 451
Indications......Page 452
Technique And Evaluation......Page 453
Clinical Outcomes......Page 454
Indications......Page 455
Technique And Evaluation......Page 456
Atherectomy......Page 458
References......Page 459
Introduction......Page 463
Category 0: Patients Not At Risk Of Ulceration (patients Without Active Or Previous Lesions)......Page 465
Category 2: Patients At High Risk Of Ulceration......Page 466
Category 3: Patients At Very High Risk Of Ulceration (secondary Prevention)......Page 471
Factors Involved In The General Risk Of Ulceration......Page 472
Aids For Patients With Active Lesions......Page 473
The Prescription And Use Of Suitable Footwear......Page 475
References......Page 476
Index......Page 481