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1 제 23 차대한당뇨병학회춘계학술대회 May 전북대학교의학전문대학원 내분비대사내과 박태선

2 Lancet 2005; 366 Nov 12 :

8 Neuropathic foot Ischemic foot Plantar aspect of the foot under the metatarsal heads or on the plantar aspects of the toes Medial aspect of first MTP joint of foot pitting edema, hallux valgus and erythemafrom pressure from tight shoe on medial aspect of first MTP joint

9 General Evaluation for Diabetic Foot General condition Glycemic control Occupational history Medical photography Six concerns vascular testing, sensory testing, ROM of joint, contracture of tendon, bony prominence, skin and nail condition

10 Diabetic Foot Disorders Frykberg RG et al J Foot Ankle Surg (2006)

11 Diabetic Foot Ulceration Frykberg RG et al J Foot Ankle Surg (2006)

12 Assessment of Diabetic foot ulcers

Wagner ulcer classification* Grade Description 0 No ulcer, but high

full thickness ulcer 2 Deep ulcer, may involve tendons.

13 Wagner ulcer classification* Grade Description 0 No ulcer, but high risk foot (bony prominences, callus, claw toes, etc) 1 Superficial full thickness ulcer 2 Deep ulcer, may involve tendons. No bone involvement 3 Deep ulcer with bone involvement: osteomyelitis 4 Localized gangrene, e.g., toes 5 Gangrene of whole foot * Not specific for diabetes and not consider other factors (e.g., infection, neuropathy) G1 G2 G3

14 Diabetic Foot Infection

15 Infection in Dibetic Foot Absence fever or leukocytosis Organism; polymicrobial; G + cocci, G - rods (Pseudomonas), anaerobes Foul smelling ; suspicious anaerobic or enteroccocal infection Culture study; swab to bone Gas(+) on X-ray; aerobic G + cocci or G - rod

16 PolymicrobialDiabetic Foot Infections

17 Charcot Foot

18 Neuropathic Ulcer: Charcot foot deformity. Large painless ulcer on bottom of foot. Lateral x-ray demonstrates marked soft tissue swelling as well as boney destruction caused by underlying osteomyelitis

19 Charcot foot (Diabetic Neuroarthropathy) Adapted from Sanders LJ and Frykberg RG. The High Risk Foot in Diabetes Mellitus p108

20 Diabetic PAD

21 Frykberg RG et al. J Foot Ankle Surg. (2006)

22 Frykberg RG et al. J Foot Ankle Surg. (2006)

23 Risk Categorization System Category Risk Profile Evaluation Frequency 0 Normal Annual Peripheral neuropathy(lops) Neuropathy, deformity and/or PAD Previous ulcer or amputation Semi-annual Quarterly Monthly to quarterly

24 Precipitating causes of foot ulcer and infection Friction in ill fitting or new shoes Untreated, self treated callus Foot injuries (eg, unnoticed trauma in shoes or when walking barefoot) Burns(eg, hot bath, water bottle, radiator, sand) Corn plaster Nail infections (paronychia) Heel friction in patients confined to bed Foot deformities

25 Clinical Manifestation Symptoms: neuralgia, swelling, discharge, ulceration, gangrene. Neuropathy burning, searing, tingling sensation 화끈거린다, 저리다, 시리다, 조인다, 이불이스치면괴로워발을내놓고잔다. worse at night bilateral and symmetric around ankle and foot

26 Physical Examination Evaluation of both feet Gait pattern and shoes ROM: ankle, toe, knee Shape of foot, foot arch Swelling, redness, warmth Deformity: bunion, claw toe, hind foot deformity Skin and nail condition Web condition

27 Pressure mat

28 Factors suggesting hospitalization Severe infection Metabolic instability IV therapy needed (and not available as outpatient) Diagnostic tests needed ( not available as outpatient) Critical foot ischemia Surgical procedures required Compliance with treatment unlikely Complex dressing changes needed

29 Neurologic Test Skin condition ; dry, flaking, crackled skin Sensory: Semmes-Weinstein monofilaments (5.07) D/Dx with other neurologic abnormality Tinnel sign for tarsal tunnel syndrome DTR EMG & NCV

30 Use of Monofilament JAMA. 2005;293:

31 Vibration threshold measure machine

32 Quantitative Sensory Test machine

33 Vascular Studies P/E ; pulse, capillary filling, warmth, skin condition Ankle-Brachial arterial Index (ABI) Ankle pressure > 70mmHg, Toe pressure > 40mmHg Doppler U/S and Pulse-Volume Recordings (PVRs) Oxymetry, TcPO2 Angiography

34 ABI -a sensitive parameter to confirm PAD Procedure: Measure the systolic blood pressure by Doppler probe in the brachial and dorsalis pedis arteries of each sides use the highest of the brachial pressure (left or right) use the highest ankle pressure (dorsalis pedis or posterior tibial) for each leg calculate the ABI: divide the ankle pressure by the highest brachial pressure. Interpretation: ABI 1.0: normal ABI : mild arterial occlusive disease ABI : moderate arterial occlusive disease ABI 0.5: severe arterial occlusive disease

35 Ankle Brachial Index

36 Hand held Doppler Ultrasound

37 Laboratory Study Blood glucose (FBS, pp2) CBS and total lymphocyte ESR/CRP Protein, Alb Smear culture Measurement of foot pressure Foot printing

38 Imaging Study Simple X-ray: Foot standing lateral, AP, oblique view MRI Bone Scan Gallium scan, Indium scan

39 Screening Methods for Diabetic Foot Monofilament (Light Touch Sensation) Biothesiometer (Vibratory Sensation) Tuning Fork (Vibratory sensation) Pressure mat or Platform (Plantar pressure) 선별검사양성기준 1 Insensate site Vibration perception threshold >25V Patient loses vibration while examiner still perceives it Cutoffs: 59 N/cm 2 ; 70 N/cm 2 ; 87.5 N/cm 2; 민감도 % ;70;64 특이도 % ;65;46 Comment Inexpensive, quick, widely available, validated; number of test sites needed unclear Accuracy similar to monofilament, but more expensive and not as widely available Inexpensive, quick, widely available, less predictive than monofilament Numerical value of plantar pressure is device-specific; optimal cutoff unknown Singh N et al. JAMA. 2005;293:

40 Multidisciplinary Team Approach Endocrinology Orthopedic surgery Vascular surgery Plastic surgery Neurology Orthosis or Shoe Rehabilitation Physical medicine

41 Conclusion Diabetic foot problems result in major medical, social, and economic consequences for patients, their families, and society Neuropathy is the major contributory factor in the pathogenesis of diabetic foot ulcers All patients with diabetes should have a thorough foot examination at least annually

42 Thank you for your attention for your patients foot!!

Microsoft PowerPoint - 발표자료(KSSiS 2016)

Microsoft PowerPoint - 발표자료(KSSiS 2016) Sang Jun Kim, MD, PhD Application of 3D Printing in the Orthotic Fields Hallux Valgus, Charcot Marie Tooth, ADL Kit, Foot Insole, Wrist Pain, Foot Drop Development of Automated Program for Ankle Foot Orthosis