Module 5 D I A B E T E S P O D I A T R Y I N I T I A T I V E N I G E R I A

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Module 6: The Art of Wound Care

The initial evaluation of the diabetic foot ulcer to bone (PTB) finding is highly predictive of must be comprehensive and systematic to osteomyelitis, although the frequency of false- ascertain the parameters that might have led to negative tests reduces its sensitivity. its onset as well as determine the presence of factors that can impair wound healing. Critical in Perhaps most importantly, the positive predictive this regard are assessments for vascular value for PTB falls off significantly when the perfusion (ischemia), infection/osteomyelitis, and prevalence of osteomyelitis decreases. The neuropathy. existence and character of odor or exudate should be noted. Cultures may be necessary As previously discussed, a thorough vascular when signs of inflammation are present. evaluation must be performed; this includes Generally, clinically uninfected ulcers without palpation of pulses, clinical evaluation of inflammation should not be cultured. Current capillary filling time, venous filling time, pallor on recommendations for culture and sensitivity elevation, and dependent rubor (283). If pulses include thorough surgical preparation of the are not palpable or if clinical findings suggest wound site with curettage of the wound base for ischemia, noninvasive arterial evaluation (eg, specimen or with aspiration of abscess material. segmental Doppler pressures with waveforms, ankle brachial indices, toe pressures, TcPO2 Wound Healing measurements and vascular surgical Phase 1-Inflammatory Phase Substrate or Lag consultation are warranted. When required, Phase : This stage lasts 3-4 days and has 3 these physiologic and anatomic data can be parts, vascular, hemostatic and cellular. supplemented with the use of magnetic a. Hemostasis is obtained via active resonance angiography or CT angiography vasoconstriction of blood vessels damaged in (CTA) and subsequent use of arteriography with the wound. Aggregation of platelets also leads digital subtraction angiography (DSA) as to the formation of a hemostatic plug. b. Platelet adhesion is in part stimulated by necessary. exposure of the platelets to the proline and Description of the ulcer characteristics on hyroxyproline matrix of mature collagen and presentation is essential for the mapping of the other connective tissue components ulcer’s progress during treatment. While some exposed by the injury. Muscle wasting occurs. The plantar fat pad characteristics are more important than others, becomes displaced and the metatarsal heads they all have prognostic value during become more prominent. Limited joint mobility management. The presumed etiology of the occurs and contributes to the potential for toe ulcer (i.e, chemical vs mechanical) and and foot injury. If Charcot foot is present, there character of the lesion (neuropathic, ischemic, or are severe bone and joint changes and the foot neuroischemic) should be determined. The is swollen and warm to the touch. evaluation should also describe the size and depth of the ulcer as well as the margins, base, c. Once platelets are exposed to and adhere to and geographic location on the extremity or foot. the connective tissue matrix, the platelets are All but the most superficial ulcers should be activated. This can only occur in the presence of examined with a blunt, sterile probe. The von Willebrand components of factor VIII which description should note whether the sterile probe is released from adjacent endothelial cells. detects sinus tract formation, undermining of the ulcer margins, or dissection of the ulcer into tendon sheaths, bone, or joints. A positive probe

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Activation endothelial cells and uncovering gaps between involves the release of ADP from the platelet. the cells. Histamine is also a powerful The ADP stimulates other platelets to stick to vasodilator. Serotonin released from the platelet one another platelet aggregation. and kinins made from plasma alpha globulins at d. Platelets store calcium and 5- the site of injury, also increase vascular ydroxytryptamine in intracytoplasmic granules as permeability. well as many other growth factors. These are i. Neutrophils, attracted by the chemotaxic released upon adhesion and promote further factors arrive in the wound about 6 hours after platelet aggregation and vasoconstriction. This the injury. They reach their highest numbers at 1- process is termed "degranulation” 2 days post injury. If no infection is present, their e. Platelet stimulation results in activation of numbers decline after this. Neutrophils are phospholipase and hydrolyzed membrane lipids responsible for wound debridement through the and the liberation of arachidonic acid. release of collagenolytic and fibrinolytic Arachidonic acid is converted by platelet enzymes. Additionally, neutrophils ingest cyclo-oxygenase into thromboxane A2. bacteria. Thromboxane A2 further stimulates platelet j. Lymphocytes reach their maximum number in aggregation and is also a potent vasoconstrictor. the wound at day 6. f. Contractile protein in the platelet, The most important role of the lymphocyte is the thrombosthenin, promotes clot retraction. Clot synthesis of lymphokines. Two of the best known retraction will not occur unless platelets are lymphokines are the migration inhibition factor present. (MIF) and macrophage activation factor (MAF). g. Coagulation occurs due to the activation of MIF attacts macrophages to the wound and clotting factors. MAF activates them. i. Intrinsic system k. The macrophages attracted to and activated ii. Extrinsic system in the wound are actually derived from The end result is the activation of factor X which monocytes in the blood. They are the most then converts prothrombin to thrombin. important inflammatory cells involved in Thrombin then converts fibrinogen to fibrin wound healing for the following reasons: monomers, which polymerize to form a fibrin I. They are the only cells able to tolerate the clot. Fibrin besides promoting hemostasis, low oxygen tensions at the wound edge. provides a scaffolding for the ingrowth of cells at ii. They appear in the wound during the first 5 a later stage. days and have a long life span (7-10 days). h. Platelets release a number of other factors at iii. Wound healing is severely inhibited in the this point which promote wound healing. These absence of monocytes. include: iv. They process and present antigens to the i. Proteolytic enzymes activate the complement lymphocytes to initiate immune response. system. Also released is 12-HPETE which in turn l. Migratory fibroblasts originate from stimulates the release of leukotriene B4 an mesenchymal cells near the wound edge. important chemotaxic agent. These cells become bound to the fibrin laid ii. Various platelet derived growth factors which down in the wound and proliferate. They then produce glycoproteins. Collagen promote various components of wound healing. synthesis begins on the 5th day post injury (See below) and lasts 2-4 weeks. h. Other substances in the plasma increase m. Eosinophil concentration reaches a peak in vascular permeability. Histamine is released by the injured area between days 7-14. mast cells. Histamine increases vascular They may be associated with collagen permeability by causing contraction of remodeling and synthesis occurring at the same

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time. There are very few and their role is unclear. capillary buds from blood vessels near the n. Fibronectin is a glycoprotein produced by wound occurs at the same time as the migration fibroblasts, endothelial cells and hepatocytes. of the epidermis. The development of capillaries Among the functions attributed to fibronectin towards the center of the wound may be are: under the influence of growth factors released by I. Fibronectin coats macrophages, aiding in macrophages. As oxygen tension increases with opsonization and the opening of new vascular channels, these phagocytosis. growth factors are inhibited and capillary growth ii. Fibronectin is found on the surface of slows and then stops. fibroblasts, where it may aid on the adhesion c. Collagen Synthesis: of these cells to the extracellular matrix. i. Within the injured dermis, fibroblasts iii. Fibronectin cross-links with collagen and (surgeon's cell) begin to appear at the end of glycosaminoglycans. This results in the inflammatory process, and adhere to the increased adhesion of epidermal cells and endothelial cells to the dermis. dermal collagen and fibrin. As the capillary iv. The matrix formed by fibroblasts and structure returns to the wound and oxygen fibronectin creates a framework over which tension increases, fibroblast replication slows. epidermal cells may migrate. As oxygen tension further increases, Phase 2- The Proliferative Phase (Migratory/Lag fibroblasts begin synthesizing collagen. Phase): This stage lasts from 5-20 days and has ii. There are at least 5 types of collagen. three parts: epidermal regeneration, iii. Collagen production by the fibroblasts are neoangiogenesis, and collagen synthesis. under control of at least 5 growth factors. iv. Collagen at this point represents 50% of the a. Epidermal regeneration: scar. I. The cells at the wound edges flatten out and v. The amount of collagen in the healing wound develop pseudopods (extensions of their reaches a maximum at two to three weeks cytoplasm), then migrate across the wound, post injury. Remodeling now begins. only migrating over viable tissue, at a Phase 3-The Remodeling Phase (Maturation)- rate directly proportional to the oxygen Can last up to a year At two weeks post injury, tension of the tissues which is highest under a wound has regained only 35% of its tensile hyperbaric conditions. The aforementioned strength. By one month this has increased to fibrin-fibronectin network serves as a 40-50%. A number of processes occur during framework over which this migration occurs. ii. Intracellular contractile filaments (actin) the remodeling phase: develop at the periphery of the migrating a. The entire remodeling process is really an cells. These filaments align themselves with equilibrium between enzymatic processes the fibrinectin strands in the extracellular lysing and resorbing old collagen and forming matrix. The interaction of these strands new collagen. actually pulls the epithelial cells along. b. Wound contraction is part of this remodeing iii. Other changes occur- the basement stage of healing. Contraction progresses at membrane under the epidermal cells 0.6 to 0.7 mm/day independent of the wound changes; the epidermal cells themselves size, but certain shapes heal faster. elongate in the direction of the wound Round wounds do not contract as quickly as defect; mitotic activity of the epidermal cells rectangular wounds. dramatically increases, and the division and Factors That Interfere With Wound Healing movement of epidermal cells may be 1. Age: Growth rate and multiplication of under the direction of epidermal growth fibroblasts decrease with age. factor (EGF). 2. Inadequate Perfusion: Inadequate perfusion of b. Neoangiogenesis: The formation of new

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results in a decrease in oxygen delivery to the c. Collagen Vascular Disease: These diseases wound, thereby impairing healing. have an autoimmune basis and result in 3. Infection: Infection leads to tissue destruction capillary damage leading to poor tissue and edema, both of which interfere with the perfusion and hypoxia, and immune response healing process. to other cells or cell constituents 4. Edema: Interferes with tissue perfusion and Treatment of Non-healing Wounds: leads to tissue destruction. a. Debridement of necrotic tissue 5. Poor Nutrition: Protein depletion results in b. Control of infection alterations in collagen synthesis and cross c. Control of diabetes mellitus linking. d. Nutritional support 6. Vitamin and Trace Element Deficiencies: e. Avoidance of trauma a. Vitamin A deficiency can interfere with wound f. Aggressive intermittent compression and healing, and may reverse wound elevation to eliminate limb edema healing problems associated with steroids. g. Tapering of steroids (paradoxically, topical b. Vitamin C deficiencies lead to scurvy, a steroids applied to wound in patients with disease associated with the failure of collagen collagen vascular disease may control the synthesis. vasculitis and actually stimulate wound 7. Steroid and Cytotoxic Medications: healing) a. Steroids slow protein synthesis when given h. Revascularization of an ischemic wound exogenously. Steroids interfere with capillary through angioplasty or reconstructive vascular budding, slow fibroblast proliferation as well surgery as the rate of epithelialization. I. Use of hyperbaric oxygen b. Cytotoxic drugs commonly used in j. Plastic reconstructive surgery chemotherapy, inhibit cellular proliferation. In k. Application of growth factors (still general, wound healing is slowed but not experimental) prevented. 8. Radiation: Microvascular changes occurring Growth Factors in Wound Repair after tissue is exposed to radiation at With the production of a platelet derived wound therapeutic doses will lead to perfusion healing formula (PDWHF) known as problems if that tissue is later injured. All cell PROCUREN, a mixture of 5 platelet-produced types involved in healing may be adversely growth factors, angiogenesis and other affected by radiation. Malignant change may aspects of wound healing are stimulated. The 5 also occur. growth factors are 9. Diseases Which are Associated With or 1. Platelet derived growth factor (PDGF) Predispose to Chronic Wounds: 2. Platelet derived angiogenesis factor (PDAF) a. Diabetes Mellitus: 3. Platelet derived epidermal growth factor I. Deposits in the arteries interfere with tissue (PDEGF) perfusion. 4. Transforming growth factor (TGFB) ii. Diabetic neuropathy leads to reduced 5. Platelet factor 4 (PF-4) sensation and gait abnormality iii. Metabolic Classification of Ulcers problems lead to a reduction in nutrients Appropriate classification of the foot wound is available for wound healing. based on a thorough assessment. iv. Impaired phagocytosis seen as part of the disease spectrum on diabetics leads to an Classification should facilitate treatment and be increase in bacterial infections and subsequent tissue destruction. generally predictive of expected outcomes. b. Venous Stasis: Poor venous return leads to an Several systems of ulcer classification are increase in tissue pressure. The increase in currently in use in the US and abroad to tissue pressure results in underperfusion of describe these lesions and communicate the skin and wounds, as well as accumulation severity. Perhaps the easiest system is to classify of inhibitory metabolites lesions as neuropathic, ischemic, or

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neuroischemic, with descriptors of wound size, depth, and infection. Regardless of which system is used, the clinician must be able to easily categorize the wound and, once classified, the ensuing treatment should be directed by the underlying severity of pathology.

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Tissue Management / Wound Bed Preparation attaining full secondary closure. Debridement. Debridement of necrotic tissue is Less frequent surgical debridement can reduce an integral component in the treatment of the rate of wound healing and secondarily chronic wounds since they will not heal in the increase the risk of infection. Surgical presence of unviable tissue, debris, or debridement is repeated as often as needed if critical colonization (314, 315). Undermined new necrotic tissue continues to form. Frequent tissue or closed wound spaces will otherwise debridement, referred to as “maintenance harbor bacterial growth. Debridement serves debridement,” is commonly required. While the various functions: removal of terms surgical debridement and sharp necrotic tissue and callus; reduction of pressure; debridement are often used synonymously, evaluation of the wound bed; evaluation of some clinicians refer to surgical debridement as tracking and tunneling; and reduction of that done in an operating room whereas sharp bacterial burden (318, 319). debridement is performed in a clinic setting. Debridement facilitates drainage and stimulates healing. However, debridement may be Enzymatic debridement. A highly selective contraindicated in arterial ulcers. Additionally, method, enzymatic debridement consists of the except in avascular cases, adequate application of exogenous proteolytic enzymes debridement must always precede the manufactured specifically for wound application of topical wound healing agents, debridement. Various enzymes have been dressings, or wound closure procedures. Of the developed, including bacterial collagenase, five types of debridement (surgical,enzymatic, plant derived papain/urea, fibrinolysin/DNAse, autolytic, mechanical,biological), only surgical trypsin, streptokinase-streptodornase debridement has been proven to be efficacious combination; only the first three products are in clinical trials. widely available commercially. Collagenases are enzymes that are isolated from Clostridium Surgical debridement. Surgical debridement is histolyticum. These display high specificity for the cornerstone of management of diabetic foot the major collagen types (I and II), but they not ulcers. Thorough sharp debridement of all active against keratin, fat, or fibrin. Papain, nonviable soft tissue and bone from the open obtained from the papaya plant, is effective in wound is accomplished primarily with a scalpel, the breakdown of fibrinous material and necrotic tissue nippers, curettes, and curved scissors. tissue. When combined with urea, it denatures Excision of necrotic tissue extends as deeply nonviable protein matter. The enzymatic and proximally as necessary until healthy, compounds are inactivated by hydrogen bleeding soft tissue and bone are encountered. peroxide, alcohol, and heavy metals, including Any callus tissue surrounding the ulcer must silver, lead, and mercury. One study found that also be removed. The main purpose of surgical wounds treated with papain-urea developed debridement is to turn a chronic ulcer into an granulation tissue faster than those treated with acute, healing wound. A diabetic ulcer collagenase, but no contrasts between rates of associated with a deep abscess requires complete wound healing were made. Autolytic hospital admission and immediate incision and debridement. Autolytic debridement occurs drainage. Joint resection or partial amputation of naturally in a healthy, moist wound environment the foot is necessary if osteomyelitis, joint when arterial perfusion and venous drainage are infection, or gangrene are present. maintained.

Necrotic tissue removed on a regular basis can Mechanical debridement. A nonselective, expedite the rate at which a wound heals and physical method of removing necrotic tissue, has been shown to increase the probability of

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mechanical debridement may include wet-to-dry significantly (343) with larval therapy. Larval dressings and high-pressure irrigation therapy seems to be beneficial, but there is or pulsed lavage and hydrotherapy. Wet-to-dry is paucity of controlled studies to support its one of the most commonly prescribed and routine use in the overused methods of debridement in acute care diabetic foot wound. settings. Hydrotherapy in the form of whirlpool may remove surface skin, bacteria, wound Moisture Balance. One of the major exudates, and debris. breakthroughs in wound management over the There may be justification in the early stages of a past 50 years was the demonstration that wound for the use of this technique, but it is moisture accelerates re-epithelialization in a detrimental to friable granulation tissue. wound. Tissue moisture balance is a term used to convey the importance of keeping wounds Biological (larval) therapy. Larval therapy utilizes moist and free of excess fluids. A moist wound the sterile form of the Lucilia sericata blowfly for environment promotes granulation and autolytic the debridement of necrotic and infected processes. Effective management of chronic wounds. Maggots secrete a wound fluids is an essential part of wound bed powerful proteolytic enzyme that liquefies preparation; it also helps in addressing the necrotic tissue. It has been noted that wound issues of cellular dysfunction and biochemical odor and bacterial count, including methicillin- imbalance. resistant Staphylococcus aureus, diminish

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Wound Dressings. Wound dressings can be protease levels and impaired growth factor categorized as passive, active, or interactive. activity. The presence of infection must be Passive dressings primarily provide a protective ascertained and identified as local (soft tissue or function. Active and interactive dressings and osseous), ascending, and/or systemic. In therapies are capable of modifying a wound’s diabetes, where the host response is reduced physiology by stimulating cellular activity and and normal signs of infection (ie, fever, pain, growth factor release. A wide variety of wound leukocytosis) may be absent, other factors such care products is available; a brief listing of as elevated glucose levels can be helpful as an dressings and topical agents is presented in indicator of infection. It is important to obtain Table 8. specimens for culture prior to antimicrobial Inflammation and Infection. In chronic wounds, therapy. inflammation persists due to recurrent tissue trauma and the presence of contaminants. Tissue specimens collected by curettage or Nonhealing wounds can become “stuck” in the biopsy are preferred, because they provide more inflammatory phase of healing, increasing accurate results than superficial swabs. cytokine response with subsequent elevated

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Pressure Relief/Off-loading. The reduction of fiberglass casting material. They concluded that pressure to the diabetic foot ulcer is essential to the latter may be equally efficacious, faster to treatment. Proper off-loading and pressure place, easier to use, and less expensive than reduction prevents further trauma and promotes TCC in the treatment of diabetic neuropathic healing. This is particularly important in the plantar foot ulcers. The findings of this study and diabetic patient with decreased or absent another study also suggest that modification of sensation in the lower extremities (50, 418). the RCW into an irremovable device may Furthermore, recent studies provide evidence improve patient compliance, thereby increasing that minor trauma (eg, repetitive stress, shoe the proportion of healed ulcers and the rate of pressure) plays healing of diabetic neuropathic wounds. a major role in the causal pathway to ulceration. Regardless of the modality selected, no patient should return to an unmodified shoe until The choice of off-loading modality should be complete healing of the ulcer has occurred. determined by the patient’s physical Furthermore, any shoe that resulted in the characteristics and ability to comply with formation of an ulcer should never again be worn treatment as well as by the location and severity by the patient. of the ulcer. Various health care centers prefer specific initial modalities, but frequently clinicians Methods For Offloading Diabetic Wounds: must alternate treatments based on the clinical progress of the wound. Even as simple a method Total Non-weight bearing: Crutches, as a felted foam aperture pad has been found to wheelchair, bedrest be effective in removing pressure and promoting Total Contact Casting healing of foot ulcers . A study published in 2001 Foot Casts or Boot (CAM Boot) Removable walking brace with rocker sole noted that use of a total contact cast (TCC) Total Contact Orthoses healed a higher portion of wounds in a shorter Patella Tendon Bearing Braces time than a half shoe or removable cast walker Half Shoes or Wedge Shoes (RCW). Healing Sandal (Surgical Shoe) Accommodative Dressings (Felt, Foam, etc) More recently, investigators compared TCC use Shoe Cutout with that of a removable cast walker that was rendered irremovable (iTCC) by circumferential wrapping of an RCW with a single strip of

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Module 7: Diabetic Foot Infections

Assessment of Diabetic Foot Infections the presence of bone or joint involvement, sinus When evaluating the patient with a diabetic foot tracts, or extension into tendon sheaths. The infection, a problem-directed history and latter are common routes for the spread of physical examination should be obtained. A infection both distally and proximally. Reliable systematic approach to the complete aerobic and anaerobic cultures should be assessment of these patients is required, since obtained from purulent drainage or curettage of there is evidence that they are often the ulcer base, since studies have shown good inadequately evaluated, even when hospitalized. concordance with the true pathogen. Simple The past medical history should swab cultures of an ulcer surface are generally assess the patient’s neurologic, cardiovascular, not advisable because they tend to be renal, and dermatologic status. Use of current unreliable, especially in the presence of medications as well as previous antibiotics may osteomyelitis or sinus tracts. interfere with planned treatments or indicate that standard treatments will likely be ineffective. Pain For patients with clinically uninfected or non should be considered an unreliable symptom in inflamed neuropathic ulcers, the role of antibiotic individuals with peripheral neuropathy. therapy is still in question. Therefore, in these instances, wound culture The patient should be questioned regarding is probably unnecessary. If osteomyelitis is previous ulcerations, infections, trauma, and suspected, bone cultures are necessary to make surgeries at the present site or at any other past the definitive diagnosis and isolate the true location of infection. Constitutional pathogen. However, this must be balanced symptoms (eg, nausea, malaise, fatigue, against the potential for contaminating non- vomiting, fever, chills) are important clinical clues infected bone in the presence of an active soft when presented with an infected diabetic foot. tissue infection. Intraoperative frozen section is Severe infection or sepsis must be considered also useful in assessing for deep infection. The when these symptoms are present. However, in presence of more than 5 to 10 neutrophils per about 50% of diabetic patients presenting with high power field is suggestive of acute infection. significant infection, systemic signs (fever and leukocytosis) are absent. Frequently, the only The majority of wounds are caused by indication of infection is unexplained or Staphylococcus aureus, beta-hemolytic recalcitrant streptococci, and other gram positive cocci. hyperglycemia. Although community acquired cases of resistant bacterial infections have been reported, patients Laboratory testing might include a CBC with or who have been without differential, blood cultures, glycosylated previously hospitalized with an open wound are hemoglobin, fasting blood sugar, sedimentation more likely to develop an infection from resistant rate, and urinalysis. Other bacteria such as methicillin-resistant S aureus tests should be performed as indicated by the (MRSA) and vancomycinresistant patient’s condition or comorbidities. enterococci (VRE). Chronic wounds may develop a more complex assortment of bacteria, The history of the wound or infection should including gram negative rods, obligate include the onset, duration, and appearance anaerobes, Pseudomonas aeruginosa, and before infection of the area. Depth or size of the enterococci. ulcer, amount of drainage, swelling, color, odor, and extent of infection should be evaluated. The Imaging studies are also important in the overall infection or ulcer should be probed to determine assessment of diabetic foot infections,

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notwithstanding their hortcomings. Plain film x- of the infection. As previously discussed, non rays may indicate the presence of bony erosions limb-threatening infections involve superficial and/or gas in the soft tissues. It should be noted ulcerations without significant ischemia and they that the demonstration of osteomyelitis by plain do not involve bone or joint. Typically, cellulitis radiographs lags the onset of bone involvement does not extend 2 cm beyond the ulcer margins by 10 to 14 days. Radionucleotide bone scans and there is an absence of systemic symptoms such as Tc-99 may demonstrate abnormal (e.g. fever, chills, nausea, vomiting). uptake of the radionucleotide before changes are visible on radiographs. This may be less These less severe infections that frequently specific in patients with peripheral neuropathy or complicate diabetic foot ulcers, may be initially with any preexisting osseous condition that treated in an outpatient setting. Many mild or causes increased bone turnover (eg, surgery, moderate infections are monomicrobial, with S fracture, neuropathic arthropathy). A combination aureus, S epidermidis, and streptococci the of scans such as the Tc-99m and an indium- most common pathogens. Reliable specimens labeled leukocyte scan or the Tc-99m HMPAO for cultures may be obtained through curettage labeled leukocyte scan may aid the clinician in of the infected ulcer. In addition to the standard differentiating Charcot arthropathy and treatment for ulcerations (ie, non weight bearing osteomyelitis with greater accuracy. MRI has and dressing changes), oral antibiotic therapy is generally supplanted the CT scan in the early usually sufficient as initial therapy. Antimicrobial diagnosis of osteomyelitis, due to its higher treatment should be started as soon as possible tissue contrast and ability to detect both soft with an agent providing adequate gram positive tissue and marrow inflammation. Additionally, coverage, recognizing that gram negative MRI can be used to follow the resolution of organisms might also be involved. All antibiotic infection or as an aid in surgical planning. treatments should be monitored for development However, none of these imaging modalities are of resistance. Most cases of cellulitis respond 100% sensitive and specific for diagnosing or within 3 to 5 days of initiation of appropriate ruling out bone infection. Furthermore, these antibiotics. If cellulitis is slow to respond, tests are expensive and may not be readily worsens, or recurs following several days of available. Appropriate clinical treatment, the ulceration should be reassessed assessment and diagnostic acumen should and possibly recultured. Bacteria frequently therefore remain the guiding principles to develop resistance to an antimicrobial agent, management. especially with prolonged therapy.

Treatment of Diabetic Foot Infections Limb Threatening Infections - By definition, limb- Diabetic foot infections should be managed threatening infections are much more serious through a multidisciplinary team approach and more often acute compared with the milder utilizing appropriate consultations. non limb-threatening infections. In the PEDIS Hospitalization of patients with limb-threatening system, limb-threatening infections are classified infections is mandatory. All diabetic foot as grade 3 or 4, depending on severity and the infections must be monitored closely. Equally presence of systemic manifestations. important for the best possible outcome are Neuropathy often predisposes such infections to patient compliance and education, especially in progression to an emergent situation before the outpatient management. patient even becomes aware of the infection’s Non-Limb Threatening Infections - Treatment of presence. Limb-threatening infections may have diabetic foot infections is guided by the severity life-threatening omplications, especially when left

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untreated. Because of diabetes-associated must be assessed and properly maintained, immunosuppression, up to 50% of patients with since relatively common nutritional and limb-threatening infections may exhibit no metabolic impairments in these patients can systemic symptoms or leukocytosis. However, adversely affect wound healing and resolution of other patients present with evidence of systemic infection. toxicity, including fever, chills, loss of appetite, and malaise. Such findings in diabetic patients Consultations are typically required in the risk should alert clinicians to the severity of infection. assessment and management of these complex Most will not be controllable hyperglycemia cases. Medical, endocrinology, cardiology, despite usual therapy and loss of appetite. Limb- nephrology, and diabetic teaching nurse threatening infections are recognized as having consultations are often routinely needed to one or more of the following findings: greater optimize patient care and fully assess surgical than 2 cm of cellulitis around an ulcer, risks. Infectious disease and vascular surgery lymphangiitis, soft tissue necrosis, fluctuance, consultations are also obtained when complex odor, gangrene, osteomyelitis. When such an infections or significant ischemia are identified, infection is recognized, the patient requires respectively. A multi disciplinary approach to the emergent hospital admission for appropriate management of these cases has been shown to intervention. Upon admission, a complete history significantly improve outcomes. and physical examination are undertaken. The patient’s cardiovascular, renal, and neurologic Early surgical treatment of the affected site is risks should be evaluated to assess for typically necessary as an integral part of secondary complications of diabetes and infection management. This may include simple associated comorbidities. A thorough foot debridement of the soft tissues, wide incision and drainage of the pedal evaluation is undertaken to determine the clinical compartments, or open amputation to eliminate extent of the infectious process. extensive areas of infection. At the time of Vascular status must be assessed to ensure that debridement, aerobic, anaerobic, and fungal appropriate arterial inflow is present. If perfusion tissue cultures should be obtained from the is inadequate, this should be addressed prior to depth of the wound to provide reliability. definitive reconstruction to enhance healing at a Although many initial drainage procedures can more distal level. be performed at the bedside for neuropathic Radiographs are necessary to evaluate for patients, most require thorough debridement in evidence of osteomyelitis or soft tissue gas. the operating room. If gas is identified in the ankle or hindfoot, Anesthesia for such interventions may include radiographs of the lower leg should be obtained local, regional, or general anesthetics. to assess the extent of the gas formation. Blood However, spinal blocks are typically avoided in cultures are required if clinical findings indicate patients who may be septic. Even the sickest of septicemia. Other appropriate laboratory patients should be considered for emergent studies, including CBC with differential and incision, drainage, and debridement procedures, sedimentation rate, are obtained as warranted. because their illness in this regard is directly Glucose management must be initiated to attributable to the infection severity. Such life- optimize metabolic perturbations and improve threatening infections necessitate immediate leukocyte function. surgical attention, without delay in obtaining The patient’s nutritional and metabolic status radiologic or medical work-up of other comorbid

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conditions. Polymicrobial infection should be and wound off-loading must anticipated in these patients, with a variety of be re-evaluated. gram positive cocci, gram negative rods, and anaerobic organisms predominating. Once soft tissue infection is under control and management of any osseous infection has been Accordingly, empirical antibiotic therapy typically initiated, consideration may be given to wound includes broad-spectrum coverage for more closure or definitive amputation. Restoration and common isolates from each of these three maintenance of function and independence is categories. Fully comprehensive empiric the ultimate goal for the patient. The residual coverage is usually unnecessary unless the extremity requires close follow-up, regular infection is life diabetic foot exams, periodic foot care, and threatening. appropriate footwear therapy.

Hospital therapies are usually initiated with Osteomyelitis and joint infection, when identified intravenous medications, although most oral by clinical assessment or imaging studies, fluoroquinolones and oral linezolid have the require a sampling of bone for microbiologic and same bioavailability as parenteral therapy. histopathologic evaluation. If the patient’s soft Once wound culture results become available, tissue infection is controlled, consideration may the initial antimicrobial therapy may require be given to stopping antibiotic therapy 24 to 48 adjustment to provide more specific coverage or hours presurgery to improve culture accuracy. A provide therapy against resistant organisms diagnosis of osteomyelitis requires that both causing persisting infection. Recent evidence culture and biopsy studies reveal positive also supports the efficacy of initial parenteral findings, including necrosis, chronic therapy followed by the appropriate oral agent in inflammatory infiltrates, and positive isolation of the management of these patients. If the patient bacteria. develops evidence of recurrent infection while receiving antibiotic therapy, repeat cultures Resection of infected bone with or without local should be obtained to assess for superinfection. amputation and concurrent antimicrobial therapy Methicillin-resistant staphylococci, which have is the most optimal management for emerged as important pathogens in chronically- osteomyelitis. treated diabetic foot ulcer patients must be detected early and treated appropriately to Antibiotics avoid further tissue loss or extension of infection. 1. The Penicillins a. Penicillin G: Parent compound introduced in The surgical wound may require repeated the 1940's surgical debridement to completely eradicate i. Good gram(+) and weak gram(-) coverage ii. Fallen out of favor since many resistant infection and soft tissue necrosis. Wound care is strains (Staph initiated on day 1 or day 2 postsurgery 100% Beta lactamase producing) and may initially involve saline gauze dressing iii. 1 mg PenG= 1667 units changes. Other dressings may be used to aid in iv. Available as Aqueous (10-30 million u/day) healing. Negative pressure wound therapy and Procaine (600,000 u Q1 2h) (V.A.C.®,KCI, San Antonio, TX) has been found b. Penicillin VK: particularly useful in this regard. If the wound I. Used in severe erysipelas and rheumatic fails to show signs of healing, the patient’s fever prophylaxis vascularity, nutritional status, infection control, c. Methicillin:

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i. For PCN-ase resistant organisms human bites ii. IV form only iv. Dosed at 250-500 Q 8h (for other than iii. Can cause thrombophlebitis endocard prophylaxis) d. Oxacillin/Dicloxicillin/Cloxacillin/Nafcillin: b. Ticarcillin/clavulanate (Timentin): Has greater (PRP's) gram(-) coverage than any 4th gen. penicillin i. PCN-ase resistant I. Has good gram(+) coverage and covers ii. Good gram(+) coverage anaerobes well (i.e. B. fragilis) iii. Oral form can cause diarrhea ii. Good drug for initial therapy for moderate iv. Requires frequent dosing, Q4-6 hours diabetic foot infections e. Ampicillin: Increased gram(-)coverage iii. Has high sodium load/use cautiously in i. Not PCN-ase resistant hypertensive-renal pt's ii. Used with UTI, typhoid fever and salmonella iv. Dosed at 3.1 Q 6-8h (3gm ticarcillin + 100mg infections clavulanate) iii. Used pre-op for endocarditis prophylaxis iv. Used in combination with aminoglycosides 3. The Sulbactams for gram(-) septicemia a. Ampicillin/ sulbactam (Unasyn): f. Carbenicillin: The original anti-pseudomonal I. Similar to Timentin but has much lower penicillin sodium load I. Can be combined with aminoglycoside for ii. Adds sulbactam, a beta-lactam inhibitor pseudomonas infection ii. Not used much iii. 99% coverage against B.fragilis/not good now since has high sodium content, against pseudomonas and good against hepatotoxic, neurotoxic and causes bleeding enterococcus disorders iv. Dosed at 1.5-3g Q 4-6h. iii. Oral form: Geopen (UTI's only) g. Ticarcillin: A 4th generation penicillin active 4. The Tazobactams against pseudomonas a. Piperacillin/Tazobactam (Zosyn) I. 2-4 times more potent than carbenicillin vs i. Similar to Timentin in coverage and spectrum pseudomonas ii. Adds Tazobactum a Beta lactamase inhibitor ii. Has increased anaerobic activity iii. Has greater activity than pipericillin h. Piperacillin: As above, gram(+) 9 (-) activity iv. Dosed @ 3.375 gm Q 6 hrs I. Azlocillin: As above but superior to ticarcillin/piperacillin vs pseudomonas 5. The Cephalosporins aeruginosa Semi-synthetic compounds derived from the i. Neurotoxic/Hepatotoxic mold, cephalosporum acremonium. There is a j. Mezlocillin (Mezlin): A 4th generation cross reactivity with penicillin allergic patients penicillin with good gram(-) and anaerobic from 5-20% depending upon the source. As a activity whole, these antibiotics are well tolerated, non- i. Can be used for Pseudomonas/B.fragilis toxic and broad spectrum. They are categorized 2. The Clavulanates in generations, which define their spectrum. a. Amoxicillin/clavulanate (Augmentin): Adds a. 1st generation: clavulanic acid to ampicillin which inactivates I. Keflin (cephalothin), Keflex (cephalexin), Ancef the beta-lactamase enzymes: (cefazolin), Cefadyl (cephapirin), Anspor & i. PCN-ase resistant Velocef (cephradine), Duricef (cephadroxil) ii. Spectrum of activity increased vs gram (-) to ii. ACTIVITY vs gram (+) cocci: S. aureus and include E.Coli & Klebsiella, also good Staph epidermidis, Strep pyogenes and pneumonia and Bacteroides coverage iii. Activity vs gram (-): Proteus mirabilis, E. coil, iii. The oral drug of choice for cat, dog and Klebsiella pneumonia (PECK) b. 2nd generation:I. Mandol (cefamandole),

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Mefoxin (cefoxitin), but should be combined with rifampin (300mg Ceclor (cefaclor), Zinacef (cefuroxime), Ceftin BID) in the treatment of these infections (cefuroxime axetil), Monocid (cefonicid), iii. Contraindicated in its use with children as it Cefotan (cefotetan), Lorabid (loracarbef), can cause cartilage degeneration Cefzil (cefprozil) iv. Can be combined with clindamycin (Cleocin) ii. ACTIVITY vs gram (+): is variable to Staph , or metronidazole (Flagyl) in the treatment of still OK to Strep diabetic foot infections iii. Activity vs gram (-): as with 1st generation v. Oral therapy for osteomyelitis when caused (PECK) plus H. flu, Enterobacter & Neisseria by Pseudomonas (HENPECK) vi. Rarely a first line antibiotic c. 3rd generation: b. Ofloxacin (Floxin): I. Claforan (cefotaxime), Cefobid I. As with the above, but with better gram (+) (cefperazone), Cefizox (cefizoxime),Rocephin coverage (ceftriaxone), Fortaz (ceftazidime), ii. Dosed for soft-tissue infections at 400 mg Q Suprax (cefixime), Vantin (cefprodoxime 12 h proxetil) ii. ACTIVITY vs gram (+): variable to both Staph 8. Aminoglycosides: and Strep a. Streptomycin: (used in treatment of TB) iii. Activity vs gram (-): as with 2nd generation b. Kanamycin (used as an irrigant) (HENPECK) plus Serratia, Morganella, c. Gentamycin: used with methylmethacrylacte Providencia, Citrobacter and Pseudomonas beads (PMMA) for osteomyelitis and in triple antibiotic therapy for serious infections 6. Other Beta-Lactams: d. Potentially ototoxic in patients with renal a. Imipenem/Cilastatin (Primaxin): Is an problems extremely poten antibiotic with the broadest d. Tobramycin (less ototoxic than gentamycin) spectrum of an available beta lactam e. Amikacin (reserved for serious infections including anaerobic coverage/ most against aminoglycoside resistant organisms) expensive antibiotic on the market. Cilastatin f. As a group these antibiotics have well is added to prevent renal hydrolysis documented toxicities (destruction of imipenem) (ototoxicity/hepatotoxicity). g. They are I. May be the drug of choice in severe/limb essentially anti-gram negative agents, but do threatening diabetic infections ( as initial have gram positive coverage. When using therapy) other than clinda/genta/ampi these antibiotics it is beneficial to, have an ID ii. Major therapeutic use for Gram (+) cocci and consult and you should perform peak/trough aerobic gram (-) bacilli serum levels as well as creatinine clearance iii. A 3% cross sensitivity with penicillin allergic and BUN tests (if BUN elevated increase time patients span between doses or lower the dose) Dosed at 0.5-1 gram Q 6h IV up to 4gm/day b. Azreonam (Azactam): Is ONLY effective 9. Other antibiotics: against gram (-) aerobes, including P. a. Vancomycin: aeruginosa I. Indicated in penicillin allergic patients or those I. Can be combined with clindamycin in patients needing coverage against gram (+) penicillin allergic patients when gram(+)and organisms, including methicillin resistant anaerobes are suspected Staph ii. It is possibly nephrotoxic and should be 7. Quinolones: monitored carefully a. Ciprofloxacin (Cipro): iii. Red neck syndrome occurs if infused too i. Its main benefit is it's p.o. gram (-) coverage quickly (not an allergy)/severe hypotension ii. Can be used for methicillin resistant staph

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can result 3. Methicillin (nafcillin/oxacillin) resistant gram iv. Oral form is for pseudomembranous colitis (+) Staph:Vancomycin 500 mg Q 6h IV or 1 only gm Q12h, Cipro 500 Q12h po + Rifampin b. Clindamycin: 300 mg Q1 2h po (Rifampin synergizes I. It is used extensively for anaerobic infections the anti-gram (+) effect of Cipro when in and in the penicillin allergic patient for gram combination with it), Minocycline, (+) coverage Trimethoprim/sulfa ii. Can cause pseudomembraneous colitis 4. Gram (-): When a gram stain is received and c. Tetracycline: initial therapy is to be started prior to a C & S I. A broad spectrum antibiotic used for rocky the following should be considered: Cipro mountain spotted fever, Lyme disease, and 750 mg Q1 2h, Azactam 1 gm Q8h IV, H. pylori infection Gentamicin 3-5 mg/kg _IV following a loading ii. To be avoided in children and pregnant/ dose, Timentin and Fortaz 1-2 gms Q8h nursing mothers (brown teeth) IV, Zosyn (tazobactam/piperacillin) 3.375 gm d: Metronidazole (Flagyl): Q6 IV I. An amebicidal drug also with excellent 5. Anaerobic coverage: Flagyl 500 mg Q8h po, anaerobic coverage Clindamycin 600-800 mg Q8h IV or 300 mg ii. Can be combined with Cipro for more bid-tid po, Primaxin, Timentin, and Unasyn complete coverage 6. Antipseudomonal coverage: 4th generation e. Erythromycin, clarithromycin (Biaxin), penicillin (in combination with another azithromycin (Zithromax) Specific antibiotic), Fortaz 1-2 gm Q 8h, Azactam 1 Antimicrobial Therapy gm Q8h, Gentamycin 3-5 mg/kg IV following 1. Gram (+) cocci (Penicillinase resistant): a loading dose, Cipro 750 mg Q 12h When a gram stain report is received and initial therapy is to be started prior to 7. Antifungal coverage: Diflucan 100 mg od, receiving a C & S the following should be Amphotericin B (very severe side effects), considered due to the increasing number of Ketoconazole (Nizoral), Griseofulvin, and betalactamase organisms: Sporanox 100mg Dicloxicillin 500 mg qid p.o., Nafcillin 1 gm IV 8. Antihelminthic Coverage: Thiabendazole Q6h, Ancef 1gm IV Q8h, Duricef 500mg bid, (Mintezole) for cutaneous larva migrans and Timentin 3.1gm Q6h IV and Unasyn 1.5-3.0 hook worms, and Gamma Benzene gm Q6h IV Hexachloride (Kwell) for parasitic skin 2. Gram (+) cocci + penicillin allergy: infestations caused by scabies. Vancomycin 500mg or 1gm Q6 and Q1 2 H IV or Clindamycin 300 Q 6h po, Erythromycin 500 mg Q6h po

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Module 8: Charcot Neuroarthropathy

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Module 9 Surgery in The Diabetic Foot Surgical management of the diabetic lower extremity with a past history of ulceration (but without active can be a daunting task, but with appropriate patient ulceration). These procedures involve correcting an and procedural selection, successful resolution of underlying tendon, bone, or joint deformity. Many ulceration and correction of inciting pathology may be reconstructive procedures in this category would be achieved. Diabetic foot surgery performed in the considered elective if the patient did not have sensory absence of critical limb ischemia is based on three neuropathy and a higher risk for ulceration. fundamental variables: presence or absence of neuropathy (LOPS), presence or absence of an open Curative Surgery. Curative procedures are performed wound, and presence or absence of acute limb- to effect healing of a non-healing ulcer or a threatening infection. chronically recurring ulcer when off-loading and standard wound care techniques are not effective. Classifications of Surgery Surgical intervention has These include multiple surgical procedures aimed at previously been classified as curative, ablative, or removing areas of chronically increased peak elective. pressure as well as procedures for resecting infected More recently, a modification of this scheme has bone or joints as an alternative to partial foot been proposed that encompasses more procedures amputation . Operations and a broader spectrum of patients, as follows: frequently performed in this regard include exostectomy, digital arthroplasty, sesamoidectomy, Class I: Elective foot surgery (performed to treat a single or multiple metatarsal head resection, joint painful deformity in a patient without loss of protective resection (Fig 17), sensation) or partial calcanectomy. Some surgeons have Class II: Prophylactic foot surgery (performed to proposed the advantages of combining plastic reduce risk of ulceration or reulceration in patients surgical flaps and skin grafts with these procedures with loss of protective sensation but without open to expedite wound healing and provide for more wound) durable soft tissue coverage. Class III : Curative foot surgery (performed to assist in healing an open wound) Emergent Surgery. Emergent procedures are Class IV: Emergent foot surgery (performed to arrest performed to stop the progression of infection. Such or limit progression of acute infection). For any of ablative surgical intervention, most often involving these classes, the presence of critical ischemia amputation, requires should prompt a vascular surgical evaluation to removal of all infected and necrotic tissue to the level consider the urgency of the procedure and possible of viable soft tissue and bone. When possible, they revascularization prior to or subsequent to the are also performed in a manner to allow for the procedure. maximum function from the remaining portion of the limb. Wounds may be closed primarily if the surgeon Elective Surgery. The goal of elective surgery is to is confident no infection or ischemic tissue remains relieve the pain associated with particular deformities and if enough soft tissue is available. such as hammertoes, bunions, and bone spurs in Other wounds may initially be packed open, requiring patients without well controlled and frequently assessed wound care, peripheral sensory neuropathy and at low risk for with delayed primary closure or closure by secondary ulceration. Essentially any type of reconstructive foot intention. operation can fall into this category, including rearfoot Another popular option is negative pressure wound and ankle arthrodeses as well as Achilles tendon therapy using a V.A.C.® device, which has been lengthenings. However, amputations are generally not found to significantly expedite granulation tissue performed as elective procedures, except in cases of formation and healing of open partial-foot severe deformity or instability resulting from prior amputations. Mechanical assistance using a variety injury or neuromuscular diseases. of skin stretching devices are the surgeon’s option and may help attain delayed primary closure for Prophylactic Surgery. Prophylactic procedures are some wounds. More often, V.A.C.® therapy is used to indicated to prevent ulceration from occurring or manage large or deeper recurring in patients with neuropathy, including those wounds until delayed primary closure can be

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achieved. Other approaches include plastic surgical influence the selection of the level of amputation. It is techniques utilizing split and full-thickness skin grafts well recognized that energy expenditure increases as and a variety of flaps. the level of amputation becomes more proximal. Simple tasks such as ambulating to the bathroom or Each patient must be assessed for the selection of other activities of daily living become increasingly the surgical management that best meets his or her more difficult for the patient needs. Secondary wound healing with or without commensurate with the level of amputation. In adjunctive wound therapies may still be the best addition, patients with more proximal amputations are choice for some patients. Pathway 6 lists the various far more difficult to rehabilitate to a functional types of surgical procedures commonly used for community or household ambulation level. managing diabetic foot complications. In the carefully selected patient, prophylactic or Recent advances in vascular surgery have enabled elective surgical correction of structural deformities the level of amputation to become more distal or that cannot be accommodated by therapeutic “limb sparing”. The capacity to re-establish distal footwear can serve to reduce perfusion with endovascular techniques or bypass high pressure areas and ultimately prevent ulcer surgery to the distal tibial, peroneal, and pedal recurrence. arteries has greatly enhanced the potential for more distal amputation. In most circumstances, patients Many of the procedures mentioned in the discussion should be given the opportunity for vascular surgical on curative surgery would also beindicated in the intervention prior to definitive amputation so that the elective/prophylactic reconstruction of the most distal level nonulcerated foot. Common operations performed in of amputation can be successful. this regard include the correction of hammertoes, bunions, and various exostoses of the foot. Tendo- Goals of Selection of Amputation Level achilles lengthening procedures are often The selection of the level of amputation should performed as ancillary procedures to reduce forefoot incorporate the following goals: pressures that contribute to recurrent ulcerations. Creation of a distal stump that can be easily Once healed, these surgical patients are at high risk accommodated by a shoe insert, orthotic device, for future ulceration and require appropriate ongoing modified shoe gear, or prosthesis care consistent Creation of a distal stump that is durable and with those prevention strategies already discussed unlikely to break down from exogenous pressure Creation of a distal stump that will not cause Amputation Considerations muscle or other dynamic imbalances. Amputation, a well recognized consequence in the Examples include medial migration of the lesser management of the diabetic foot, is performed for a digits after 1st MTP joint disarticulation; varus deformity and lateral overload after 5th ray variety of reasons and can be characterized as resection; and equinus contracture after curative or emergent. transmetatarsal or Chopart amputation. Healing with primary intention. In most instances it Indications for amputation include removal of is advisable to perform an amputation at the most gangrenous or infected tissue, often to control or distallevel that would allow for primary healing. arrest the spread of infection; removal of portions of Unfortunately, there are few objective tests or the foot that frequently ulcerate; and creation of a strategies that can consistently and reliably predict functional unit that can accommodate either normal healing potential or modified shoe gear. In general, the amputation should be performed at a level that balances preservation of limb length and function with the capacity for the surgical site to heal primarily.

Although this concept is intuitive, several factors may

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MODULE 10: CARE OF THE FEET AND THERAPEUTIC FOOTWEAR

• INTRODUCTION rubbing skin lotion over the tops and bottoms of • DAILY FOOT CARE CHECK LIST the feet, but not between the toes. • CHOOSING A FOOT WEAR • THERAPEUTIC FOOT WEAR Toe nails should be trimmed when needed. • CHOOSING SOCKS Toenails should be trimmed straight across and • RECOGNISING THE FOOT AT RISK the edges filed with an emery board or nail file. • CARING FOR THE FOOT AT RISK They must never walk barefoot, but wear INTRODUCTION comfortable shoes that fit well and protect their Type 2 diabetes is a leading cause of non- feet. traumatic lower limb amputation worldwide. It is The insides of shoes must be checked with therefore important to teach the person living shoes turned upside down and shaking off any with diabetes, and his immediate care givers the foreign object in them before wearing them. basics of preventive foot care. Prevention they They should ensure the inside lining is say is better than cure. smooth and there are no objects inside.

DAILY FOOTCARE CHECK LIST This starts with emphasizing the need for proper care of diabetes through ensuring blood glucose levels and blood pressure control are to the appropriate target for the individuals. Home blood glucose monitoring should be discussed and incorporated into routine self-care if not already being done. The cholesterol level should also be to target. Adopting a healthy lifestyle, with a healthy diet, regular exercise and weight Feet should be protected from temperature management when needed are also important extremes – either hot or cold; ensuring shoes are topics to be discussed with the person living worn at the beach or on hot pavement. with diabetes. Where available the services of a registered dietitian, and certified diabetes Persons living with diabetes should avoid thong educator should be used. slippers or sandals as they may cause injury to the feet if not well fitted. The person living with diabetes should be taught Avoid thong sandals and slippers to inspect and examine the feet every day, “ carefully inspecting in between the toes; looking out for red spots, athletes’ foot, cuts, swelling, and blisters. If they cannot see the bottoms of their feet, they should be taught to use a mirror to check under their feet or ask someone for help.

Feet should be kept clean with daily washing in clean water, after which they should be dried with a clean towel, especially in-between the toes. Skin should be kept soft and smooth by

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Soaking of feet in water or dipping of feet into hot water should be avoided. The water temperature should be tested with the elbow before putting their feet into water for cleaning feet.

They must NEVER use hot water bottles, heating pads, or electric blankets; as they can burn feet without realizing it. 2. Wide Toe Box: Pain from squeezing feet into too- Daily feet exercises to keep the blood flowing to into small and too-narrow shoes can lead to feet or their feet are recommended. bruises and ulcers. 3. SUSTAINABLE MATERIAL: Leather and microfiber are two materials that expand, preventing irritating friction if your foot swells. A shoe without some give is a shoe that will cause a blister.

4. Special Foot Bed: Therapeutic shoes typically have a foot bed that is wider and made with shock- They shouldn’t cross their legs for long periods of absorbing materials. The foot care Specialist might time. also suggest a custom insert, which can relieve heel For individuals who are not ambulant, and maybe or arch pain, and can take pressure off areas that bed bound, general care of the feet to prevent might be prone to calluses. pressure ulcers are recommended.

Smoking of cigarettes and any other smokeable items should be totally stopped. Shoes should be bought late in the afternoons, avoiding shoes with narrow toe-boxes, instead buying shoes with a wide toe-box.

THERAPEUTIC FOOT WEAR Everyone can benefit from a shoe that fits well. People with foot deformities such as claw or hammer toes, bunions etc. will benefit from therapeutic shoes. Therapeutic shoes have special features. Below are features that qualify them as medical treatment for people at risk for foot problems or who already have some damage. CHARACTERISTICS OF A THERAPEUTIC FOOT WEAR

1. Adjustable: An adjustable closure, such as shoelaces or no-tie straps, can allow for different foot needs, day to day and hour to hour. Persons who have difficulty tying laces (for example, because of nerve damage in their fingers or joint problems). A Velcro closure might be best.

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5. Extra Deep: An extra-deep shoe cradles the foot. Patients should be taught to avoid socks that have Support around the ankle gives more stability. The extra seams as they can cause rubbing or irritation that depth gives foot deformities such as bunions and can lead to a blister or callus hammer toes the space they need. A deeper shoe also Socks that fit appropriately are important therefore gives room for an insert or orthotic. they must not be too tight and cut into your leg or ankle or too loose leading to socks that fall down Who Needs a Special Shoe? the ankle and bunch 1. People with existing foot problems; therapeutic shoes up in the shoe can help them prevent more complications. A breathable material, such as cotton, or a wicking 2. People with a previous amputation, past ulcers, material, such as microfiber, can keep bacteria calluses that could lead to foot ulcers, nerve damage from forming. (neuropathy), poor circulation, or a foot deformity Persons with circulation problems may need a 3. People with plantar ulcers compression sock or stocking, depending on the circulation in the feet or legs.

RECOGNISING THE FOOT AT RISK The following can be present in a foot at risk but this list is not an exhaustive list. Feet with neuropathy Feet with poor circulation Feet with deformities; e.g. hammer toes, calluses, bunions etc

Previous Ulcer Previous amputation Feet of a person who is bed bound

CARING FOR THE FOOT AT RISK: This involves teaching the patient and/or care giver how to incorporate all CHOOSING SOCKS the dos and don’ts as listed above into the The layer between the shoe and the foot is important patient’s daily routine When being fitted for new shoes, it is important to foot care. make sure one wears the same kind of socks they will wear with the shoes.

Patients should be taught to avoid socks that have seams as they can cause rubbing or irritation that can lead to a blister or callus

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