Introduction Ulceration in diabetic foot due to lack of protective sensation Epidemiology incidence approximately 12% of diabetics have foot ulcers most common medical complication causing diabetics to get medical treatment foot ulcers are responsible for ~85% of lower extremity amputations risk factors factors associated with decreased healing potential uncontrolled hyperglycemia inability to offload the affected area poor circulation infection poor nutrition factors associated with increased healing potential serum albumin > 3.0 g/dL total lymphocyte count > 1,500/mm3 Pathophysiology neuropathy has largest effect on diabetic foot pathology sensory dysfunction leads to lack of protective sensation and is primary risk factor for ulcer development autonomic dysfunction leads to drying of skin due to lack of normal glandular function net effect is increased mechanical and axial stress on skin that is more prone to injury due to drying angiopathy lesser effect than neuropathy >60% of diabetic ulcers have decreased blood flow due to peripheral vascular disease Associated conditions infection / osteomyelitis high rates of associated osteomyelitis if bone is able to be probed, or is exposed at the base of the ulcer 67% of ulcers that probe to bone have osteomyelitis organisms usually polymicrobial gram-positive most common pathogens are aerobic gram positive cocci (s. aureus) gram-negative increased gram-negative organisms are found in chronic wounds and wounds recently treated with antibiotics anaerobes obligate anaerobic pathogens with ischemia or gangrene deep cultures and bacterial biopsies help guide management Prognosis diabetic foot ulceration is considered the most likely predictor of eventual lower extremity amputation in patients with diabetes mellitus Classification Wagner Classification and Treatment Description Treatment Grade 0 Skin intact but bony deformities lead to "foot at risk" Shoe modifications with serial exams Grade 1 Superficial ulcer Office debridement and contact casting Grade 2 Deeper, full thickness extension Operative formal debridement and contact casting Grade 3 Deep abscess formation or osteomyelitis Operative formal debridement and contact casting Grade 4 Partial Gangrene of forefoot Local vs. larger amputation Grade 5 Extensive Gangrene Amputation Brodsky Depth-Ischemia Classification and Treatment Depth Classification Definition Treatment 0 At risk foot, no ulceration Patient education, accommodative footwear, regular clinical examination 1 Superficial ulceration, not infected Off-loading with total contact cast, walking brace or special footwear 2 Deep ulceration, exposing tendons or joints Surgical debridement, wound care, off-loading, culture-specific antibiotics 3 Extensive ulceration or abscess Debridement or partial amputation, off-loading, culture-specific antibiotics Ischemia A Not ischemic B Ischemia without gangrene Non-invasive vascular testing and vascular reconstruction with angioplasty/bypass C Partial forefoot gangrene Vascular reconstruction and partial foot amputation D Complete gangrene Complete vascular evaluation and major extremity amputation Presentation Symptoms often painless Physical exam depth of ulcer probe for bone presence of infection look for cellulitis, pus check for gangrene assess Achilles tendon tightness Silverskiöld test improved ankle dorsiflexion with knee flexed = gastrocnemius tightness equivalent ankle dorsiflexion with knee flexion and extension = Achilles tightness circulation assess dorsalis pedis and posterior tibialis pulses Studies Transcutaneous oxygen pressures (TcpO2) considered Gold Standard to assess wound healing potential > 30 mm Hg (or 40mmHg depending on review source cited) is a good sign of healing potential ABI's and ischemic index calcification in the arteries can result in inaccurate doppler flow readings calcifications falsely elevate the ABI's due to decreased compliance of the calcified vessels index of > 0.45 and toe pressure >40mm Hg are needed to heal ulcer Imaging Radiographs recommended views AP, lateral, and oblique of foot and ankle MRI best for differentiating abscess from soft tissue swelling difficult to differentiate infection from Charcot arthropathy on MRI Bone scan views obtain with technetium Tc99m, gallium (Ga)67, or indium (In) 111 useful to differentiate between soft tissue infection osteomyelitis Charcot arthropathy Treatment General factors important in deciding a treatment plan include angiopathic vs. neuropathic deep vs. superficial +/- osteomyelitis, antibiotics based on bone biopsy culture sensitivities +/- pyarthrosis Nonoperative shoe modification indications prevention when signs of potential ulcers are present includes deep or wide shoes, custom insoles, rocker bottom soles, etc. of the available shoe only modifications, rocker sole shoes best reduce the plantar pressure on the forefoot medicare will cover modifications and custom shoes/insoles yearly wound care indications first line of treatment goals of wound care and dressings provide moist environment absorb exudate act as a barrier off-load pressure at ulcer total contact casting (TCC) indications gold standard for mechanical relief plantar ulcerations contraindications absolute infection relative marginal arterial supply to affected area patients unable to comply with cast care patients unable to tolerate a cast (cast claustrophobia) outcomes if ulcer recurs, it is typically 3-4 weeks after cast removal Operative surgical debridement, antibiotics, local wound care, contact casting indications grade 3 or greater ulcers should undergo I&D with antibiotic treatment before casting outcomes high rates of associated osteomyelitis if bone is able to be probed, or is exposed at the base of the ulcer ostectomy +/- TAL indications bony prominence causing internal pressure technique TAL indicated if tight Achilles several studies have shown TAL to be effective to help heal and prevent recurrence of plantar forefoot ulcers partial calcanectomy +/- TAL indications large heel ulcers with associated calcaneal osteomyelitis outcomes preserves limb length and decreases morbidity compared to higher level amputations Syme amputation indications forefoot gangrene and a palpable posterior tibial artery pulse Keller resection arthroplasty indications IPJ plantar neuropathic ulcer with hypomobile/stiff MTPJ that has failed total contact casting Techniques Total Contact Casting often necessary for up to 4 months TCC followed by Charcot restraint walker then custom shoe pneumatic walking brace alternative to TCC, same principal allows better wound surveillance significant deformity and/or extremely large girth often requires custom pneumatic walkers patient compliance with offloading can be an issue because the pneumatic walker is removable
Percutaneous Achilles Tendon Lengthening Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Authors: Orthobullets Team Removal of Plantar-Hindfoot-Midfoot Bony Mass Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Authors: Orthobullets Team Midfoot Amputation Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Authors: Orthobullets Team Below Knee Amputation Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Authors: Orthobullets Team
QUESTIONS 1 of 29 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Previous Next (OBQ05.20) A 34-year-old patient is noted to have a lack of ankle dorsiflexion by 5 degrees with knee extension as seen in Figure A. However, the ankle dorsiflexion improves to 20 degrees with knee flexion as seen in Figure B. Which of the following diagnoses would benefit MOST from a gastrocnemius recession (Strayer procedure)? Review Topic QID: 57 FIGURES: A B 1 Chronic peroneal tendonitis 15% (241/1586) 2 Freiberg's infraction 3% (50/1586) 3 Chronic retrocalcaneal bursitis 4% (61/1586) 4 Chronic calcaneal osteomyelitis 1% (20/1586) 5 Chronic plantar forefoot ulcer 76% (1203/1586) Select Answer to see Preferred Response PREFERRED RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.104) A 65-year-old patient with poorly controlled diabetes develops 2nd metatarsal head osteomyelitis deep to a superficial ulcer. Which of the following treatment modalities would have the highest chance of success? Review Topic QID: 2917 1 IV Vancomycin 1% (27/2197) 2 Oral Levofloxacin 0% (6/2197) 3 IV antibiotics based on ulcer swab culture sensitivity 2% (39/2197) 4 IV antibiotics based on percutaneous bone biopsy culture sensitivity 94% (2071/2197) 5 Elevation and non-weight bearing 2% (44/2197) Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.130) A 57-year-old man taking metformin for diabetes and gabapentin for peripheral neuropathy has a superficial plantar midfoot ulcer with a clean, noninfected appearance. Total contact casting is implemented for mechanical relief. Which of the following radiographs most likely corresponds to the clinical situation described? Review Topic QID: 2943 FIGURES: A B C D E 1 Figure A 0% (5/1510) 2 Figure B 1% (16/1510) 3 Figure C 72% (1093/1510) 4 Figure D 8% (116/1510) 5 Figure E 18% (275/1510) Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.130) A diabetic ulcer shown in Figure A probes down to bone when a cotton-tipped applicator is used. What is the approximate likelihood this patient has osteomyelitis? Review Topic QID: 4765 FIGURES: A 1 5% 0% (15/3715) 2 25% 2% (78/3715) 3 35% 4% (138/3715) 4 65% 57% (2122/3715) 5 100% 36% (1347/3715) Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ10.261) A 44-year-old man with diabetes mellitus has a non-healing Wagner grade 1 ulcer shown in Figure A for the past 8 months. Conservative management with total contact casting has not resolved the ulcer. Physical examination reveals loss of protective sensation by Semmes-Weinstein testing, no signs of infection, positive Silfverskiold test indicating gastrocnemius contracture, and palpable pedal pulses. What is the next most appropriate step in management? Review Topic QID: 3358 FIGURES: A 1 Integra artificial dermis placement followed by split thickness skin grafting 2% (48/2580) 2 Continued total contact casting 2% (62/2580) 3 Split thickness skin grafting to ulcer 1% (22/2580) 4 Strayer procedure (gastrocnemius lengthening) 90% (2315/2580) 5 Weil metatarsal decompression osteotomy 4% (115/2580) Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ10.150) A 65-year-old diabetic male presents with the foot ulcer shown in Figure A. There is no exposed bone, and no signs of infection. Pulses are palpable. What additional information should be obtained next to help guide this patient's treatment? Review Topic QID: 3238 FIGURES: A 1 MRI scan with contrast 6% (131/2367) 2 Ankle-brachial index 12% (274/2367) 3 Results of Silverskiold test 56% (1334/2367) 4 Transcutaneous oxygen measurements of the toes 18% (418/2367) 5 Hemoglobin A1C level 8% (201/2367) Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ09.271) You are caring for a 72-year-old male with diabetes and peripheral neuropathy with a non-healing forefoot ulcer as shown in Figure A. To reduce the plantar pressure on his forefoot, which of the following shoe modifications would you suggest? Review Topic QID: 3084 FIGURES: A 1 Polyethylene foam insole 6% (103/1593) 2 Open toe sandals 0% (2/1593) 3 Rocker sole shoes 68% (1089/1593) 4 Custom indepth shoes 23% (370/1593) 5 Hard postoperative shoe 2% (26/1593) Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ12.189) A 66-year-old male with a known history of uncontrolled Type 2 diabetes presents for follow up of a forefoot ulcer that is seen in Figure A. All of the following are strong prognostic indicators of osteomyelitis EXCEPT: Review Topic QID: 4549 FIGURES: A 1 Exposed bone at ulcer site 3% (95/3331) 2 Periarticular erosions at 1st MTP joint 12% (394/3331) 3 Increased signal within metatarsal diaphysis on T2 weighted MRI 4% (148/3331) 4 Increased signal within indium labeled WBC scan 3% (97/3331) 5 Positive wound culture 77% (2565/3331) Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ04.84) A 37-year-old man with type-1 diabetes mellitus reports a 3-month history of a plantar foot ulcer shown in Figure A. His pulses are palpable and sensation to a 5.07 Semmes-Weinstein monofilament is absent on the entire plantar surface of the foot. There is no erythema or drainage and there is no bone encountered during probing of the ulcer. There is no fever and the white blood cell count is normal. The C-reactive protein and erythrocyte sedimentation rate are normal. What is the most appropriate next step in treatment? Review Topic QID: 1189 FIGURES: A 1 Total contact casting and empiric IV antibiotics 3% (44/1548) 2 Surgical debridement, dressing changes, and empiric IV antibiotics 3% (47/1548) 3 Charcot restraint orthotic walker (CROW) 4% (69/1548) 4 Surgical debridement, dressing changes, biopsy, and culture specific IV antibiotics 9% (132/1548) 5 Total contact casting 80% (1246/1548) Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ06.224) Which of the following is least likely to predict future amputation in diabetic patients? Review Topic QID: 235 1 Diabetic foot ulceration 4% (27/707) 2 Loss of sensation with 5.07 Semmes-Weinstein monofillament testing 6% (41/707) 3 Infection 2% (14/707) 4 Hemoglobin A1c level of 10.7 5% (37/707) 5 Ankle-brachial index of 1.07 82% (583/707) Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ06.117) Which of the following is not financially covered during one calendar year for Medicare patients under the United States Therapeutic Shoe Bill? Review Topic QID: 303 1 Three pair of inserts for extra-depth shoes 25% (139/559) 2 Shoe wedges 7% (40/559) 3 Inserts for missing toes 9% (52/559) 4 Two pairs of custom-molded shoes 50% (278/559) 5 Velcro closure shoe modification 8% (43/559) Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ06.158) A 62-year-old diabetic female presents with a Wagner grade 1 foot ulcer. Upon examination of the foot, no dorsalis pedis pulse is palpable. Each of the following noninvasive vascular tests indicate a good prognosis for ulcer healing EXCEPT: Review Topic QID: 344 1 Triphasic waveforms 1% (14/979) 2 Ankle-brachial indices (ABI) of 0.72 27% (264/979) 3 Absolute toe pressure of 45 mm Hg 2% (24/979) 4 Transcutaneous oxygen measurements (pO2) of 15mm Hg 66% (649/979) 5 Presence of hair on the toes 2% (24/979) Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ07.125) Which of the following variables is not predictive of poor healing of diabetic foot ulcers? Review Topic QID: 786 1 Transcutaneous oxygen pressure < 20 mmHg 2% (33/1544) 2 Systolic blood pressure > 140 mmHg 89% (1379/1544) 3 Ankle-brachial index < 0.45 1% (21/1544) 4 Albumin < 3.0 g/dL 1% (16/1544) 5 Total lymphocyte count < 1,500/mm3 6% (91/1544) Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ06.54) Which of the following patients with type 2 diabetes mellitus is most likely to develop a foot ulcer? Review Topic QID: 165 1 54-year-old female unable to feel the presence of a 5.07 Semmes-Weinstein monofilament on the plantar aspect of the foot 78% (489/628) 2 63-year-old male with transcutaneous oxygen pressures (TcpO2) of 30 mm Hg 4% (23/628) 3 51-year-old male with ratio of ankle to brachial pressures of < 0.6 14% (89/628) 4 71-year-old male with serum albumin of 3.1 g/dL 0% (3/628) 5 60-year-old with autonomic dysfunction leads to drying of skin due to lack of normal glandular function 3% (16/628) Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ07.90) A 45-year-old diabetic male has a Wagner type 3 heel ulcer shown in Figure A that measures 4x2cm and is recalcitrant to debridements and total contact casting for 4 months. The patient has palpable pulses, active drainage at the ulcer, and does not have protective sensation with a 5.07 Semmes-Weinstein filament. Radiograph and MRI (sagittal and axial) images are shown in Figures B-D respectively. In addition to bone culture biopsy, debridement and antibiotic therapy, what surgical intervention is most appropriate? Review Topic QID: 751 FIGURES: A B C D 1 Ankle disarticulation 4% (85/2102) 2 Soft tissue fasciocutaneous flap coverage 6% (134/2102) 3 Partial calcanectomy 74% (1565/2102) 4 Below knee amputation 10% (218/2102) 5 Soft tissue free flap coverage 4% (87/2102) Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ10.81) A 44-year-old male with long standing insulin dependent diabetes complains of a non-healing plantar foot ulcer. The ulcer is shown in Figure A. The second metatarsal head can be probed at the base of the wound, and he lacks plantar sensation. Laboratory work-up for infection is negative. Which of the following is the best initial treatment? Review Topic QID: 3169 FIGURES: A 1 Ray resection and primary wound closure 2% (37/1792) 2 Oral antibiotics and local wound care 1% (24/1792) 3 Local wound care and non-weight bearing in a removable boot 20% (351/1792) 4 Surgical debridement, dressing changes, and IV antibiotics 53% (956/1792) 5 MRI of the foot to evaluate for underlying osteomyelitis 23% (418/1792) Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ11.151) A 55-year-old female with longstanding type I diabetes presents for evaluation of her left foot, which is shown in Figure A. On exam, the soft tissue infection extends to the metatarsals plantarly, and there is a palpable posterior tibial artery pulse. She is otherwise medically stable, and without sepsis. Which of the following treatment options will most likely result in definitive management of her forefoot gangrene and allow the highest level of functional activity after surgery? Review Topic QID: 3574 FIGURES: A 1 Transmetatarsal amputation 20% (429/2148) 2 Below the knee amputation 7% (154/2148) 3 Syme amputation 72% (1537/2148) 4 Above the knee amputation 0% (5/2148) 5 Extensive soft-tissue debridement, local wound care, and antibiotic therapy 1% (15/2148) Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
Options for Achilles Tendon Lengthening: Michael Clare, MD (CSFA #23, 2017) Foot & Ankle - Diabetic Foot Ulcers - Treatment Consult Options for Achilles Tendon Lengthening: Michael Clare, MD(CSFA #23, 2017) 5/15/2017 499 views