Statistics
What percentage of lower limb amputations result from non-traumatic diabetic complications?
60%
Describe the pathophysiology behind the development of neuropathy.
Sorbitol accumulation and Accretion of advanced glycosylation
The classification system developed in the 1970s at Rancho Los Amigos Hospital in California has been the most widely used and accepted grading system for lesions of the diabetic foot
Wagner Classification
A histology report returns to your office without definitive diagnosis - it reads:
"Acute and chronic inflammatory cells within marrow spaces with or without osteonecrosis and fibrosis"
What is your diagnosis?
Osteomyelitis
This is a non-infective bone and joint destructive process that often occurs in assoc. with peripheral neuropathy
Charcot Neuroarthropathy
What is the lifetime risk of a diabetic developing an ulcer?
15%
Autonomic neuropathy results in these symptoms
Loss of normal sweating ability & temperature regulation
Leading to skin that is dry, stiff, & scaly
This classification system uses a depth–ischemia classification in its definitions of wound depth and separation of that from evaluation of ischemia and infection.
University of Texas Ulcer Classification
You are consulted for a patient that presents with "subcutaneous emphysema" on radiographs. Your clinical suspicious is for these (name a few) bacteria:
Clostridium perfringens
Group B Strep
Enterococci
Staph aureus
Bacteroides
DM 1 & 2 are the most common cause of this in the world followed by syphilis, Leprosy (Hansen’s Disease)
Charcot Neuroarthropathy
Charcot Neuroarthropathy has bilateral incidence in what percent of cases?
30%
DM plaques cause calcification circumferentially in this layer of the vessel and cause elevated ABIs
Tunica Media
This classification system has four main stages
1. Prodromal
2. Development
3. Coalescent
4. Reconstruction
You are consulted at a local hospital for possible early Osteomyelitis vs Charcot Foot. The infectious disease doctor has taken it upon himself to order you a bone scan (Gallium). What do you tell the ID doc regarding the outcomes of the bone scan?
Gallium scans are too nonspecific to be helpful in making the distinction between a Charcot joint and osteomyelitis and are usually not helpful in the diagnosis of a diabetic foot.
Regarding ABIs - Wagner’s original work cited a ratio of _____ as necessary to heal diabetic foot lesions.
0.45 or greater
Brodsky Type 1 account for what percentage of CN
60%
Name the two theories regarding the etiology of Charcot
Neurotraumatic & Neurovascular
Your non-diabetic patient obtains ABIs and is found to have a ratio of 0.40 what is the likelihood the patient will heal their digital ulcer.
Possible.
Wagner’s original work cited a ratio of 0.45 or greater as necessary to heal diabetic foot lesions and a ratio of 0.35 to heal lesions in the nondiabetic patient with peripheral vascular disease
Your 55yo DM patient presents with a red, hot, swollen, 2nd digit with a distal ulcer +probe to bone and radiographic evidence of osteomyelitis. You elect for digit amputation. Post-operatively antibiotics will be given for
7-10 days until final pathology / microbiology results return
This free-radical scavenger antioxidant has been shown to aid in diabetic neuropathy if given as 600mg/day IV for 3 weeks
a-Lipoic Acid
Even with the aid of a total contact cast, this percentage of patients will develop na ulcer during treatment of their Charcot Neuroarthropathy.
Up to 30%
According to the ACCORD study in 2008, intensively lowering blood glucose to a target below current recommendations lead to what critical outcome
(<6.0%) increased the risk of death compared with a less intensive standard treatment strategy (A1c 7.0-7.9%).
According to the Cierny-Mader classification, a diabetic patient with osteomyelitis of the medullary canal of a bone is classified as
1B
A patient presents with previous diagnosis of Charcot Neuroarthropathy - on radiographs the deformity appears to be at the Lisfranc joint. According to the Schon Classification this is a type
Individuals with these systemic risk factors had risk factors higher than diabetes for developing nerve entrapment.
Inflammatory arthritis, corticosteroid use, estrogen replacement, and hypothyroidism