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Diabetic and Charcot Foot for Orthopaedic Exams
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Diabetic and Charcot Foot for Orthopaedic Exams
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Upload Date:
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Language: EN.
Segment:0 .
I think everyone. Welcome to this FRCS teaching session from the FRCS mentor group. Our presenter this evening is Abdullah hanoun, he's a surgeon from yeoville hospital, moving soon to the Manchester area.
He's passed his exam few months ago and he's been very active mentoring the group and we are very thankful for his contribution is presenting tonight a very important topic about diabetic foot and chakra joint. This could obviously present in Aviva as well as the clinical sections. In attendance also, we have Ashish. He is he presented last week, and he's going to continue today.
Some Viva topics towards the end. We have also Samir got with the new mentor here, and he will be supporting and giving us a hand in the teaching myself and Firas, and I'll be moderating the session for you. If you have any questions, please either raise the hand symbol next to your name or write the question in the chat area. I will try to respond to you as soon as we can.
If you also like to speak and talk directly to one of the mentors and just raise your hand symbol, anyone who attends can have a CPD certificate. Please get in touch if you would like one and we leave you now in the safe hands of Abdullah. Hello good evening, everyone. Thank you for joining us today. I will be talking about diabetic foot and because this is a connecting or connected topic, I'm going to talk about chocolate's joint as well.
I'm not aware of anyone who had a diabetic foot as such in the clinical exam, however, the shortcuts joint can present. And I believe it has presented in the past. Both could come in the vyver, though, and there is a lot of interconnectivity between the two that even if you are presented with a shark with a shark joint in the clinical, they could ask you about the diabetic and the diabetic foot management.
In addition, with the new curriculum, they have included diabetic foot and the critical cases that every registrar should know about before they are granted the certificate. So that means that they are aware of its importance, and it is very fair for them to ask about it in the exam and for people who are present. Preparing for Caesar again, they have to have evidence that they have discussed that and they have knowledge about it more to it.
Is there is some NICE guidelines which talks about both diabetic foot and chocolate's joints, and being aware of that is very important for the exam. I will try and make it as short as possible, and I will try and make it focus towards the exam. So the diabetic foot, as you can see here, the number of people presenting with diabetic foot to the hospitals is increasing. And 10% of them will develop an ulcer.
And that means that they would present to the hospital with that. This has a huge cost implications. As you can see, 1 pound in every 150 pounds spent on diabetic diabetes care is spent on diabetic foot, and about 100 limb amputations per week in the UK is done because of diabetic foot and short cuts joints. The ulcers in general, as we all know, is about three thirds, one third in neuropathic, one third ischemic and one third next.
Let's talk about the vascular components as we know its micro and macrovascular. Both of them combined or alternate to cause impairment to the blood supply to the small tissues, which leads to necrosis and infection. And that reduces the immunity of that area. The neuropathy because of the damage to the nerves, there will be different types of nerve damage. We have autonomic, sensory and motor.
The autonomic loss leads to dry skin because of loss of sweat, and that leads to fishing, which gives access to the bacteria to grow and cause more damage. In addition, the damage itself because of the vascular loss there would be less response and less ability to build defenses against it. The sensory means that the patient will cause damage without them realizing, and we all know about the history or stories of diabetic patients burning their toes or cutting them without them realizing.
And that continues to bleed cause infection later on. The mortar causes several deformities in the foot because of the imbalance between the intrinsic and extrinsic muscles, and that can cause the closing of the foot cavers, foot iguanas, contractures all of these foot certain areas of the foot at higher pressure. It's especially the metatarsal heads, so you have increased pressure because of the deformities.
You have lack of sensation. You have more entry to the bacteria and lack of defenses, all of them combined. Lead to the ulceration in addition to having significant food for bugs, which is the sugar leads to the disaster that is diabetic foot. The assessment. If you are presented with a diabetic patient, this is what comes in the exam.
How would you assess the patient presenting with diabetic foot? The first buzzword is the mdc-t, so it is an mdc-t approach. Next, you have to have a holistic approach to it, so you start by diabetic control. And by that. You have to assess the AVM, which is not sugar and HbA1c and usually that is done by the endocrinologist. You have to assess the ulcer itself and whether there is or there isn't any infection that can be with inspection, probing.
And then investigations like white cells, CRP, ESR and then we will talk about the ulcer classification. You have to assess the vascular and that can be with capillary fill general pulse. We know that its micro and macro pulse itself is not enough. You have to assess the ABI and I will be talking about it in a second. Doppler turns cutaneous saturation and occasionally angiography.
And again, you may have to refer the patient to plastic surgeon at some stage. You have to assess the neurology and we will talk about these. But basically, it is just doing a general neurological examination using sense Weinstein monofilament vibration test and occasionally again, nerve conduction tests now coming to the orthopedic side of things. You have to look at the deformities, which can be the cause of the ulcerations.
So if there is a bony prominence, you have to address that. And we talked about the classification. And this is the final bit and we will have a little talk about it. This is actually basic stuff, the neuropathic versus ischemic ulcers just to touch on it basically neuropathic, you have less pain or no sensation, the ischemic, you have no granulation tissue and that's the basic difference.
But however, they may ask you about it. And as we said, one third of the ulcers will be combining both. Let's talk about SIEM Weinstein monofilament test, this is again something that can be asked about in the exam, in the vyver question. Divide the table. It's a simple test whereby you have a 10 gram nylon monofilament, which is applied to the skin.
What happens is, if you put it under more pressure, it will bend. So it only allows a certain amount of pressure to the area. And the normal person will be able to feel the touch with the pressure of it. If there is lack of that, then we call the patient as having lack of protective sensation. The ideal way of testing it is three points at the plant side of the foot, so you have the first, third and fifth metatarsal heads.
The next test is vibration, and we use 1 to 8 Hertz tuning fork. And the patient should be able to assess the feel the vibration again, you use a prominent bony prominences. Next, I will be talking about the AVP we all know about it. It's for people who are not familiar with it. It is measuring the blood pressure of the humerus of the same side, and the ankle, and it is ankle brachial.
So you start with the ankle on top and the brachial plexus brachial blood pressure on bottom and it's systolic. And the index, usually should be something like one because they have both the same pulse. If it is more than one point three, it means that there is a lot of classification that allows more blood to go there. If it is less than 0.8, then we are suspecting ischemia. And if it is more less than four, then it is critical asking I'm talking 0.4. OK we can use handheld Doppler instead of the listening with the stethoscope and with a handheld Doppler.
You expect to hear again, this is a buzz word. Try phase signal. OK transcutaneous oxygen saturation, which is similar to the thing we use for the finger saturation, but it has a certain probe that you could put anywhere in the skin and the normal saturation should be 440 mercury. Anything below 25 is called high risk of bone diseases. And again, ischemia.
Let's talk about classification. I started with the Wagner classification because of historic reasons, but also as the progresses with deep ulcers and then gangrene. OK, great. 0 to 5. However, NICE guidelines recommend Sinbad classification and sin ban stands for site ischemia, neuropathy, bacterial infection area and depth.
In addition, there is another classification, which is University of Texas classification. This is slightly difficult, I'll take you through it. So you have the first column, which is the stage. OK, and you have the grade. So the stage would look at whether it is simple or complicated. And that's the column there, the line in there. The first line tells you how deep it is.
OK, so the ground 0 is a 0 means that it is very superficial and complicated, so there is pre or post ulceration lesions completely realized. And then you move on to deep penetration all the way down to the joint now in stages. Now that's a b, you have infection, C you have ischemia. And you have infection and ischemia. And again, this is recommended by the NICE guidelines.
Talk about management in general, and this is mainly from the Markovich prevention, education, accommodation, accommodative footwear. And then you deal with the ulcer itself. The mainstay is offload the area and prevent further damage and allow the body to heal it on its own. So for non-infected, you put a DCC. You correct muscularity as much as you can. And of course, you have control the blood sugar and then you correct the deformities at a later time if they are causing repetitive or recurrent ulcers.
If it is an infective ulcer, however, you have to start antibiotics with the bridesmaid, and occasionally you might have to do the radical development, which is obviously amputation. Management of chronic deformities, again, you start non-surgical or conservative and then surgical. So the non-surgical you do modified footwear, orthotics and braces.
Surgery, the indications are uncontrolled, failed treatment, so the highlights of the guidelines is each patient coming with the diabetic foot, especially a diabetic foot ulcer, has to have a named consultant. It is left to the local guidelines or local hospital to decide who that consultant is in our hospital. It is the diabetologist or endocrinologist. The patient has to be managed in an mdc-t method. There has to be a local protocol or pathway for prevention, assessment and treatment of diabetic feet, and the assessment has to be urgent and urgent if there is a critical ischemia or critical foot or what they sometimes is called foot attack, where there is significant risk of infection and ischemia.
The assessment has to be within 24 hours. The guidelines will elaborate on that. The components of the mdc-t team, and this is a question from viper, I've been told that some people have been asked that it has to include anyone that has anything to do with diabetes or vascular problems. So you can imagine it is a big group, but they are trying to be pragmatic.
So they said the component has to be people that can be in any hospital. While they should have access to people that can be only in specific centers like the plastic surgery or vascular surgery. OK there is another MDT. So the first MDT we talked about is hospital based MDT. Now this is a community based MDT, and again, the guidelines state that there has to be one and it is called food protection service and this is podiatrist led and that is in the community.
Patients should have access to it as well. And this is the component of the team. So the urgent referral to MDT service has to be for any limb or life threatening diabetic problem, which is, for example, ulcerations with fever or signs of sepsis, ulcerations with limb ischemia, clinical concerns of deep seated soft tissue or bone infection or gangrene.
Again, the classifications recommended by the guidelines are the same bad or University of Texas. And there is, they said, that specifically do not use the vector classification system. Now again, the guidelines state that the treatment for uncomplicated and by uncomplicated means superficial ulcers, even if there is a little bit of infection superficially is, as we discussed before, offloading control, a foot infection control of ischemia when the right dressings and consider negative pressure wound therapy or dermal skin slap substitutes.
However, if it's become if it becomes infected, then microbiological examination with samples, even deep samples has to be taken, and exclusion of osteomyelitis with MRI is to be done. And then the treatment is with long term antibiotics starting as oral. And then IV and then moving to oral as per local protocol in conjunction with a discussion with the microbiologists.
And with urgent, obsessed incision and drainage. OK, I will be talking about osteomyelitis a little bit more when I talk about shark woods joints. I will stop here for a second. If anyone has any questions before we proceed to Shark joints, please ask. Thank you, Abdullah. That has come out very well. Abdullah has explained how the need for the use of buzzwords in this station.
So I encourage you all to remember the buzz words to say. If you say nothing, just say MDT and glucose monitoring. Opposing that approach. All this with the likes playing a very, very important and as yet, it's very this is essential now it's a critical case. So it's one of the hot topic nowadays. It's the same vinous time test for being able to describe it, either in a vaguely clinical situation will give you extra points.
I have a question of lie, if you don't mind. First, I would say the way you specified ulcers into infected and non-infected, I think that's very nice approach to this. And in the exam, they like clear definitions and they like clear classifications to be classified into infected and non-infected. The examiners are very relaxed straight away. They know you, you know what you're talking about and you're going to approach each different also in a slightly different way.
You'll be surprised how easily missed and you could be muddled up. So it's nice to have a nice classification of you. Give the examiner. You show that you have a clarity of thought and in your normal day to day practice and you are safe and you know what you're going to approach. But my question of the lies is, you said in your presentation do a dry face like signal Doppler and check for traffic signal.
Do you have any can you elaborate more, what does that mean? So when you put the Doppler, it is listening to the pulse as it travels from the heart all the way to the peripheral vessels. The normal pulse is biphasic because the blood pressure wave comes in 3 stages. The first stage is the blood pressure. Rushing into the vessel as of the elasticity of the arteries allows some of that blood to when the heart stops pumping with the contraction stops.
Some of that blood flow a tiny bit back, but then to be pushed by the next wave. So that's why it has three phase 3 try phase. So when you put the Doppler, you listen to a wave with three components to it. I haven't, you know, we are not expecting that because this is specialized vascular thing. But basically, when you put the Doppler, it goes, it gives a three wave thing like something like that.
OK, so one wave is the blood approaching, then a little bit of receding and then more approaching. You can imagine it like a wave from the sea. If you stand in front of the sea, waves comes, then recedes a bit and then comes back again because of the loss of laxity or elasticity of the vessels in the diabetes patients. They have. They lose that.
So it comes like a big wave, and that's it. And that's why you have one phase and it is something that you would hear rather than something that you would see. Some of the droplets would allow that to be represented as a wave on a monitor, and it'll show a three peaks or two peaks and one bottom. So you would see it like that. I don't need to know any more, I ask you this question.
Abdullah, just to show that if our, you know, participants if they say, try phasing in the exams or at least the examiner wants to drag them more on this or, you know, drop them, at least they have some principles to say and I don't think they need more than this. So thank you for explaining Abdullah. I think I will leave it again for each of you to come back to your nice presentation if you like to.
OK, so moving on shortcuts joins. So shortcuts joint is defined as non-infectious destructive process, leading to dislocation periodically fracture in patients with peripheral neuropathy who has lost protective sensation? It is. There is a debate about how much is the incidence of it in people who have diabetes, but some studies say that worldwide the incidence is 0.125 29% As you can see, it's a very wide margin.
I think it's because of the methodology of diagnosing it. However, people who have shortcuts joined at least 50% of them will need an operation at some stage in their life, and they have a 50 15% risk of amputation that can jump up to 67% 2/3 if there is an ulcer. So ulcer with shortcuts joint is bad. Bad news.
We all know they present with deformity that has been accumulating over time, which is caused by inability to feel the damage, so there will be. But when they present to you, they may present with acute or subacute inflammation. The pain may be present, although the patients do not have the normal sensory of the area, but there will be pain and that pain is related to the inflammation.
The hallmark is an increased of temperature on that side by 3 to five degrees compared to the other side. And this may have an implication in the follow up and monitoring of the patient because it tells us whether the which space. The patient is in. The differential diagnosis is for any as for any inflammatory process that happens in the foot that can be osteomyelitis, gout, cellulitis, necrotizing fasciitis.
Of particular interest is the infection. And again, this can come in the exam and it has come in the exam in the vibha. So is it shortcuts or is it infection? And the way to differentiate the first one is to say that they cannot coexist. And they have similar features. However, the infection infection will have higher inflammatory markers compared to osteomyelitis.
So the White cells CRP, ESR will be much more raised. The systematic response will be more. In addition, you can do one test by elevating the limb. So if you elevate the limb, the inflammation from Chicago, its joint is to do with the vascular permeability, and that will decrease if you leave it up for a bit of time. The inflammation from the sepsis is due to the infection, which means if you elevate the limb, it will not improve.
All the tests that you could use is isotope scan, and they combine the White blood. And the bone marrow label, so they use indium and technician together to diagnose whether this is chocolate's joint or infection. If you have pet scan, then that could help as well. Whenever you have an ulcer and that and you can probe down to the bone, it is osteomyelitis almost by definition.
So you can say, although the patient has shackled joints, but he has osteomyelitis as well. MRI scan may show some reaction, but it's not very reliable. 100% This is some talk about which radiographs you use a chocolate's joints. You start always with a weight bearing foot X-ray. This is for everyone. And then you use other in, you know, judgmentally. So, for example, if you are suspecting a deep infection, you use nuclear medicine.
If you are assessing deformities and you planning a surgery, use a CT scan. If you are looking at the soft tissue, extensive damage. You use MRI and PET scan to differentiate between the osteomyelitis and shortcuts. Joint I can hold has come up with the classification. And this simply fragmentation hypertrophic and then consolidation and fragmentation is the acute phase when the inflammation and inflammation is present and patients will have pain.
And this can last six months or even up to a year, then the inflammation phase goes out and then the reduction in inflammation comes and then the body starts to absorb all the debris and the damage that's happened from the inflammation and then the consolidation. The body is dealing with the outcomes, which usually leads to arthritis. What are the causes now?
Diabetic foot is the main cause. However, it's again, I'm in the IT. It's not been put in any order. It's just bullet points. But it would be better if you're in the exam. You put on the headlines and choose whatever headlines do you want? I put them as surgical scissors. The pathology and this is again, another vyver question, what are the theories behind shortcuts?
Why does it happen? There are different theories. The neuro traumatic theory means that says that because you lack the neurological response, you cause more micro trauma without realizing and the repetitive trauma would lead to that further damage. The neurovascular theory says that actually, it is to do with autonomic with sympathetic and parasympathetic drive, and by losing them, there will be vasodilation, which encourages bone resorption.
And the evidence for that is patients who have critical who have ischemia do not develop chocolate's joints. A new theory, or the theory that combines both, which is favored by the American consensus in 2011, is the inflammatory theory, which says that there will be an inflammation happening triggered by trauma in susceptible people. And the evidence for that is the cytokine activation and anti TNF tumor necrosis factor, alpha presence and activation in addition to lack of interleukin 10, which is anti-inflammatory.
All of that activates their uncle and leads to us osteoclast activity and bone resorption. The truth is, somewhere in between all of these, as I said, the American Diabetic association consensus in 2011 11 said that it is a combination of all of these. This leads to bone resorption and bone damage. However, the ligaments are affected because of the general inflammation in the area. In addition to glycol the absorption of the tendons because of the presence of glucose, it's not enzymatic damage or breakdown.
Localization, the classification, according to sites, I don't think they will ask about it in the exam, but it is there if you are interested. The management aims again, it is. It's very important whenever you start talking about the management is to give the aims because that puts that means that you understand what you are dealing with and you have a holistic approach.
So you would say I would like to stop the inflammation, protect and maintain the function and the architecture. I would like to relieve the patient's pain and rest the mineralization and limit the deformity. All of that while addressing the main issue. If that can be addressed, for example, controlling the diabetes. So this is a holistic answer. You haven't said anything, but you've said everything.
So specifically, the management can be conservative and/or surgical. We always start with conservative, they say never touch our good joints during its inflammatory process because whatever you do, you are going to cause more damage. So the first time you see the patient, you treat the infection, you treat the ulcer. And then you put them in TCC with, they say, one weekly change for up to six months or even longer than that.
And there is a big debate on how would when to stop using the TCC and allow the patient to walk. Some use the temperature difference. If the temperature goes down to equal to the other side, they would start mobilizing the patients. However, new evidence suggests that even that is too early and you need longer than that. And some centers use PET scan to dictate this bisphosphonate and have to warn you guys.
Bisphosphonate has been mentioned in berkovitch. The NICE guidelines say do not use it unless part of a trial. So be aware of that. If you are relying on banaszak for reading, be aware that if you mentioned bisphosphonates, the NICE guidelines goes against it. The surgical management is usually corrective and that it's exactly like diabetic foot, but once the inflammatory phase has subsided.
Surgical complications, non-union amputations, wound healing issues and infection, and we said that amputations is a high risk for these patients. These these are the summaries. The two slides are very busy, but these are the summaries of the NICE guidelines concerning the charcoals joints. So first of all, you have to have high suspicion of that. You have to refer to the mdc-t foot care.
You start always with a weight bearing X-ray and you supplement that with MRI scan. The mdc-t will always start with non-removable offloading device unless there are reasons not to, and then you give removable device. And as you can see here, do not offer bisphosphonates unless part of a clinical trial. And then you have to monitor with skin temperature difference.
And zero X-rays until the acute phase passes. And then the NICE guidelines state about the temperature. OK however, it's not worldwide accepted. OK and this is a very, very quick run through the both diabetic foot and chocolate's joints. If anyone has any questions, please do ask. Simple, but Abdullah has managed to make it simple.
He classified things and made them very clear. Thank you very much, Abdullah, for that. You clearly have worked very hard on this presentation. Thank you. It's obviously there, Abdullah has mentioned a lot of the guidelines to court and that will give you extra marks in the exam. So your courage to read the NICE guidelines. No, the summary the main points to quote from that and that would give you extra points on the exam.
You highlighted Abdullah the importance of the classification system. Yes it can hold the classification system to guide treatment, and the most important part of it probably is the inflammatory stage. And that you should not operate on a patient during the inflammatory stage. Yes correct.
And one parameter to decide if we still in there from a three stage is the temperature correct? Some parameters to decide if we still within the acute stage or we've passed that acute stage. So temperature, pain. I know it's a neuropathy. There is an point, but they still have pain, isn't it in the acute?
Correct so they still could have pain when the pain resolves, that could be an indication that they passed the stage. In addition, the redness that they have, which resolves by elevating of the limb, you would expect that to ease after the acute phase as well. So you have to rely on all of these. And as I said, the only accurate way. So far, even though it hasn't been officially validated, is the PET scan.
Yeah, thank you very much, Abdullah, it's very useful. Any other comments from the mentors we have, Ashish, we have Amjad and Samir. Any comments or questions or is that all? As Abdullah said, like in London, area kings is the Center for all its hardcore joints, and we were actually told that they follow up their patients with PET CT scans to see regarding settlement of inflammation.
We are shown some images as well in the course the King's FRC is, of course. I see, yes, very good. And do they do emphasis on is how to differentiate between infection and chocolate? And they usually they go to a clinical scenario. How to like, how do you differentiate clinically? And the point you said it quite nicely that you elevate the limit and that will differentiate between the charcoal and the infection.
Then the measurement of the temperature. I don't know about the. Yes, you can say it's the PET scan in London or in the new centres, but usually they rely on the clinical and especially on the clinical scenario that if you are faced with, basically assess the degree of the ulcer and the depth. And yes, but try to stay aseptic and be gentle with the patient. Yes thank you.
Thanks very much. I think that was very nicely covered. The presentation will be on the first mentor group YouTube channel once it's been edited. And anyone who would like to have a CBD certificates if you get in touch. I will issue with one. Thank you again, Abdullah, and Thanks to all the mentors.
Segment:0 .
I think everyone. Welcome to this FRCS teaching session from the FRCS mentor group. Our presenter this evening is Abdullah hanoun, he's a surgeon from yeoville hospital, moving soon to the Manchester area.
He's passed his exam few months ago and he's been very active mentoring the group and we are very thankful for his contribution is presenting tonight a very important topic about diabetic foot and chakra joint. This could obviously present in Aviva as well as the clinical sections. In attendance also, we have Ashish. He is he presented last week, and he's going to continue today.
Some Viva topics towards the end. We have also Samir got with the new mentor here, and he will be supporting and giving us a hand in the teaching myself and Firas, and I'll be moderating the session for you. If you have any questions, please either raise the hand symbol next to your name or write the question in the chat area. I will try to respond to you as soon as we can.
If you also like to speak and talk directly to one of the mentors and just raise your hand symbol, anyone who attends can have a CPD certificate. Please get in touch if you would like one and we leave you now in the safe hands of Abdullah. Hello good evening, everyone. Thank you for joining us today. I will be talking about diabetic foot and because this is a connecting or connected topic, I'm going to talk about chocolate's joint as well.
I'm not aware of anyone who had a diabetic foot as such in the clinical exam, however, the shortcuts joint can present. And I believe it has presented in the past. Both could come in the vyver, though, and there is a lot of interconnectivity between the two that even if you are presented with a shark with a shark joint in the clinical, they could ask you about the diabetic and the diabetic foot management.
In addition, with the new curriculum, they have included diabetic foot and the critical cases that every registrar should know about before they are granted the certificate. So that means that they are aware of its importance, and it is very fair for them to ask about it in the exam and for people who are present. Preparing for Caesar again, they have to have evidence that they have discussed that and they have knowledge about it more to it.
Is there is some NICE guidelines which talks about both diabetic foot and chocolate's joints, and being aware of that is very important for the exam. I will try and make it as short as possible, and I will try and make it focus towards the exam. So the diabetic foot, as you can see here, the number of people presenting with diabetic foot to the hospitals is increasing. And 10% of them will develop an ulcer.
And that means that they would present to the hospital with that. This has a huge cost implications. As you can see, 1 pound in every 150 pounds spent on diabetic diabetes care is spent on diabetic foot, and about 100 limb amputations per week in the UK is done because of diabetic foot and short cuts joints. The ulcers in general, as we all know, is about three thirds, one third in neuropathic, one third ischemic and one third next.
Let's talk about the vascular components as we know its micro and macrovascular. Both of them combined or alternate to cause impairment to the blood supply to the small tissues, which leads to necrosis and infection. And that reduces the immunity of that area. The neuropathy because of the damage to the nerves, there will be different types of nerve damage. We have autonomic, sensory and motor.
The autonomic loss leads to dry skin because of loss of sweat, and that leads to fishing, which gives access to the bacteria to grow and cause more damage. In addition, the damage itself because of the vascular loss there would be less response and less ability to build defenses against it. The sensory means that the patient will cause damage without them realizing, and we all know about the history or stories of diabetic patients burning their toes or cutting them without them realizing.
And that continues to bleed cause infection later on. The mortar causes several deformities in the foot because of the imbalance between the intrinsic and extrinsic muscles, and that can cause the closing of the foot cavers, foot iguanas, contractures all of these foot certain areas of the foot at higher pressure. It's especially the metatarsal heads, so you have increased pressure because of the deformities.
You have lack of sensation. You have more entry to the bacteria and lack of defenses, all of them combined. Lead to the ulceration in addition to having significant food for bugs, which is the sugar leads to the disaster that is diabetic foot. The assessment. If you are presented with a diabetic patient, this is what comes in the exam.
How would you assess the patient presenting with diabetic foot? The first buzzword is the mdc-t, so it is an mdc-t approach. Next, you have to have a holistic approach to it, so you start by diabetic control. And by that. You have to assess the AVM, which is not sugar and HbA1c and usually that is done by the endocrinologist. You have to assess the ulcer itself and whether there is or there isn't any infection that can be with inspection, probing.
And then investigations like white cells, CRP, ESR and then we will talk about the ulcer classification. You have to assess the vascular and that can be with capillary fill general pulse. We know that its micro and macro pulse itself is not enough. You have to assess the ABI and I will be talking about it in a second. Doppler turns cutaneous saturation and occasionally angiography.
And again, you may have to refer the patient to plastic surgeon at some stage. You have to assess the neurology and we will talk about these. But basically, it is just doing a general neurological examination using sense Weinstein monofilament vibration test and occasionally again, nerve conduction tests now coming to the orthopedic side of things. You have to look at the deformities, which can be the cause of the ulcerations.
So if there is a bony prominence, you have to address that. And we talked about the classification. And this is the final bit and we will have a little talk about it. This is actually basic stuff, the neuropathic versus ischemic ulcers just to touch on it basically neuropathic, you have less pain or no sensation, the ischemic, you have no granulation tissue and that's the basic difference.
But however, they may ask you about it. And as we said, one third of the ulcers will be combining both. Let's talk about SIEM Weinstein monofilament test, this is again something that can be asked about in the exam, in the vyver question. Divide the table. It's a simple test whereby you have a 10 gram nylon monofilament, which is applied to the skin.
What happens is, if you put it under more pressure, it will bend. So it only allows a certain amount of pressure to the area. And the normal person will be able to feel the touch with the pressure of it. If there is lack of that, then we call the patient as having lack of protective sensation. The ideal way of testing it is three points at the plant side of the foot, so you have the first, third and fifth metatarsal heads.
The next test is vibration, and we use 1 to 8 Hertz tuning fork. And the patient should be able to assess the feel the vibration again, you use a prominent bony prominences. Next, I will be talking about the AVP we all know about it. It's for people who are not familiar with it. It is measuring the blood pressure of the humerus of the same side, and the ankle, and it is ankle brachial.
So you start with the ankle on top and the brachial plexus brachial blood pressure on bottom and it's systolic. And the index, usually should be something like one because they have both the same pulse. If it is more than one point three, it means that there is a lot of classification that allows more blood to go there. If it is less than 0.8, then we are suspecting ischemia. And if it is more less than four, then it is critical asking I'm talking 0.4. OK we can use handheld Doppler instead of the listening with the stethoscope and with a handheld Doppler.
You expect to hear again, this is a buzz word. Try phase signal. OK transcutaneous oxygen saturation, which is similar to the thing we use for the finger saturation, but it has a certain probe that you could put anywhere in the skin and the normal saturation should be 440 mercury. Anything below 25 is called high risk of bone diseases. And again, ischemia.
Let's talk about classification. I started with the Wagner classification because of historic reasons, but also as the progresses with deep ulcers and then gangrene. OK, great. 0 to 5. However, NICE guidelines recommend Sinbad classification and sin ban stands for site ischemia, neuropathy, bacterial infection area and depth.
In addition, there is another classification, which is University of Texas classification. This is slightly difficult, I'll take you through it. So you have the first column, which is the stage. OK, and you have the grade. So the stage would look at whether it is simple or complicated. And that's the column there, the line in there. The first line tells you how deep it is.
OK, so the ground 0 is a 0 means that it is very superficial and complicated, so there is pre or post ulceration lesions completely realized. And then you move on to deep penetration all the way down to the joint now in stages. Now that's a b, you have infection, C you have ischemia. And you have infection and ischemia. And again, this is recommended by the NICE guidelines.
Talk about management in general, and this is mainly from the Markovich prevention, education, accommodation, accommodative footwear. And then you deal with the ulcer itself. The mainstay is offload the area and prevent further damage and allow the body to heal it on its own. So for non-infected, you put a DCC. You correct muscularity as much as you can. And of course, you have control the blood sugar and then you correct the deformities at a later time if they are causing repetitive or recurrent ulcers.
If it is an infective ulcer, however, you have to start antibiotics with the bridesmaid, and occasionally you might have to do the radical development, which is obviously amputation. Management of chronic deformities, again, you start non-surgical or conservative and then surgical. So the non-surgical you do modified footwear, orthotics and braces.
Surgery, the indications are uncontrolled, failed treatment, so the highlights of the guidelines is each patient coming with the diabetic foot, especially a diabetic foot ulcer, has to have a named consultant. It is left to the local guidelines or local hospital to decide who that consultant is in our hospital. It is the diabetologist or endocrinologist. The patient has to be managed in an mdc-t method. There has to be a local protocol or pathway for prevention, assessment and treatment of diabetic feet, and the assessment has to be urgent and urgent if there is a critical ischemia or critical foot or what they sometimes is called foot attack, where there is significant risk of infection and ischemia.
The assessment has to be within 24 hours. The guidelines will elaborate on that. The components of the mdc-t team, and this is a question from viper, I've been told that some people have been asked that it has to include anyone that has anything to do with diabetes or vascular problems. So you can imagine it is a big group, but they are trying to be pragmatic.
So they said the component has to be people that can be in any hospital. While they should have access to people that can be only in specific centers like the plastic surgery or vascular surgery. OK there is another MDT. So the first MDT we talked about is hospital based MDT. Now this is a community based MDT, and again, the guidelines state that there has to be one and it is called food protection service and this is podiatrist led and that is in the community.
Patients should have access to it as well. And this is the component of the team. So the urgent referral to MDT service has to be for any limb or life threatening diabetic problem, which is, for example, ulcerations with fever or signs of sepsis, ulcerations with limb ischemia, clinical concerns of deep seated soft tissue or bone infection or gangrene.
Again, the classifications recommended by the guidelines are the same bad or University of Texas. And there is, they said, that specifically do not use the vector classification system. Now again, the guidelines state that the treatment for uncomplicated and by uncomplicated means superficial ulcers, even if there is a little bit of infection superficially is, as we discussed before, offloading control, a foot infection control of ischemia when the right dressings and consider negative pressure wound therapy or dermal skin slap substitutes.
However, if it's become if it becomes infected, then microbiological examination with samples, even deep samples has to be taken, and exclusion of osteomyelitis with MRI is to be done. And then the treatment is with long term antibiotics starting as oral. And then IV and then moving to oral as per local protocol in conjunction with a discussion with the microbiologists.
And with urgent, obsessed incision and drainage. OK, I will be talking about osteomyelitis a little bit more when I talk about shark woods joints. I will stop here for a second. If anyone has any questions before we proceed to Shark joints, please ask. Thank you, Abdullah. That has come out very well. Abdullah has explained how the need for the use of buzzwords in this station.
So I encourage you all to remember the buzz words to say. If you say nothing, just say MDT and glucose monitoring. Opposing that approach. All this with the likes playing a very, very important and as yet, it's very this is essential now it's a critical case. So it's one of the hot topic nowadays. It's the same vinous time test for being able to describe it, either in a vaguely clinical situation will give you extra points.
I have a question of lie, if you don't mind. First, I would say the way you specified ulcers into infected and non-infected, I think that's very nice approach to this. And in the exam, they like clear definitions and they like clear classifications to be classified into infected and non-infected. The examiners are very relaxed straight away. They know you, you know what you're talking about and you're going to approach each different also in a slightly different way.
You'll be surprised how easily missed and you could be muddled up. So it's nice to have a nice classification of you. Give the examiner. You show that you have a clarity of thought and in your normal day to day practice and you are safe and you know what you're going to approach. But my question of the lies is, you said in your presentation do a dry face like signal Doppler and check for traffic signal.
Do you have any can you elaborate more, what does that mean? So when you put the Doppler, it is listening to the pulse as it travels from the heart all the way to the peripheral vessels. The normal pulse is biphasic because the blood pressure wave comes in 3 stages. The first stage is the blood pressure. Rushing into the vessel as of the elasticity of the arteries allows some of that blood to when the heart stops pumping with the contraction stops.
Some of that blood flow a tiny bit back, but then to be pushed by the next wave. So that's why it has three phase 3 try phase. So when you put the Doppler, you listen to a wave with three components to it. I haven't, you know, we are not expecting that because this is specialized vascular thing. But basically, when you put the Doppler, it goes, it gives a three wave thing like something like that.
OK, so one wave is the blood approaching, then a little bit of receding and then more approaching. You can imagine it like a wave from the sea. If you stand in front of the sea, waves comes, then recedes a bit and then comes back again because of the loss of laxity or elasticity of the vessels in the diabetes patients. They have. They lose that.
So it comes like a big wave, and that's it. And that's why you have one phase and it is something that you would hear rather than something that you would see. Some of the droplets would allow that to be represented as a wave on a monitor, and it'll show a three peaks or two peaks and one bottom. So you would see it like that. I don't need to know any more, I ask you this question.
Abdullah, just to show that if our, you know, participants if they say, try phasing in the exams or at least the examiner wants to drag them more on this or, you know, drop them, at least they have some principles to say and I don't think they need more than this. So thank you for explaining Abdullah. I think I will leave it again for each of you to come back to your nice presentation if you like to.
OK, so moving on shortcuts joins. So shortcuts joint is defined as non-infectious destructive process, leading to dislocation periodically fracture in patients with peripheral neuropathy who has lost protective sensation? It is. There is a debate about how much is the incidence of it in people who have diabetes, but some studies say that worldwide the incidence is 0.125 29% As you can see, it's a very wide margin.
I think it's because of the methodology of diagnosing it. However, people who have shortcuts joined at least 50% of them will need an operation at some stage in their life, and they have a 50 15% risk of amputation that can jump up to 67% 2/3 if there is an ulcer. So ulcer with shortcuts joint is bad. Bad news.
We all know they present with deformity that has been accumulating over time, which is caused by inability to feel the damage, so there will be. But when they present to you, they may present with acute or subacute inflammation. The pain may be present, although the patients do not have the normal sensory of the area, but there will be pain and that pain is related to the inflammation.
The hallmark is an increased of temperature on that side by 3 to five degrees compared to the other side. And this may have an implication in the follow up and monitoring of the patient because it tells us whether the which space. The patient is in. The differential diagnosis is for any as for any inflammatory process that happens in the foot that can be osteomyelitis, gout, cellulitis, necrotizing fasciitis.
Of particular interest is the infection. And again, this can come in the exam and it has come in the exam in the vibha. So is it shortcuts or is it infection? And the way to differentiate the first one is to say that they cannot coexist. And they have similar features. However, the infection infection will have higher inflammatory markers compared to osteomyelitis.
So the White cells CRP, ESR will be much more raised. The systematic response will be more. In addition, you can do one test by elevating the limb. So if you elevate the limb, the inflammation from Chicago, its joint is to do with the vascular permeability, and that will decrease if you leave it up for a bit of time. The inflammation from the sepsis is due to the infection, which means if you elevate the limb, it will not improve.
All the tests that you could use is isotope scan, and they combine the White blood. And the bone marrow label, so they use indium and technician together to diagnose whether this is chocolate's joint or infection. If you have pet scan, then that could help as well. Whenever you have an ulcer and that and you can probe down to the bone, it is osteomyelitis almost by definition.
So you can say, although the patient has shackled joints, but he has osteomyelitis as well. MRI scan may show some reaction, but it's not very reliable. 100% This is some talk about which radiographs you use a chocolate's joints. You start always with a weight bearing foot X-ray. This is for everyone. And then you use other in, you know, judgmentally. So, for example, if you are suspecting a deep infection, you use nuclear medicine.
If you are assessing deformities and you planning a surgery, use a CT scan. If you are looking at the soft tissue, extensive damage. You use MRI and PET scan to differentiate between the osteomyelitis and shortcuts. Joint I can hold has come up with the classification. And this simply fragmentation hypertrophic and then consolidation and fragmentation is the acute phase when the inflammation and inflammation is present and patients will have pain.
And this can last six months or even up to a year, then the inflammation phase goes out and then the reduction in inflammation comes and then the body starts to absorb all the debris and the damage that's happened from the inflammation and then the consolidation. The body is dealing with the outcomes, which usually leads to arthritis. What are the causes now?
Diabetic foot is the main cause. However, it's again, I'm in the IT. It's not been put in any order. It's just bullet points. But it would be better if you're in the exam. You put on the headlines and choose whatever headlines do you want? I put them as surgical scissors. The pathology and this is again, another vyver question, what are the theories behind shortcuts?
Why does it happen? There are different theories. The neuro traumatic theory means that says that because you lack the neurological response, you cause more micro trauma without realizing and the repetitive trauma would lead to that further damage. The neurovascular theory says that actually, it is to do with autonomic with sympathetic and parasympathetic drive, and by losing them, there will be vasodilation, which encourages bone resorption.
And the evidence for that is patients who have critical who have ischemia do not develop chocolate's joints. A new theory, or the theory that combines both, which is favored by the American consensus in 2011, is the inflammatory theory, which says that there will be an inflammation happening triggered by trauma in susceptible people. And the evidence for that is the cytokine activation and anti TNF tumor necrosis factor, alpha presence and activation in addition to lack of interleukin 10, which is anti-inflammatory.
All of that activates their uncle and leads to us osteoclast activity and bone resorption. The truth is, somewhere in between all of these, as I said, the American Diabetic association consensus in 2011 11 said that it is a combination of all of these. This leads to bone resorption and bone damage. However, the ligaments are affected because of the general inflammation in the area. In addition to glycol the absorption of the tendons because of the presence of glucose, it's not enzymatic damage or breakdown.
Localization, the classification, according to sites, I don't think they will ask about it in the exam, but it is there if you are interested. The management aims again, it is. It's very important whenever you start talking about the management is to give the aims because that puts that means that you understand what you are dealing with and you have a holistic approach.
So you would say I would like to stop the inflammation, protect and maintain the function and the architecture. I would like to relieve the patient's pain and rest the mineralization and limit the deformity. All of that while addressing the main issue. If that can be addressed, for example, controlling the diabetes. So this is a holistic answer. You haven't said anything, but you've said everything.
So specifically, the management can be conservative and/or surgical. We always start with conservative, they say never touch our good joints during its inflammatory process because whatever you do, you are going to cause more damage. So the first time you see the patient, you treat the infection, you treat the ulcer. And then you put them in TCC with, they say, one weekly change for up to six months or even longer than that.
And there is a big debate on how would when to stop using the TCC and allow the patient to walk. Some use the temperature difference. If the temperature goes down to equal to the other side, they would start mobilizing the patients. However, new evidence suggests that even that is too early and you need longer than that. And some centers use PET scan to dictate this bisphosphonate and have to warn you guys.
Bisphosphonate has been mentioned in berkovitch. The NICE guidelines say do not use it unless part of a trial. So be aware of that. If you are relying on banaszak for reading, be aware that if you mentioned bisphosphonates, the NICE guidelines goes against it. The surgical management is usually corrective and that it's exactly like diabetic foot, but once the inflammatory phase has subsided.
Surgical complications, non-union amputations, wound healing issues and infection, and we said that amputations is a high risk for these patients. These these are the summaries. The two slides are very busy, but these are the summaries of the NICE guidelines concerning the charcoals joints. So first of all, you have to have high suspicion of that. You have to refer to the mdc-t foot care.
You start always with a weight bearing X-ray and you supplement that with MRI scan. The mdc-t will always start with non-removable offloading device unless there are reasons not to, and then you give removable device. And as you can see here, do not offer bisphosphonates unless part of a clinical trial. And then you have to monitor with skin temperature difference.
And zero X-rays until the acute phase passes. And then the NICE guidelines state about the temperature. OK however, it's not worldwide accepted. OK and this is a very, very quick run through the both diabetic foot and chocolate's joints. If anyone has any questions, please do ask. Simple, but Abdullah has managed to make it simple.
He classified things and made them very clear. Thank you very much, Abdullah, for that. You clearly have worked very hard on this presentation. Thank you. It's obviously there, Abdullah has mentioned a lot of the guidelines to court and that will give you extra marks in the exam. So your courage to read the NICE guidelines. No, the summary the main points to quote from that and that would give you extra points on the exam.
You highlighted Abdullah the importance of the classification system. Yes it can hold the classification system to guide treatment, and the most important part of it probably is the inflammatory stage. And that you should not operate on a patient during the inflammatory stage. Yes correct.
And one parameter to decide if we still in there from a three stage is the temperature correct? Some parameters to decide if we still within the acute stage or we've passed that acute stage. So temperature, pain. I know it's a neuropathy. There is an point, but they still have pain, isn't it in the acute?
Correct so they still could have pain when the pain resolves, that could be an indication that they passed the stage. In addition, the redness that they have, which resolves by elevating of the limb, you would expect that to ease after the acute phase as well. So you have to rely on all of these. And as I said, the only accurate way. So far, even though it hasn't been officially validated, is the PET scan.
Yeah, thank you very much, Abdullah, it's very useful. Any other comments from the mentors we have, Ashish, we have Amjad and Samir. Any comments or questions or is that all? As Abdullah said, like in London, area kings is the Center for all its hardcore joints, and we were actually told that they follow up their patients with PET CT scans to see regarding settlement of inflammation.
We are shown some images as well in the course the King's FRC is, of course. I see, yes, very good. And do they do emphasis on is how to differentiate between infection and chocolate? And they usually they go to a clinical scenario. How to like, how do you differentiate clinically? And the point you said it quite nicely that you elevate the limit and that will differentiate between the charcoal and the infection.
Then the measurement of the temperature. I don't know about the. Yes, you can say it's the PET scan in London or in the new centres, but usually they rely on the clinical and especially on the clinical scenario that if you are faced with, basically assess the degree of the ulcer and the depth. And yes, but try to stay aseptic and be gentle with the patient. Yes thank you.
Thanks very much. I think that was very nicely covered. The presentation will be on the first mentor group YouTube channel once it's been edited. And anyone who would like to have a CBD certificates if you get in touch. I will issue with one. Thank you again, Abdullah, and Thanks to all the mentors.
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