Chapter 113 - Diabetic foot ulcers

Question 1

Risk of diabetic foot ulcer resulting in amputation

Answer 1

85%

Question 2

Mortality annually of a diabetic foot ulcer

Answer 2

10% 20% if amputated

Question 3

Diabetic foot ulcer major amputation 5 year mortality

Answer 3

70%

Question 4

Major amputation in contralateral limb in 3 years in diabetic

Answer 4

40%

Question 5

Multifactorial etiology of diabetic foot pathology

Answer 5

1) vascular insufficiency: tibial disease, medial calcinosis 2) infection risk 3) neuropathy: decubitus, autonomic issues, sensory and motor

Question 6

Diabetic neuropathy risk of foot ulceration increase

Answer 6

7x

Question 7

Autonomic dysfunction causing diabetic foot ulcer

Answer 7

1) sympathetic nerve dysfunction = reduce sweating –> dry fragile skin 2) arterial-venous shunt and impaired microvascular regulation of skin

Question 8

How often does contribution of arterial disease in DFU

Answer 8

50%

Question 9

Diabetic endothelium

Answer 9

Elevated serologic concentration of adhesion molecules WBC and platelets clog up endothelium diminishing ability of antibiotics and other healing factors to get in

Question 10

Classification system of diabetic foot infection by international working group on DFI PEDIS definition

Answer 10

TABLE 113.1 PEDIS = perfusion extent depth infection sensation

Question 11

Pressure points of a diabetic foot

Answer 11

FIGURE 113.2

Question 12

4 essential components of a diabetic foot exam

Answer 12

1) Vascular: palpate pulses, look for distal hair growth, cap refill 2) Neurologic: loss of protective sensation, biothesiometry, electronic tuning fork 128 mHz; muscle atrophy 3) Dermatologic: ulcer depth, wound bed, sign of infection, preulcerative lesions 4) Musculoskeletal: Charcot foot, dorsiflexion of ankle and great toe joint

Question 13

Monofilament used to test diabetic foot sensory function

Answer 13

Semmes-Weinstein 10g more reliable than tuning fork

Question 14

Charcot foot

Answer 14

1) Collapsed arch 2) Charcot neuropathic osteoarthropathy 3) red hot swollen foot 4) rocker bottom foot

Question 15

Wagner classification system of DFU

Answer 15

TABLE 113.3

Question 16

University of Texas method of DFU

Answer 16

TABLE 113.3

Question 17

Scans to rule out osteomyelitis

Answer 17

XRAY CT MRI SPECT PET BONE SCAN

Question 18

Benefit of wound debridement

Answer 18

1) remove dead and infected tissue 2) release plt growth factor, inhibit proteinases 3) limit action of bacterial biofilm

Question 19

Number of debridements of a DFU before attempted closure on average

Answer 19

4

Question 20

Dressing in between debridements of DFU

Answer 20

1) silver 2) cream 3) vac dressing - speeds closure

Question 21

Offloading modalities

Answer 21

1) post-op shoes 2) wedge shoes 3) healing sandals 4) braces 5) boots 6) total contact casting

Question 22

Double plantar rotation flaps limitation

Answer 22

only close < 2 cm central plantar forefoot ulcers

Question 23

single stage debridement with closure healing rate

Answer 23

97% 54% without complication 88% without recurrence at 2.5 years

Question 24

Achilles tendon lengthening goal

Answer 24

neutral or 5 degrees of dorsiflexion

Question 25

Achilles tendon lengthening vs not in diabetic foot ulcer recurrence

Answer 25

2% vs 25% without at 3 years

Question 26

TBI level that’s predictive of tissue healing

Answer 26

> 0.6

Question 27

pulse volume recording cut off for healing

Answer 27

> 5 mm

Question 28

Photoplethysmography above this level for healing

Answer 28

> 50 mmHg

Question 29

Transcutaneous oxygen tension greater than this for healing

Answer 29

> 40 mmHg

Question 30

TcPO2 index to heal wound

Answer 30

> 0.6 < 0.4 is non healing

Question 31

skin perfusion pressure cutoff for healing

Answer 31

> 50 mmHg < 30 mmHg is non healing

Question 32

Overall noninvasive vascular studies for DFU and cutoff interpretations

Answer 32

TABLE 113.4

Question 33

Rate of amputation in DFU without a single tibial runoff

Answer 33

62% 1.7% if at least one patent

Question 34

Pedal loop technique

Answer 34

1) traversing lesions in pedal arch to establish blood in prograde or retrograde manner

Question 35

Infrapopliteal stenting outcome 1 year

Answer 35

Restenosis 20% primary patency 70%

Question 36

PREVENT III trial

Answer 36

1) 1404 bypasses 2) 64% diabetic and 75% tissue loss 3) primary patency 61% 4) amputation free survival at 1 year improved

Question 37

Percentage of diabetics that do not have adequate GSV

Answer 37

30% 50% if redo operation

Question 38

Perioperative morbidity and incisional complication rate for diabetic getting vein bypass

Answer 38

20% morbidity 10% wound complication

Question 39

Organization structure of a multidisciplinary team to optimize care of DFU

Answer 39

1) limb preservation program 2) physician team 3) physician champion 4) staff, space 5) imaging ability 6) endo vs open 7) wound care 8) rehab 9) education 10) research 11) marketing 12) financial analyst