Questions to Answer Systems Approach to the Exam 1. What are - PowerPoint PPT Presentation

4/8/2017 Approach to Non-healing Approach to Non-healing Diabetic Foot Ulcers Diabetic Foot Ulcers Gary M. Rothenberg, DPM, CDE, CWS The University of Michigan Medical School Clinical Assistant Professor Department of Internal Medicine Metabolism, Endocrinology and Diabetes Division No relevant financial relationships related to this presentation UCSF Vascular Symposium April 8, 2017 Patient Evaluation and the Questions to Answer Systems Approach to the Exam 1. What are expected healing rates for DFU with standard of Successful wound healing depends on comprehensive assessment care? 2. When to move to advanced wound therapies to accelerate History Physical Exam wound healing potential? • HPI • Vascular • PMH 3. What are the choices for true non healing DFUs? • Neurologic • Meds / Allergies • Orthopedic • Social history • Dermatologic • Previous surgeries Palliative Surgery – Wound History • Family History Wound Care • Shoegear • Review of Systems 1

4/8/2017 Healing DFUs with Patient Evaluation and the Standard of Care Systems Approach to the Exam Laboratory Studies Ancillary Testing Purpose: To evaluate the CBC Plain film x-rays 450 patients rate of neuropathic ulcer Comp panel CT / MRI / Bone Scan healing in 10 control groups 12 week endpoint from prospective clinical trials HbA1C Vascular Testing Healing rate 24% via meta-analysis Pre-albumin TCP02 / SPP ESR / CRP Biopsy 172 patients Good wound care Tissue cultures 20 week endpoint • Debridement Local Wound • Offloading Healing rate 30.9% Evaluation Systemic Evaluation • Saline gauze or gel Probe to bone Smoking cessation Moisture balance Hypertension There is significant need for advanced wound therapies……. Size, structures, quality Glycemic control Margolis, D, et al. Healing of Neuropathic Ulcers: Results of a Meta-Analysis. Diabetes Care 1999;22: 692-695 Advanced Wound Care: Patient Factors Affecting Predicting Healing Wound Healing – the Science Percent Change in Wound Area of Diabetic Foot Ulcers General wound appearance Over a 4-Week Period Is a Robust Predictor of Age Periwound skin integrity Complete Healing in a 12-Week Prospective Trial Nutrition Wound evolution • Wound area changes over a Infection Wound etiology 4-week period can strongly Perfusion Drainage predict complete wound Senescent cells Bacterial bioburden healing over an extended Metabolic disorders 12-week period 53% Sustained inflammation • 4-weeks can be a pivotal clinical decision point in Deficient growth factor response the management of diabetic foot ulcerations Sheehan, P et al. Percent Change in Wound Area of Diabetic Foot Ulcers Over a 4-Week Falanga V. Wound healing and its impairment in the diabetic foot Period Is a Robust Predictor of Complete Healing in a 12-Week Prospective Trial. Diabetes Care , Volume 26, Number 6, June 2003 Lancet. Vol 366; Nov. 2005 2

4/8/2017 Patient Factors Affecting When to Consider Surgery? Wound Healing – the Art Consider surgery when conservative therapy fails Smokers Failure of conservative treatment -- Ulcers that cannot Depression be accommodated and offloaded by footwear, Fibromyalgia orthoses, or related care Homelessness Therapeutic shoes – recurrence rates of ulcers 28% at Financial distress 12 months to 100% at 40 months Goals and motivation Deformity which places limb at risk Lack of social support General medical status Patient attitude and buy-in Arterial perfusion Previous experiences with health care teams Rigid vs. flexible Surgeries for Treating Wounds in Surgeries for Treating Wounds in Patients with Diabetes Patients with Diabetes Procedures should be chosen to correct the underlying problem in the most minimally invasive manner. In some cases, amputation may offer a better functional outcome. Curative Procedures Debridements Prophylactic Procedures Wound closure Correction of Deformities Flaps and grafts Hammertoes Closure devices Charcot Ankle joint equinus Ablative Procedures Procedures addressing underlying Amputation etiology in the presence of a wound Armstrong, DG et al. Classifying Diabetic Foot Surgery: Toward a Rational Definition . Diabetic Medicine 20.4 (2003): 329-331. 3

4/8/2017 Healing Lesser Toe Ulcers Healing Hallux IPJ Ulcers Retrospective comparative Clinic based flexor tenotomy Results cohort study of operative procedure for digital ulcers vs non-operative Ulcer healing management of hallux IPJ • 24 days vs 67 days Results ulcers Ulcer recurrence • Ulcers without osteo healed within 34 toes in 14 patients • 21 Surgical patients • 5% vs 35% 3 weeks 8 male / 6 female underwent Keller type Infection • Ulcers with osteo healed within 8 24 ulcers / 10 at risk arthroplasty weeks • 40% vs 38% 3 Osteomyelitis • 20 age, sex-matched • No complications Amputation patients receiving Average duration of • No recurrence • 10% vs 5% standard non-surgical ulceration 11 months care • No hyperextension deformities Mean f/u 13 months seen • 6 month f/u Armstrong et al, Clinical Efficacy of the First Metatarsalphalangeal Joint Arthroplasty as a Tamir et al, Outpatient Percutaneous Flexor Tenotomies for Management of Diabetic Curative Procedure for Hallux Interphalangeal Joint Wounds in Patients With Diabetes Diabetes Care , Vol 26, No 12, Dec 2003 Claw Toe Deformities with Ulcers: A Preliminary Report Can J Surg , Vol 51, No 1, Feb 2008 Approach to Patients with Healing Ulcers Sub 5 th Met Head Non-healing DFUs? Retrospective cohort Palliative Wound Care Historical focus of wound care study to evaluate Results has been: Chronic Wound Maintenance outcomes of operative Ulcer healing Wound Hospice • Curing / managing the versus non-operative underlying disease • 5.8 weeks vs 8.7 weeks treatment of • Healing the wound ulcerations sub 5th Ulcer recurrence metatarsal head • 4.5% vs . 28% Palliative wound care is the • 22 patients underwent evolving body of knowledge and Infection 5th met head excision skills that take a holistic • 18% vs. 22% • 18 patients received approach to relieving suffering standard non-operative Amputation and improving quality of life for care patients and families living with 4.5% vs. 12% • • 6 month f/u chronic wounds, whether the Armstrong DG. Int Wound J. 2007;4(4):286-287 wound is healable or not. Ferris, FD et al, Palliative Wound Care: Managing Chronic Wounds across Life’s Continuum: Armstrong et al, Efficacy of Fifth Metatarsal Head Resection for Treatment of Chronic Diabetic Foot Ulceration . JAPMA 2005 A Consensus Statement from the International Palliative Wound Care Initiative . J Palliative Med , Vol 10;1, 2007 4

4/8/2017 Approach to Patients with Summary Non-healing DFUs? Encompasses therapeutic Would life be The majority of wounds will not heal with interventions that aim to: standard of care different if the • Guide effective communication, Advanced wound care can accelerate wound healed? decision making, and care wound healing in the appropriately delivery selected patient • Stabilize the wound Successful wound healing is dependent • Minimize the risk of infection upon comprehensive local and systemic and further progression of the wound assessment • Manage the multiple issues that Surgery has a role in the prevention and cause patient and family management of DFUs suffering Palliative wound care is an acceptable • Optimize the patient’s function and quality of life for as long as alternative in many cases possible Ferris, FD et al, Palliative Wound Care: Managing Chronic Wounds across Life’s Continuum: A Consensus Statement from the International Palliative Wound Care Initiative. J Palliative Med , Vol 10;1, 2007 Thank you! 5