Suhad Hadi, DPM reviews the management of foot ulcers emphasizing the importance of recognizing vascular disease, infection, appropriate offloading, nutritional deficiency, factors contributing to non-compliance, the phases of healing and the importance of a team approach.
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Suhad Hadi, DPM
Louis Stokes Veterans Administration
Akron Community Based Outpatient Clinic
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Dr. Robert Frykberg: So now we’ve talked about the pathophysiology. We’ve talked about neuropathy, critical components and the sequence of complications in the lower extremity. So I wanted somebody to come forward and speak about the management principles which I believe all rely on basic tenants of care. I could think of nobody better to give this talk than my friend Suhad Hadi who actually trained years ago under Dr. Lavery I believe in University of Texas and who’s now at the VA up in Seattle. So let’s welcome Dr. Suhad Hadi.
Dr. Suhad Hadi: Dr. Lavery was at UT when I was there and just also reminded me how old I am getting now. So thank you to the Superbones committee for having me. I definitely also think this is an important topic in regards to the management of diabetic foot ulcers. There are some basic tenants like Dr. Frykberg mentioned. So just basic essentials in regards to developing an algorithmic approach as to how you treat your diabetic ulcers. I have nothing to disclose unlike our priority speakers. So the key to this talk is hopefully to take home some of the statistical impact of diabetes which we heard a lot of it from Dr. Frykberg. Understanding the risk factors and taking those and learning to ask the right questions to best assess your patients and their ulcers, and implementing and developing a short and long term management for the ulcers and also understanding the importance of the team approach which also again was mentioned. Again, not to deliver the statistics but 60% to 70% of patients with diabetes will develop neuropathy and over 25% of them will develop a foot ulcer. The yearly incidents thus vary based on studies as mentioned and can range anywhere from 2% to 32%. One of the keys is from within about 20% of these patients will result in an infection and potential amputation risk. The healing time for ulcers and wounds has ranged anywhere from six weeks, three months to seven months based on the location of the ulcer, and the comorbid factors that may complicate the overall healing regiment. Again, we heard about the mortality associated with patients with diabetes and in the presence of an ulcer and later we’ll talk more about that more mortality associated with charcot. So the international consensus on the diabetic foot made recommendations on the management of diabetic foot ulcers. There are four key factors that they recognize. On the next slide I’m going to add to this list by a few more. First is the restoration of skin perfusion and recognizing vascular disease in these patients, aggressive treatment of an infection, appropriate offloading and early referral for management. To this list I like to add identifying whether or not there’s a nutritional deficiency, what factors may affect the patient’s ability to be compliant which to me has become a huge factor in regards to treating these ulcers because of the prolonged treatment regimen and the healing times that we’ve seen in some of these patients. Then what’s happening at the cellular level? Do you know where your wound is at? Where the ulcer is at? What adjunctive therapies you can implement based on the knowledge and identification in the ulcer? So we’ll talk first about restoring skin perfusion. It’s important to identify whether or not your wound is ischemic. We’re going to revisit this case a little bit later in the top. But essentially, recognizing that this patient developed an ulceration to the middle 1st metatarsal head and had the start of an ischemic pressure area at the 5th metatarsal head. He was lost to follow up for about a month and we’ll also talk about why later, but you can see the progress, the ischemic changes to the area. The ulcer is opened the necrotic central base and the discoloration to the toe itself. In a patient like this, it’s important to evaluate all the parameters, not just their clinical findings in regards to pulses. Keep in mind too that the presence of pulses does not necessarily mean that the vascular supply is adequate enough to heal. So when you have other red flags on your examination and you incorporate these findings with what you see in your laboratory studies, whether it’s an arterial index, a TBI toe pressure, or skin oxygen measurements, you can definitely alert yourself and the patient and your vascular colleagues to help assess this patient and augment their healing in the long term. We noticed too. We were told too that it’s important for us to help recognize this. We are often times the gate keeper. We often times see these patients more frequently like it was mentioned, as well as when there is an ulcer or an event, these patients are referred to us and we get that consult. But it’s important for us to recognize vascular disease in these patients even though it’s been shown that about 50% are asymptomatic or show occlusive disease.
Probably about 60% to 70% are stable predicators. Then there’s that 20% or so that present to you with acute or chronic limb ischemia that needs to be addressed in order to optimize the healing. Again, I won’t [indecipherable] [05:18] too. It’s important for us to understand the vascular component to our patients and their healing. Not only in the immediate sense for healing but to also bring the point home to them as to the associated morbidity and mortality. Fatal events can be as high as 30% and then the non-fatal events, whether it’s a stroke or heart attack in these patients, can range anywhere to 20%. The other component is identifying an infection. Is your wound infected? If your wound is not healing, if the ulcer is not healing, you really need to rule out the infectious source. There are criteria that should raise also the flag as to whether or not your ulcer maybe infected. The chronicity of the ulcer. So if an ulcer has been present in an area of osseous prominence and despite offloading attempt and you can’t get it to heal. You really need to be critical in sequential evaluation whether it’s radiographic or other imaging studies to make sure that there’s not an underlying osseous process such as osteomyelitis that could be the inhibiting factor to your wound. The progression of the wound, if it continues to heal or recur or if it remains non-healing, to try to address an infectious source. Cause of the ulcer. Often times puncture wounds are more related to an infection that needs to be addressed an appropriate antibiotic regiment. Then the clinical appearance, again, tied in with these factors, the depth and proving. Drainage and the consistency of that drainage. I’ve always found that the more soupy the drainage, the more it’s related to things like the MRSA. Fluctuance. If there’s fluctuance in the area, be critical of any red streaking or any increase in temperature or redness in the area. Your classic signs of infection. The IDSA has conveniently provided for us the foundation for a universal treatment course a way to stratify these infections from an infected grade one to a severely infected grade four where there are systemic and metabolic signs and symptoms and these patients maybe septic. It’s important for us to I think understand how to classify these infections. One, it provides the uniform categorization of these patients plus it’s also going to guide your therapy. There are recommendations made by the IDSA in regards to a question and answer format as to how they change or implement an antibiotic regiment in these patients. What are the appropriate first line antibiotics in patients who had an ulcer before and had been treated with antibiotics versus those who – this is an initial event, and what antibiotics would be the appropriate treatment course for these patients? Again, it’s a very reader-friendly format. Appropriate offloading. Is there a focus of pressure? So you follow these ulcers and you heal them, they reoccur. You heal them, they reoccur. We put them in shoes. We get insoles. Deformities can vary from anything as simple as a digital hammer toe. Not that I undermine the simplicity or difficulty of anything, but tendon contractors, Charcot deformity, bunions, limited joint motion, hallux limitus, all of these can cause pressure areas that result in laceration. I think the key in assessing the deformity or the focus of pressure is to determine whether or not this deformity is flexible or if it’s rigid. In general, flexible deformities can be offloaded. So you have options in the immediate sense such as hemlock or boots, offloading boots or offloading sandals, to get the ulcer to healing. Then once healed, we have options that include pads, costumed insoles, and depth in-lay shoes. It’s important though to not just blindly prescribe these things. You really need to understand what it is you’re prescribing and to follow up on that product. So here’s the patient who healed his ulcer of 1st metatarsal head. After healing it, continue to develop this ulcer – this callus about every two months when he come into the clinic. One of the key factors in this callus is that you can see the streaking, the hemorrhagic appearance streaking distally. The concern was not just the focus of pressure but how is his shoe fitting? Is he shearing in the shoes, he’s slipping, is he sliding around? Because we’re seeing everything straightforward. So when we evaluated his shoes that he did receive, I did literally stick two hand widths in the back of his shoe. He said that he has trouble keeping them on and he’s always sliding in it. Once we corrected that problem, even though he had an ulcer, once we corrected that problem, he really just get a thin callus in that area. It does have that hemorrhagic appearance, and it’s that less risk of ulcerating. So we’re going to continue the offloading. But it’s important to be critical when you see these pre-ulcerative or ulcerative lesions and to follow up the products once you get them healed to make sure that they’re appropriate.
Then in general, rigid deformities are more difficult to offload permanently and often cannot be offloaded permanently. They usually recur after a period of successful offloading. So no matter how effective your initial offloading techniques may be, whether it’s a total contact cast, a CAM walker boot, an offloading sandal, often times these ulcerations will continue to recur. Then I think this is on us to be aggressive and recognize the need as to whether or not we need to start considering surgical options to off-load these areas and to decide when enough is enough for these patients. Because part of that will play a role into how compliant or how much these patients buy into your treatment. The more something recurs for them, the less likely they’re going to buy into your treatments and your future treatments. That will also affect the overall compliance if the patient can afford you. This patient had a third metatarsal head excision. There were antibiotic beads placed in here. I think it was done like seven to ten years ago. It was a while back. But since then he’s had this repeated. Ulceration continues to recur. You can clearly tell that the metatarsal parabola is off. I didn’t post his x-rays but you can see the callus starting under the subsequent lesser metatarsal heads as well. So for him, even though we get him healed and he comes back and he breaks down within a month later or gets that hemorrhagic appearance in the calf, it’s more ideal that there’s surgical options with him in the long term, something like a pan metatarsal head to try to reestablish some level of an acceptable parabola. I’m not going to harp on surgery because I have a talk coming up later about surgically offloading the foot. But I think it’s important to remember to consider surgery when conservative therapy fails in the presence of a deformity that cannot be maintained in appropriate shoeing once it is healed. Again, this is another case example that got the 1st metatarsal head. All parameters conducive to healing but he would have to come in literally every two weeks to get the hallux trimmed so that he wouldn’t have an ulcer. When I saw him, when I first joined out there in Seattle, I asked him when his last x-ray was and he said he couldn’t remember the last time somebody had x-rayed his foot or if he’s even had one before. Sure enough I didn’t find one in the system. So the x-ray was compelling. I mean his 1st metatarsal is sitting on the – his hallux is dislocated on the 1st metatarsal. You can tell this has been an ongoing process because you can see the delve in the first metatarsal neck and the distal shaft. So it’s been a chronic problem. He was told that it was just because had bad hammer toes. We took him in. We did a pan metatarsal head resection and a [talar mayo] [12:40] type arthroplasty. Reduced the deformity and this is him four months post op doing well and very pleased wearing his shoes and ambulating. So we’ve been able to give him a successful outcome with this. So there is definitely a role. I think we shouldn’t underestimate how aggressively we address the deformity because I think we’re pretty effective in identifying why patients have the ulcers. Is there a nutritional deficiency that’s affecting the patient’s overall healing? The key component to this fact is that there are key nutrients that are involved in each phase of wound healing. When patients are deficient in any of these, your overall wound healing, your ulcer healing, can be affected. It’s not uncommon for our hospice team or our medicine team to start supplementing these patients when there is a deficiency noted to help augment the overall healing. You can see that vitamin C plays a role in all three phases where some of the other components are interspersed throughout the phases. Again, this is a key component and also why it’s important to understand where you’re at in the phase of healing. So what factors affect the patient’s ability to be compliant? This part becomes key as well. We’re going to revisit back this case. So this gentleman who has lost to follow up for month was lost to follow up because he actually was admitted to an alcohol rehab program for abuse. But the other part is that this patient has a TMA on the right side. Now has these problems on the left side. This is the shoe he wears every day because he swears he’s going to keep wearing his Stacy Adams despite how many shoes we order for him. His daughter can’t get him to wear any other shoes. So it’s easy to label this patient is non-compliant. As you probe deeper into this gentlemen’s history, he’ll tell you that he still has yet to accept the fact that he’s at a mid foot amputation and that he feels that he’s a lesser of a person because of it. He’s going to refuse to have any further amputation done or anything done on the other side because he doesn’t want to feel anymore inferior. This gentleman has had his TMA for about eight years, ten years, and says that during that whole time nobody has ever really sat him down and talked to him about the amputation. How much of the community ambulatory he really could be and how active in his everyday life and family life he really can be?
So sitting him down and educating him and talking to him more and letting him perceive what his quality of life could be and should be with this level of TMA. How the shoes helped promote that for him really took him to a different level. The risk of amputations scares patients. It can also lead to them being less adherent to our treatment regimen. Healthcare access is a factor. Again, the importance of support groups is key when you do identify these factors in patients rather than quickly labeling them non-compliant. We have the advantage of having a regional amputation center at our facility. We actually have patients that we select. They get actual classes. They are educated on how to be amputation mentors. So whenever we see a patient like this having difficulty acceptance which can long term – accept the amputation which can long term complicate our treatment course and plan for him. We team these patients up with the amputee mentor. So if you can develop something like this or if you have access to something like this, I think it’s important to take advantage of it to really get these patients where they need to be. There are five dimensions of adherence. What’s interesting is that there’s only one component that is really patient related. The other components, as much as we label patients non-compliant of the five, only one of them is patient related. So like we discussed social and economic factors, if patients don’t have access to healthcare access, if they are the breadwinner at home and feel that they always have to be at work and can’t commit that time to healing, the healthcare system, the patient really needs to buy into the healthcare system that they’re going to the physician, the team that’s treating him. Patient doctor relationship becomes important in your bedside manner. Your approach to these patients become important if you want them to really follow a treatment regimen. Condition related. So like in our last gentleman he had the history of alcohol abuse and had to be admitted. So this was a factor that impeded his adherence to the treatment regimen that we’re applying. Therapy related. Some patients realistically cannot do a total contact cast. They cannot do a CAM walker boot. Their access in their home is not conducive to them wearing some of these assisted devises. I think I used to be of a thought that I will never compromise my treatment plan. I know what’s right for the patient. I’ve really come full circle and that in talking to patients it’s better for me and for them if I develop a treatment plan that is something that is effective yet still acceptable for the patient without compromising what I believe is what they need. So I think that becomes important too. We have so many things at hand that we can use in terms of offloading ulcers and treating ulcers and management principles that I think it’s become a little bit easier to tailor the therapy to meet both needs. Then the patient-related factors. Again, the patient has to buy-in to the treatment and sometimes we do get patients who are for lack of better word a little bit more stubborn. But I think once you explain all the other parameters, it’s easier to get a buy-in from the patients. What’s happening at the cellular level? Again, like we saw earlier. It’s important to understand what phase of healing any wounds or ulcers are in. If you’re in the inflammation phase, you really need to control that environment to optimize the healing. The proliferative phase is when you might want to optimize healing by using some of the adjunctive therapies. Some of the skin equivalents, grafting techniques, stem cell treatments, there are so many out there now but I think they have to be used appropriately at the right time. I think it’s our job to be able to identify when these wounds, when these ulcers will benefit from such treatments. If a wound is in remodeling or the ulcer is remodeling and healing, then really nothing else needs to be implemented. So we need to understand these phases. Then finally the consensus. The importance of early referral for management and patient education as well as provider education. I’m sure this is what all of our staff teams look like. Here we go. So patient education. Whether you dispense it in terms of pamphlets, materials, or if it’s verbally given, I think it’s an important component. Make sure it’s appropriate for the patient. If a patient has a language barrier or maybe doesn’t read as illiterate, make sure that you’re giving the appropriate level of information. Something that they can understand. Something that they can take home with them or have a family member present. Understand who the patient’s social network is. Often times that’s a key component as well in terms of the patient factors. Some patients have family members at home who can’t help them or they live alone. These are patient factors that really will impede our success in terms of addressing an ulcer and identifying just one of the basic essentials to getting these people healed. Sometimes I’ll ask the patient to bring a family member with them if I feel like I’m not quite getting across to them. It’s important sometimes and helpful to see the dynamics between the patients and these members of the family.
It kind of gives you better understanding as to why maybe they’re behaving the way that they’re behaving. So often times I find myself asking them to bring somebody in with them. If they can’t or that person will not come, I might ask for a phone number and I’ll call. Refer to appropriate specialist. The multidisciplinary approach is key. We really can’t do this alone. We can be the gatekeepers at times but I think you need to maximize the treatment by getting all the appropriate specialists involved as well. Just a couple of things. I like to study because back in ’96, it showed how we are inadequately evaluating diabetic foot ulcers. So this was 255 patients admitted and there was minimum evaluation compensation seen only 14%. For example the patient I presented were known had never gotten an x-ray according to him and I couldn’t any in the records. Could have had his problem solved a lot earlier than what he did. Things like infection that are not evaluated, radiographs. Then we go in 2002 and we find that this is still a problem where we’re not fully evaluating ulcers in patients appropriately. I think since then we’ve probably come a lot more full circle with the education we provide and the multidisciplinary approach that diabetic foot is taking. So hopefully we’ll see that these numbers are changing. Finally the comprehensive foot examination risk assessment from the task force. Again, focused on key components of the foot exam as it’s mentioned earlier. The neurologic. Have a thorough neurologic exam. Have a thorough vascular exam. Maintain that annually at minimum in these patients. Implement a risk classification. Learn to stratify these patients in terms of risk. This will help not only hit the point home to providers who maybe reading your charts and monitoring the patients there with you, but also allow you to stratify patients in terms of how frequently they need to come back to your clinic and how often you should be seeing them so that you don’t put patients out too far who have a higher risk. Then for patient education like we mentioned and timely referral to your primaries, all these things are key components and really getting ulcers healed. I put these pictures on only because I really amused by them but still a bit disappointed by them. Because I think we should be beyond where patients coming with these problems, this guy has his piece of candy stuck in his shoe and couldn’t feel it. So we had to really reeducate him again on checking his shoes before he puts him on. This gentlemen, this is from residency. I don’t know, Dr. Lavery, if you remember this. I’ve had this one since residency but I love this slide because this patient’s hallux amputation is where he doesn’t walk barefoot at home and then swears that he doesn’t drink. Didn’t even realize he had that on his foot when we walked into the room. He became a good tap dancer overnight [Laughs]. Again, we do have a long way to go. I think education doesn’t stop the first time you give the patient education or their family members. I think you have to do it every time the patient comes into the office as redundant as it may seem and as frustrating at times as that may get. So hopefully we hit these points home in regards to evaluating diabetic foot ulcers. I do think these are some of the details that have to be addressed every time you look at an ulcer to maximize the long term healing in these patients. Thank you.