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Hello? Hello, everyone. Can someone just post in the chat if they can? If they can hear and see me on screen, please. Okay. Perfect. Thank you. Okay. Well, thanks for joining us. This this'll evening. My name is said I'm one of the cold leads for the vascular surgery teaching program. Run by mind The sleep. We've done two sessions so far. This is our third one. Um, I hope some of you guys are returning for our third session. Um, we've got here today. Miss Loring. Coffee. Who is a consultant? Vascular surgeon working the role Stoke University Hospital. She's very kindly giving up her time to do a session for us on the diabetic foot. So I've just seen your question, Mr Caulfield. So what's gonna happen now is I'm going to in invite you to stage on. Once you click that you're on stage, you will be able to share your slides. There will be an option that comes at the bottom of your screen. Sorry, everyone, just bad with us. Two minutes as we a sweet get the slide sorted. Thanks for your time. Hello. Hi. Uh, thank you for joining us. Okay, So if you see now on the Boston go screen, there is a button at the middle that says is that now. So when you click that we was your slides on you. Okay, Come here and you can hear me. All right? Yeah, we can hear you. Okay, good. So you should be able to see something saying the diabetic foot. Hopefully, yeah, we can fill it up. Excellent. Lovely. Yeah. So thank you very much for for asking me to talk. I think at one point there was a discussion about where this would be the diabetic foot and leg ulcers. But I felt that was probably quite a lot to do in in 40 minutes. So I'm gonna just talk predominate about the diabetic foot on. So what I thought we do is very briefly mention what a diabetic foot is on. Why we're talking about it. I'm with that the sort of spectrum of foot disease on then a few slides that perhaps a little more mundane about diabetic for mg t. But I think that is important is it's in the nice guidelines. And then we'll move on to the bit that you will be most interested in but is actually really a very small part of diabetic foot management and something we should all be trying trying to avoid. We should be trying to prevent our patients. Getting a far as a surgical management on what I thought I'd do is actually really focus on the practical day to day side of it. So not the sort of pathophysiology or or the complex mechanisms behind the development of the diabetic foot, but what I sort of do on a day to day basis, uh, not the sort of rarely used but exciting, complex treatments that you might read about in journals or hear about in meetings. So obviously the diabetic foot is a foot belonging. 21 who has diabetes on it really ranges from a foot that's basically normal, which undergoes a yearly foot track through a foot that has neuropathy for that's developing callouses on the foot that becomes deformed on. Then, at the far end, the side that we get more involved with the surgeons when there's ulceration, gangrene, infection, particularly osteomyelitis or acute infection on the Charcot foot. So why are we talking about it when it's obviously very common? Diabetes is common on lots of people who have diabetes have an active foot problem. And not only is it absolutely miserable having the foot ulcer that requires dressing and effectual walking, but there's a high mortality rate associated with a diabetic for talk, sir. It's sort of a sign on west of you, like of end stage diabetic disease. And it's expensive with the NHS on. We know diabetes is on the creek on the increased, so it's no surprise that diabetic foot problems are also on the increase. It's also the most common cause off limp. You take a shin that's obviously mixed into so with that with arterial disease because some patient with diabetes also, you have arterial disease. Um, and it won't surprise you to know that diabetic produces tend to proceed amputation in many cases of amputation. Hi. Sorry to interrupt. Just to say that we we can still is the audience. Just see the first slide. Know. Okay. There with me. Me see if I can. So if you I think looking at the top of your screen there Yeah, the button on the letters is from beginning. Okay. Okay. Does it move now? Uh, know Could you try that again for us? Okay. Should we go to, uh oh, actually, where it will be on you. You? Yeah. Yep. On there should be a normal line. The other thing, if I does it, make it so nap the week it we can see it move, but we just can't see it as a slideshow. But I think I've worked it out. If if you look looking at the bottom of your screen there, Yeah, where the zoom I/O bar is there's a button just to the left of that. And I think that should make it a slight. Yeah. How's that? Is that moving now? Can you see plan? I can't see plan. I can still see the diabetic like a first. What? Maybe we'll do it. Not as a slide, Children. Okay, Um so can you see my screen now saying plan so I can Yes, we can. Okay, so just be a bit smaller, but that's probably easiest to do it like this isn't yet. Um, so that's the data. I was just mentioning on how common it is. And on been. Not only do many people with diabetic foot ulcers end up with an amputation, but also, unfortunately, the mortality rate is high, Um, and that the numbers I've seen have been 50 to 70% of people will die within five years of having a major amputation. So So it's a huge problem, and that's probably because of the general cardiovascular risks that these patients have. Um, and obviously I think you will know this from your medical school days. But diabetic people are a risk of foot problems because of the demyelination. They get do to neuropathy on that results in deformity and pressure area formation, which can lead to ulceration. And then, of course, people that are beauties have poor healing, high risk of infection as well as the the well known microvascular and microvascular disease, said It's not. What we really want to do is prevent the patient getting to us. Our surgeons on that is absolutely about education of patients and education in primary care, and you may think that is obvious and well known, but it's really not I still I had a patient referred to me on the Q on call recently, you had a tiny daughter, women and pressure over a claw toe with normal pulses and the GP was panicking cause that foot looked a bit pale. But what they hadn't done was thinking about the HBA. One c all referred him to a podiatrist, and that was what they needed. They certainly didn't need my input. There's a lot of education that needs needs to happen and prompt podiatry referrals. Because the podiatrists are experts at this on they are they're absolutely key, not come onto a bit later. But really, the podiatrists run the show in terms of diabetic foot Mg T s office. The diabetes control is really important, as it's control of other fat risk factors and particularly smoking. And then what the podiatrist may need to do is look at foot, foot care and footwear on. Does the phrase that you should all be able to try it out? One of your asked about management of diabetic foot ulcers, which is, um, offloading any pressure areas, which is, as it sounds, just taking the pressure off. Um, and that's important because Neuropathic foot, the Neuropathic foot will develop changes, and I think the and how this actually happens is quite complex and still open to debate. But nevertheless, the feeling is that probably some motor paralysis of the intrinsic foot muscles, which causes some imbalance, and that together with decreased sensation, decreased proprioception and possibly an autonomic neuropathy affecting the moisture of the skin is important. And the main things that we see a past gave us, which you can see that which is a high arch foot and often hammertoes and clot a Z. Um, and obviously the providence of the knuckles there makes those areas really praying to pressure and then also aeration. And then we'll talk briefly in, um, it's about a Charcot foot. So it's really a teaspoon point when the dog well before this. But certainly at this point when a diabetic has foot deformity is like this that we're really, really This is a proper at risk foot because of the drop metatarsal heads and the clot toes. This is where podiatrist really key in offloading. Then we may consider referral to the orthopedic team who may be able to straighten the toes or may be able to help with significant offloading on diabetes control is vital, and if it's no done properly at that stage, we may well end up in this situation, which is when the patient ends up in in our diabetic foot clinic in trouble. So the shark is is a huge topic in its own right, and I'm not gonna talk to much about it. I know some of you will probably go for some of you may go on to the orthopedic specialists, but really it is managed much more by the orthopedic team and podiatrist, a vascular person. But nevertheless, vascular surgeons need to recognize it. It's basically an extensive destruction of the bone and soft tissues due to neuropathy on. It's not always diabetes. It could be an alcoholic neuropathy, for example. Classically, there's several joint dislocations of pathological fractures on the The Charcot Foot is swollen, deformed and often has that rock her bottom appearance that you can see there, which makes it very prone to pressure related ulcer, a shin on very difficult to walk on a swell, and the treatment for Charcot Foot predominantly is offloading. There are peaks urgency. We'll do some some fancy reconstructive surgery to try and realign the foot, Um, but that's a that's that's sort of complex orthopedic foot and ankle surgery, and you will have seen. I expect off loading device is S o commonly on the bottom left here, that sort of Velcro shoes on that come in various forms. Some habits that could be lifted out inside to allow offloading of a pressure area. Um, and then in the middle here, we've got an air cast boot type offloading, which is nice. Constipation can take on and off, up at the top. There on the left is a total contact cast on, and they're used variably. I think some units like them very much of some units don't like them so much, but they would be predominately used under the care of the orthopedic team in a patient with quite significant foot deformity, toe offload any actual or potential pressure areas. And then I just put the bottom right there, Um, an image to indicate offloading heels of people in bed because we mustn't forget when we talk about offloading that some of our patients aren't mobile, and we still need to think about the pressure areas when they're in bed. So one of the things that's always really hard on, I think it's really hard for everyone. Even the people that sit on our diabetic for mg t at stake. It's, um when is a Charcot foot? Well, when is the red hot, swollen foot in a diabetic? When is it in acute Charcot Foot, which the treatment is offloading and immobilization on? When is it severe infection? So clinical assessment can help if there's no portal of entry of infection. So if there's no ulcer or skin break, it makes acute Charcot more likely an acute infection. Less likely. But that's not 100% neither or inflammatory markers because they can be up in both, Um, an MRI can help, particularly if you have ah, musculoskeletal specialists. You can look at it uninterpretable, but at the end of the day, it's the clinical judgment on this is where MG T Working, I think, works very well. For complex cases like this. However, the acute shocker for is an emergency. The patient is to be immobilized or not floated immediately. Um, so that's an emergency orthopedic referral. And so it's just important to be to be aware of the acute Charcot foot. I'm not going to talk anymore about the Charcot foot than that, Um, unless there's questions at the end. So, as I said, I've got a couple of slides just on the slightly more mundane nitty gritty of how a diabetic foot, multi disciplinary service should run on what nice say about it. And I think, without doubt, nice are generally right about this. So there should be a multidisciplinary foot care on the slides. I'm talking the's. The multiple foot care I'm talking about is predominately inpatient care, although there is, this should should be a similar system for patients in the community. Um, let my A podiatrist. So for inpatient or significant outpatient diabetic foot problems, I should be a team, and as a minimum, I think that would be a diabetologist to podiatry. It's in a vascular surgeon. Some units have really big teams where they have a North Pedic surgeon in the clinical. Well, a microbiologist, um, others have those people sort of on on tap as needed. Mostly, we need access to radiologists on people you can cast patients or off load patients, and the nice guidelines additionally say that the MG T service should have access to rehab services, plastic surgery, psychological services and nutrition. That's quite a big ask on in today's world, where everything has to be funded and proven. Trying to particularly get a psychologist into a foot clinic, it would be very difficult on time is obviously limited if you've got to clinic rooms on the darvocet or adjust the podiatrist, the vascular surgeon needs to see the patient. It's hard to imagine how a psychologist would also fit into that because obviously they interpret quite prolonged consultation. And similarly, a nutritionist is going to have a prolonged consultation if a patient is Mr Hospital. And I think this is a key for you as well at your your stage two to realize this any patient who comes into hospital with an active diabetic foot problem should be referred to the most disciplinary diabetic foot team within 24 hours. That doesn't mean that they're necessary. See them? It doesn't mean they get a full MG t review, but it doesn't mean the person who's in who's involved in triaging, which is often a podiatrist, will assess the case and take it further is a is appropriate. So that means if there's a patient on the care of the elderly of water, he comes in with the chest infection who happens to have a stable but chronic foot ulcer. They should still be referred to that team, her mother impatient. And the idea behind that is to try and pick up problems earlier. Reduce the risk of amputation. So how does it work for us at Stoke? We're We're up! Husband spoke. So spoke is the main hub hospital, which does from a vascular point of view, which does the arterial work. And then we have spoke site where we have clinics and day case operating. So how much disciplinary team in steak is consists of? A daily foot clinic led by the podiatrists with input from other people are appropriate with the weekly MG T, which works really well for particularly complex cases on that has usually several diet wrists on the call. Two or three Baskin a surgeon's often to orthopedic surgeons, often a microbiologist, a musculoskeletal, um, Grady Ologist Um, so it's actually an adult, but I'll just So I said, it's a good it's a good discussion, and impatient referrals will be treated by podiatry, and there's a weekly foot around on. We closely work with with other specialties that we need a little bit harder at the smaller spoke hospital cause. Obviously there's fewer people around, but there's also a fewer patients. So there we have a weekly for clinic, a weekly MG two in a week and walk around. But a very good podiatrist who runs hot the next one of the days and, um has direct access to people when she needs them on. Then the spoke links very closely with the Hub. So aside from sort of knowing the basics about the nice requirements, I think you also do. But we don't need to know a huge amount. I'm about the MG t working apart from just to be aware how important mgt working is in the diabetic foot. So what I thought I do for the last part of the tour, it's just put up a collection of pictures that are in no particular order on D talk through how I might manage a foot that looks like that. So this is a bit that was, will be over a lot more interesting, I think, because this is when we're getting towards surgery. So if you imagine the foot on the left is a foot that might well turned up in the vascular clinical for the diabetic foot clinic. So patient has already lost part of the big toe. Who's got gangrene of their fourth toe? That's mainly dry, Maybe, maybe a little bit wet here. So what would we do with that? Well, hope. Hopefully you're all thinking. Well, I take history and examine the patient. Make sure they're not smoking. Make sure that see whether they have peripheral pulses or not anything. In this case, this is something I would probably try and manage is an outpatient unless the patient was in severe pain and not coping. If they didn't have pulses, I would do some imaging and at stake. We normally do a CT angiogram in the first instance, but equally you might find out the units do MRI angiography. Other units might be duplex scanning. Um, it's whatever works, works best on the unit per unit basis, and then you looked to revascularize the leg of possible and then, almost inevitably, that toe's going to be apatate it unless it auto amputate. It's so if we compare that to the foot on the right, this is a definite diabetic for two militancy, so if you see this patient when you're on call? This is something you need to take very seriously, so particularly if the patient is unwell. But But even if they're not, because if they're not going to get on well very quickly. This is diabetic foot sepsis on This needs debriding on it probably needs to go to theater pretty quickly. And that's because of the gangrenous toe, but also what looks like a collection here with some person it. So I'd probably be looking at predominantly managing that with an acute debride mint toe amputation, getting control of the infection, then thinking about the Bloods. Try, um, you might if the patient was very well on when you look at the foot. This wasn't really somebody in Fluctuance as it looks. If it might be, you might put the patient on antibiotics on, try and get some imaging and see if you could re vascularized. First. You have to keep a really close eye on the patient. Is that to me? Looks like a foot that's going to make someone very sick very quickly, and that is not too dissimilar from this foot on the left. Um, so obviously there's not a gangrenous toe here, but you can see there's a necrotic ulcer and there's this large area of redness and it looks shiny and hot. I'm very unhappy, so I think with this foot, what I would do is assess it clinically. Obviously. Assess the perfusion. The pulses assess her to see what she had any saying her. It's just got purple nail polish could be assessed this person, um, for any signs of sepsis again if they were well and there wasn't an obvious abscess. Maybe I'll try and ride it out with some antibiotics, but I have a very low threshold for operating on this on. Defy wasn't sure whether there was an abscess there. This might be foot that I would consider doing an MRI scan for to assess for any obvious call any collection that wasn't obvious. But if the patient was unwell or that was Puss coming out through that also, then I would just get straight on and take him to the attorney and debride that something That's the foot. I would be very likely just to be taking two data pretty quickly, and then at the other end of this sort of acute spectrum. You got something that I see regularly in the diabetic foot clinic, which is the sort of more chronic foot ulcer. So no signs of infection? Probably probably cause if we could see the other side of this foot, we probably see clot ozwald, the dropped metatarsal head on. Then pressure over this area that's caused ulceration on the treatment for that is very different. Eso initial treatment for That's going to be all the things that put up on a much earlier slide. Good diabetes control, making sure that patients not smoking and offloading. So getting the pressure off that metatarsal head that's with a sort of dark, a Velcro boot or something more significant in terms of an air cast boot or something similar, I would depend on the situation and what's been tried before. I'm not what's available locally. Very occasionally, I might operate on, and also like that. If it's really no healing on, say it really wasn't healing. I'll be looking at the blood supply on, then could consider amputation but amputee so it could consider surgery. But surgery is going to be a ray amputation, including quite a bit of the metatarsal probably not only of the second Table, possibly the third, so it's gonna be quite significant surgery on. Sometimes when you operate to take two toes away or you, all you do is move the pressure to another part of the foot. So you just move the problem. So you got to really seriously consider the benefits surgery in that situation on, that might be a put if it really wasn't improving. That I might take two are complex for mg T and see if, for example, the orthopedic surgeons had any other thoughts about how to manage that. So next a clot time and you can see what's happened. Does this toes become Claude Thie? Tip of the toe is probably if you saw this from decide that total probably be sticking out more than the others, So that's being pressure on it. The tip of the toe was rubbed on that some exposed bone there, so realistically, that's probably a toe that's not going to heal up because it's gonna be very difficult to keep the pressure off that, and that's probably a patient. I we might try some more floating on, but if it was an ongoing problem. I'd have a fairly low threshold for offering that patient to toe amputation, or at least a terminal ization of the toe, depending on their blood supply and so on. But I would obviously be making sure they're diabetes. Control was good as possible first, then the game or acute picture on the right. So again, this is someone you should definitely be an impatient, very nasty, aggressive cellulitis. Somebody's obviously D rift a blister or abscess there, but they're still quite extensive readiness. So if I was to see that patient on on the ward, maybe the night before the registrar, it bride it that I would still be concerned that was passed in that foot. That looks a very unhappy foot on, often with diabetes, the obvious bit of infection, which would be a the base of this toe. I'm It's just this tip of the iceberg, and there can be cavities and collections throughout the foot, and I suspect that's the foot that's got other past collections in it on. That might be obvious. Clinically, if you squeeze the throat, you might see Puss coming out through the wound on. Then it's a trip back to the attorney for further debridement that day. Um, or they might just be very unwell with a high temperature, and you might want to explore it. Or if you really weren't sure whether this this is ulcerative colitis without an abscess or whether there was an abscess, then you might do an MRI scan. But I suspect if you examine that foot closely, you'll find a clinically a pocket of past somewhere else. The same. Really with this put on the left. That's a really nasty, horrible looking diabetic foot, and I suspect there's Puss in that foot, and I suspect this patient would end up losing their 2nd and 3rd toe. But again, if there was nothing obvious to drain, I might do an MRI scan to see, um, what was what was happening and also that might help guide any incisions I make. The foot on the right is very different, is honestly extensive. He'll necrosis and extensive ulceration, and this person really is in trouble because once you start getting extensive ulceration around the heel and the calcaneum is involved than it really is almost a losing battle in terms of keeping the foot on this patient I think would require such an extensive debridement to get back to healthy tissue that probably they wouldn't have a usable foot on. They may well be served best with a timely below knee amputation before they get unwell. Um, rehabilitation. If it's a smaller ulcer, Um, sometimes a localized bribing it's feasible with removing part of the calcaneum. The orthopedic team tend to be a bit keen on that on that then vascular surgeons. But I have done it several times, and in some patients it's successful, but enough. There's it enough to be leads to a bologna amputation. But I think this one is really quite extensive, so probably wouldn't be successful. And then on the yeah, left a nice picture of a fairly innocuous looking also. But obviously someone squeeze this and this past coming out again. This is a patient that probably needs a surgical exploration, cause I've got friends Puss coming out through the ulcer gain. If you weren't sure of the patients, well, you may have time to get an MRI scan to look for obviously past. Probably if you started exploring it, you'd find all kinds of connections has shown by the picture on the right. There's often connections between multiple ulcers on the feet. Um, that need training. Um, and that's, you know, you drain that either by just laying it all opened. Or sometimes I've got a photo later. Putting a corrugated drain through come work quite well. Similarly nasty diabetic foot here. You might manage that initially with antibiotics and dressings on then revascularize, Um, but if the patient was on well, this worsen, they may need immediate surgery on the picture on the right. I think it is a similar kind of thinking as we've discussed before. Is that a Q Charcot or is that acute infection? And it's, I think it's impossible to tell just by looking at that picture. So when we're thinking so we see a patient on where, you know would be sure they need to go to the theater. So we so we book thumb in often with the diabetic foot. As I said, what you see on the surfaces is the tip of the iceberg on Do you need to do really quite extensive to brightness? I couldn't find any really, unfortunately, really good pictures of extensive deprive. It's, but I've certainly done somewhere. I've really opened up a significant amount of the Protonix for flayed up the side of the legs well, when the patients have managed to keep their leg on. So sometimes very extensive deprived mint is necessary in and sometimes you start and you keep finding tracks into different pockets of pass, and you just basically have to carry until you've drained all the infection. And, as you can see from the left, sometimes even quite extensive deprived mint heels up very well in leaves. A patient with a very good functional foot picture on the right shows you some corrugated drains around the lateral border of the foot, so I use those a fair bit. If if the patient's foot it's the so the areas of necrosis or infection of fairly localized in the foot. And I feel I don't need to want to lay open an awful lot of healthy foot, then I may put corrugated drains on 32 areas that connect underneath and that allows any ongoing person infection to drop Teo to drain out so often put corrugated drain through. I have to cut it in half because it's often too wide to put the whole corrugated drinking three on All I do is as similar as two they've done in that picture. I think bring it around onto itself is a loop and stitch it together. So it's a proper loop on. Then just pat it out so it doesn't rub on the foot. So I think that's that's the trick to remember and then use a slightly more extensive debridement. They're really showing. You just got to do whatever you need to do to get control of infection on the picture. On the right is a reminder, really that sometimes we do see people presenting for the first time with major diabetic foot sepsis. Unfortunately, at presentation there either so sick or the foot's in such a bad way, it's just not possible to save it. So every now and then, you know, maybe once or twice a year in a big unit like steak, we'll see a patient who comes in with significant diabetic foot sepsis and has a bologna amputation is there at first line treatment, and then a reminder that the infected diabetic foot that needs surgery is an emergency. It often gets a little bit sidelined if there's a other surgeon cases on the emergency list. But a diabetic foot with person needs to go to there to that day. So on the sun should know, set on a diabetic foot abscess we often does in in reality, but really, these are These are absolutely emergencies. And then, uh, just moving into the slightly more recent Eric Well, that this is an esoteric really, but term it just to show you a back dressing, which I know you will be familiar with. That that is very useful in the diabetic foot. If you debrided a lot of tissue gain factor sings Kenly to really good wind coverage. Some people in plastic surgeons might consider using skin grafts. Um, personally, it's not something I I've used in the diabetic foot fuse it a bit in leg ulcers, but not the diabetic foot. And I think that's partly because often the tissues just not really good enough you don't particularly in the acute setting. You've done an extensive debridement, and there's still quite a lot of infection around, and there's a lot of swelling, but in the more non acute setting, it is used sometimes, Um, I think my sort of feeling about it and thats think of many of my colleagues is is our concerns about how a robust of splits congrats will be on the sole of the foot. Perhaps it might be more robust on a transmetatarsal was you could see on the left, but that still is an area that's gonna be praying to rubbing. So this again is that value. I think of having her on mg T. You set up on access to a plastic surgeon who who may feel differently. All may have different experience of May feel that skin graft It's appropriate. So that certainly would be. You know, it's something I've never seen done in practice. And then I mentioned orthopedic surgeons doing interesting things with diabetic with Charcot feet. Um, as you can see from there is an awful lot of metal work. Teo Realign a adopt their a diabetic foot there and again, selected cases only. We do see some coming through our diabetic for MG T, and I think there is a role for it. But there's there are few and far between, and again, really, MDT discussion is key and similarly at the other pictures on the right show really extensive reconstructive surgery with no any orthopedic but also plastic involvement, to put a flap over a very deformed foot to try and get good function back. So so these things can work, but they are on a case by case basis. And of course, if you have a patient with diabetes, you're putting a lot of metal work into. There's a really risk of metal work infection. And if that metal work in that picture on the left got infected, that would undoubtedly lead to a bologna amputation. I don't think there'll be a way, a way back from that. But it it doesn't say the orthopedic team at stake. Do do some of these in patients who were not smoking, who have more chronic, stable disease on who have good diabetic control, and they are having some some good success. But that really is a little bit Easter Terex. That sort of in in our everyday world is yes, uh, foundation doctors and CT trainees who are who are on the ward seeing a cute feet that come in through the through the Take it, really. It's draining sepsis, removing any necrotic tissue, thinking about an appropriate dressing that might be a backdrop. Sing on, making sure the other things the right like controlling diabetes and foot where. And I'm remembering that the diabetic foot who may have an upset so has an obsessive. He's got wet gangrene, um, or who Septic is an emergency. And if it's four o'clock in the morning and you're seeing a patient in this surgical assessment unit and you're not sure people patient know by mouth. So at least then a senior review at eight o'clock, they're in a state. Teo, go to theater if need be. Start I would finish with some conundrums. And so what? What still makes me think about the diabetic foot? So we talked a bit about one of them. So when is it? When is a red foot infection? And when is it shark hose? The other thing that comes up time and time again. I think everybody who looks after diabetic feet is if there's a foot with osteomyelitis. When did I treat it with antibiotics? And when do I operate and debride it and then just briefly? Because it's quite a think. It's quite a ah sort of senior in a consultant level thinking. Really? But when should I think about Revascularizing? A foot that looks pink, um, warm, that has an ulcer but doesn't have any pulses in a patient with diabetes? Um, and I think that just briefly talk about the last one. I think it's very difficult because the etiology of ulceration in diabetic patients is so multi factorial that even if a patient doesn't have pulse is the underlying problem might not be macro vascular disease. It may still be a neuropathy, and you could really vascularized the leg, and they would still be exactly where they are now. Um, people have different approaches. I suspect some units will be very in very aggressive, and the patient had a diabetic foot ulcer on no pulses. They would image them on revascularize them on. That may well be appropriate or not for a minute, saying it's not. I tend to have a slightly more time to take a slightly more one step back. And if I think it may heal where if I think the primary treatment needs to be controlling diabetes and offloading, I may get that an attempted treatment for six weeks. If the ulcer is not a huge problem and then imaged Um, after that, I provided the foot looks pink and there's no sort of acute warning signs. Um, so it's it is a stroke. It's a case by case thing. I think something we see all the time is the question of osteomyelitis. So you can see here There's a foot ulcer, doesn't look overtly affected from the outside, but on the X ray, it's, um, osteomyelitis around the first time and mpj joint and TP joint. And that's difficult cause to surgically debride that which, actually, I think, how microbiologists would feel they prefer we did. You've got to take that joint out, will take their great toe off on the ball of the foot, which has, um, implications for healing but also implications for walking. You can walk without the ball of your foot, but it's much harder to learn to walk and re balance than it would be with another time. So in that situation that that might be a time I might be tempted to say, Let's have six weeks or three months of antibiotics. If it gets worse, we'll operate. If it gets better. Great if it if It's sort of becomes a chronic problem where we'll keep it under review and make a decision based on them how it's looking on what the patient wants. That's very different from the one on the other side. Um, where you can see this exposed bone there on my rule tends to be once exposed bone. Having any antibiotics in the world are gonna get it to heal up. Particularly dramatic is that are seeing the very occasionally a total with a bit of exposed bone or exposed joint has healed up, but they really are the exception to the rule, so I tend to tend to operate this exposed bone or joint pain ding a bit on. Where is in the foot, of course, is easy to remove a toe with the posters and normal much harder if it's on the mid foot or find foot. So I talked about doing MRI scans point a lot, but actually in practice very rarely doing MRI scan, it really is. I think my main indication for doing an MRI scan acutely in a diabetic foot would be a very red hot, angry foot I thought might be sharp okay or foot I debrided or had an ulcer, but there was no obvious plus clinically, but yet the patient was spiking temperatures or the foot was very red and angry, despite 24 hours apart IX and in terms of osteomyelitis, I'm often surprised by the MRI's that requested. So the foot on the left, I think Teo us a surgeon's. It's very clearly going to need some operative intervention on those toes, the three black toes. They're almost certainly gonna have osteomyelitis in them because the bones all but exposed. And it's irrelevant anyway because the treatment is going to be imputation. There's not gonna be an antibiotic in the world that's going to cure that foot, but nevertheless often see feet like that being through the MRI scanner. Um, so I think, um, part of my roller actually is to stop people having in a in a stop people having inappropriate MRI scans and somebody the one on the other side, even that they've obviously have had an MRI scan, has quite a bit of exposed bone, so that bone's going to have osteomyelitis in it. And actually, the surgical treatment is removal of that bone to let's looks hard in theater. So just in summary, really, for osteomyelitis, I tend to operate if there's exposed bone or this necrotic tissue. If it keeps coming back. If it's chronic osteomyelitis and it's a real nuisance, the patient that I might to bring the wind when might I use antibiotics is my first choice? Well, if somebody, for example, had quite extensive osteomyelitis in their mid and hindfoot and really the only other option surgical when surgical department would be a bologna amputation, you might try antibiotics first or if you've got a very unfit patient, Um, but then he may, except that you're just holding their symptoms are trying to prevent them getting flare ups and sepsis by giving the magic tricks. Most people fall in between those two, and you have to make a case by case assessment. But I think it's fairly clear when I speak to our our diabetic foot specialist microbiologist at stake. She's very clear that if someone's got osteomyelitis, particularly chronic osteomyelitis, antibiotics are never going to treat it. So the treatment is a surgical deprived mint or a decision not to operate on them, maybe antibiotics to try and keep a lid on things, but obviously there are cases in between where you might, um it is a spectrum where he might try antibiotics. But really, I think chronic osteomyelitis The definitive treatment is is usually debride mint, but it's not done that often. Acute acute osteomyelitis if there's no exposed bone and so on, can resolve with antibiotics. So just coming to the end of my slides. But I wanted to finish with to really important, and this one is about antibiotic resistance. So we'll we'll talk about antibiotic resistance and what a problem it is. But it is actually a huge problem. Um, Onda. In the very near future, people will be dying of infections because of antibiotic resistance. Say what I think is probably actually for us as doctors and surgeons. The most important Sorry. That's the spelling state that the most important slide of this whole presentation is a little bit of a plate. Just but fact, I'm a basket a surgeon. I think the take home message is is about antimicrobials June ship. So this is a non infected for cancer on the number of times I see that patient coming to my clinic, and they've had several courses of antibiotics because the district nurse has done a routine swell. The routine swaps not surprisingly, growing stuff or es because football's will grow stuff or is there will be contaminated on the patient's being put on antibiotics. And that's a really worry because no only for antimicrobial resistance in in general, but also for the patients say these patients require lots of antibiotics throughout their life, a good reason. And if we're giving it to them when they don't need it, we are breeding resistant bugs for that patient as well. So we're not doing them any favors. Um, something that's just worth remembering if this that if you're if you see that patient on the ward and you take a swab, which you probably shouldn't do anyway, it's going to grow something. It doesn't mean there's a clinical infection that needs treating Good. Say I will finish with that slide and say Thank you very much for listening. Thank you. Serve on five or 10 minutes ago. Sorry. No, no, that's it. Thank you. Thank you very much for that presentation. Just I'm gonna leave it to the floor to see if anyone in the audience has any questions. I have one that comes to mind, but I'll give it a couple of minutes before asking just to see if anyone else has got something. Guys, Any questions from the audience? Um, yeah, a couple of things. I I thought what was really interesting was trying to work out between the foot that you maybe could sit on for a little bit with antibiotics and images on the foot of that needs to be taken to theater straight away. Is that always an obvious decision? Or you sometimes faced with, you know, situations where you're unsure about course of action to take? I think I think it's self. It's often quite difficult decision on it. It's often a decision that I think, um, you often can take until your at senior extraoral level. You've seen a lot of a lot of feet and you sort of aware of of the payoff either way, um, so and I think it depends a little bit, Yeah, dependability. So I think it is a difficult decision. I don't really Yeah, I'm not sure I can ask that more that I think it is. It it very it is a tough tough decision on, I think what you do need to do. If you're If doesn't put your consider that might need to get it. You're going to give it antibiotics. Then I think you do have to take responsibility of going the next morning and seeing it or going later that day and seeing it. Um, it's about this for regular review. Thank you. Because anyone else any other questions. I think the other thing is that will be taking dressings off. Looking at feet were probably a bit better at that than in surgery than there on the medical wards. But if you're in surgery and the patients come in with a diabetic foot problem if they're unwell, even if they're being on antibiotics, even if they're being too theater the day before, it's always worth looking at the foot because you never know when you you know we've. We've we've all seen it on a regular basis. Foot's being taken to the theater. Think process will be in drained and then 48 hours later or 24 hours later, that would behold, there's another abscess and the patients really quite sick. So yeah, you should be afraid to look at feet of patients on? Well, yeah, on I had I had one more, actually. If you let's say as the audience and myself, if we were the doctor in Edie or on the take coos who saw something like this and we were concerned, maybe died but sepsis on. We were making referral to Vascular. Is there anything specifically you would be looking out to here? I mean, I can think of the obvious things in terms of history on examination, but there are other specific road flags or anything else that you would look here on the phone from us. I think this is a really good question, and it happens. But particularly now we all work in Hobson spokes, and it works. So you might be the surgical S h o at the site where the person you're talking to can't even look at the X rays, and you've got to convey a lot of information. So I think it's about the theophylline things that I think you're thinking off. You know? What's the patient like? Have they got a temperature? One of their blood results have had an X ray. What does that show I had the gout, foot pulses, but also about looking at the foot. And really, if you're really worried about it emphasizing, yes, that's the most normal itis. But that's not my main worry. My main worry is actually, there's a fluctuate area and this past coming out, and I think this patient needs that foot draining, unfortunately, see, time and time again, the sort of referral comes out. So I've got I've got this patient who's got foot pulses. But they've got a bit of osteomyelitis on the information given suggested patient could be left on IV antibiotics for 48 hours. Actually, when you see the patient got foot full of puss So I think it is about trying to really explain what you're seeing in the foot. And if you're concerned about it trying to say why you're concerned Yeah, so, yeah, thank you very much. Thank you. I think I think that might be it for questions. Lots of thank you, sir, and kind comments from the audience here, but I don't think any questions as off yet. Okay, So I think Okay, so we give I don't if you could read that, make you don't want me to read it? You know, I can say yes. Okay, Um, what you mean, but scan? I just clarify what you mean by plant a PDS. Do you mean the plant of fascia or I'm not sure it's not term I'm terribly familiar with, but I think in general, the answer to your question is it's more about whether there's necrotic tissue on whether this, huh? So so antibiotics won't work for necrotic tissue and past. It's more about what that looks like. Done and what? And if it was very deep, one MRI looks like on any sort of particular layer or level of disease. Yeah. So I so I've not heard that before. I've not heard that, Um although I would be concerned if, for example, an MRI scan showed deep seated infection like that. But if the MRI wasn't showing an acute collection and there was no obvious necrosis, then I might I might try antibiotics that after to look clinically at that, I'd be more inclined to treat what I saw in front of me. Um, in the d Would I ct before MRI? I think it depends what you're looking for. So if you're trying to assess the blood supply, then you're going to do some sort of angiography or duplex scan. You probably won't get a Jeep lexiscan overnight. So if you really want to know about the blood supply of the night, you might have to do a CT angiogram or another angiogram. But often in these cases, the blood. If the blood supply is normal, then you don't need to do that. If you're talking about an MRI scan for infection with this more relevant something in the diabetic foot on MRI, I'm not sure whether this collection, but the patients like the temperature in the choir it out. Then I would do it at our eye scan. A CT is probably not gonna give you enough information, but we do use it sometimes if a patient has got a pacemaker. So it could be some information, but it won't be as good. Okay, anyone else goes okay. If not, then I will sign out of this. Uh, thank you for joining on. Thank you so much, Miss Corporate. For your talk in your time. Really? Thank you for asking. All right, Thanks. Finally