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Orthopaedics
Evaluation and Management of Vascular Disease in the Diabetic Patient
Built from The Surgical Management of the Diabetic Foot and Ankle
What’s inside
7 sections · 79 slides
Overview
- Scope of this topic
- Historical and epidemiological context
- Gangrene risk in diabetes
- Why the orthopedic surgeon needs this topic
Pathophysiology
- Early atherogenesis
- Metabolic syndrome as a driver
- Components of the metabolic syndrome and their defining levels
- Interpreting the metabolic syndrome criteria
- Advanced glycation end products
- Glucose to plaque: the mechanism chain
- Duration of diabetes and insulin use
- Evidence from the Diabetes Control and Complications Trial
Clinical Manifestations
- Intermittent claudication
- Atypical presentation in diabetes
- Typical versus diabetic presentation
- Distribution of arterial lesions
- Calcified posterior tibial artery on plain radiograph
- Prevalence of peripheral arterial disease in diabetes
Evaluation of Peripheral Arterial Disease
- Principles of preoperative vascular assessment
- History taking
- Rest pain as a red flag
- Physical examination of the lower limbs
- Neurological assessment of the diabetic foot
- Noninvasive vascular tests
- Indications for noninvasive testing
- Technique of the ankle-brachial index
- Normal range and grading of the ankle-brachial index
- Ankle-brachial index values and corresponding clinical status
- Reading the ankle-brachial index table
- Limitations of the ankle-brachial index in diabetes
- Falsely elevated ankle-brachial index with usable toe pressure
- Technique of toe pressure measurement
- Toe-brachial index
- Toe-brachial index values and corresponding clinical status
- Reading the toe-brachial index table
- Doppler analog waveform analysis
- Waveform patterns and their meaning
- Doppler waveform tracings
- Indications for duplex imaging
- Capability of arterial duplex scanning
- Sensitivity of duplex mapping by vessel
- Calcified anterior tibial artery on ultrasound
- Computed tomography angiography
- Limitations of computed tomography angiography
- Imaging pathway when creatinine is elevated
- Therapeutic advantage of angiography
Risk Factor Modification
- Rationale for risk factor modification
- The four major modifiable risk factors
- Glycemic control
- Effects of nicotine on the vasculature
- Tobacco exposure and disease progression
- Benefits of smoking cessation
- Hyperlipidemia and lipid-lowering therapy
- Hypertension management
Management
- Preoperative screening requirement
- Toe pressure thresholds for wound healing
- Toe pressure decision points
- Preoperative vascular decision pathway
- Lower extremity orthopedic procedure algorithm
- Workup of suspected vascular compromise
- Revascularization then orthopedic surgery
- Timing of surgery after revascularization
- Antiplatelet therapy after vascular intervention
- Lifelong aspirin and perioperative interruption
- Tourniquet use in the diabetic limb
- Tourniquet after prior lower extremity bypass
Conclusion
- Role of the orthopedic surgeon
- Summary of key management thresholds
- Take-home points
- References
- References
- References
- The Surgical Management of the Diabetic Foot and Ankle