糖尿病足的红外线诊断PPT课件.pptx

THEINFRAREDIMAGINGOFTHEDIABETICFOOT,Zhi-jieXi,M.D.DepartmentofOrthopaedicsShanghaiGuanghuaHospitalofIntegratedTraditionalChineseandWesternMedicine,.,ALITTLEHISTORYInfraredThermographyinDiabetesMellitusP.I.Branemark,S.E.Fagerberg,L.LangerandSaveSoderbergh,Diabetologia3,196716diabetics,12womenand4man,meanage28,averagediseaselength13years,.,Theemissionovertoesandmetatarso-phalangealregionswasdistinctlydecreasedandgaveasharptransverseboundary.Littleornoreductionoftheemissionwasshownoverthedorsumofthefootandtibia.Asymmetricpatternswererecordedfromtheonlydiabeticwithlocalgangrene.,.,.,.,DisturbancesinthearterialcirculationDetectionofareasathighriskforulcerationorre-ulcerationAssessmentoftissuesviability,amputationlevel,andtheintra-operativeskinflapviabilityDiagnosisofosteomyelitisEvaluationofthemedicaltreatmenteffectivenessAssessmentofmicroangiopathyandothersvascularchangescausedbytheneuropathy,.,Theexaminationofthediabeticfoot,Roomtemperature:24CAcclimatizationtime:20minutesUndressedlegsPosition:Orthostatismorseatedwiththelowersextremitieshangingfreely,.,Theimagesaretakenatfixedcamera/objectdistancesfromthebothlegsintheanteriorview,thefootfromatopviewandthesolesHotspotisdefinedasanareaatleast0,5CwarmerthansurroundingsThethermalgradientrepresentsthedifferencebetweentheskintemperatureatthekneeandatthedorsumofthefoot.ThermalimagingofskinchangesonthefeetoftypeIIdiabeticsK.Ammer,P.Melnizky,O.Rathkolb,E.F.Ring-200123rdAnnualEMBSInternationalConference,.,Changesinthearterialcirculation,Eco-DopplerAngiographyThermography,.,The“macro-circulation”pathologylocalizesmoreoftenbelowthepoplitealfossa,thanattheleveloftheaortaoriliacvesselsTheinjuriesrespectthedistal(pedal)arteriesThechangesareusuallyasymmetric,thetibialperonealtrianglebeingthemostcommonlyaffected.,.,Thermographyisespeciallyusefultodifferentiatebetween“ischemicfoot”(cold)andthe“neuropathicfoot(warm).Detectingareasofcriticalischemia,.,.,.,.,ARTERYOGRAPHY,Severeatheromatosisaffectingtheentirelengthofthetibial-peronealtrunk,.,.,Neuropathic(40%)Neuro-ischemicIschemic(10%),ULCERATION,.,.,.,Itwassuggestedthatexaminingthermographicpatterns,patientswithdiabetiscouldbescreenedforriskofulcerationandthathightemperaturewerepredictiveofulceration.Inpatientswithdiabetesperipheralneuropathies,andnoadditionalpathology,thetemperatureoftherightandtheleftlowerextremitieswerenotdifferent.,.,InfrareddermalthermometryfortheHigh-RiskdiabeticfootD.Armstrong,L.Lavery,P.Liswood,W.Todd,J.Tredweell-PhysicalTherapy,77,2,february1997Allpatientswhoexperiencedulcerationorre-ulcerationduringthefollow-upperiodshowedelevatedskintemperaturegradients.,.,Thepatientscanbemonitoredtopreventulcerations,highertemperatureshavingapredictiveroleforulcerationorre-ulceration(20-58%ofpatientsdevelopanotherulcerwithinoneyear)Wehavetokeepinmindthattheincreasedtemperatureindicatesthereisaproblemandwhereitis,NOTWHATITIS!,.,ThetemperaturemonitoringisalsorecommendedinpatientswithCharcotsfractures,inthepost-acutephase,aftertheinflammationhadsubsided.Thermographyisalsousefulindetectingsubtletemperaturechangesthatmaypersistinthepostacutephase;aprematurereactivationindicatingreoccurrence.,.,.,InfraredimagingisasensitiveindicatorofthepresenceorabsenceofosteomyelitiscomplicatingthediabeticfootulcerationwhencomparedwithotherimagingmodalitiesImagingindiabeticfootulceration:ablindedcomparisonofinfraredimagingwithaplainfilmradiology,MRI,clinicalassessment,andhaematologicalandbiochemicalinvestigation-R.Harding,J.Jones,A.Griffiths,H.MorrisRoyalGwent&STWoolosHospital,Newport,Gwent,UK,OSTEOMYELITIS,.,Thetemperatureoninfraredimagingissignificantlyincreasednotonlyaroundtheulcerbutalsointheentiresoleofthefootinpatientswithradiologicallyconfirmedosteomyelitis.Quantitativeinfraredimagingcanpointouttheosteomyelitisinstallation,reducingmorbidityandmortalitybyselectingthosepatientswhowillbenefitfromappropriateaggressiveantibiotictherapy.,.,THERMOGRAPHYINTHEASSESSMENTOFTHEAMPUTATIONLEVELVIABILITY,Diabeticfootamputation:theneedforanobjectiveassessmenttool(Wounds15(7):241-245,2003,Healthmanagementpublication)Thermographyandlatertheclearanceoftheradioisotopeweresuccessfullyusedtodeterminetheviabilityofskinflapsforbelowthekneeamputation.Thecombinationofthesetechniquesyieldedasuccessrateof93%fortransifibialamputation.(NinewellsHospital,Dundee,Scotland),.,Amputationoftheischemiclimb:selectionoftheoptimumsitebythermographyV.A.Spence,W.F.Walker,I.M.TroupVascularLaboratory,NinewellesHospitalandMedicalSchool,Dundee,ScotlandResultsfrom104patientsdemonstratethatthethermographicmethodisareliableindicatorforthelevelofamajorlimbamputation.,.,IRlacksinformationaboutthelocalanatomyandonlyindirectlyestimatethechangesinthecutaneousmicrocirculatorybloodsupply.Theobtaineddatabymergingbothimagingtechniques(IR&MRI)allowsthedeterminationoftheextentofanatomicandphysiologicalcompromise,thusleadingtoabetterandmoreadequatesurgicalintervention,.,MICROANGIOPATHYANDNEUROPATHY,Thesetwotopicscanbediscussedtogether,sincethemicroangiopathyofthevasanervorumcontributestotheneuropathypathogenesis,whichinturninduceschangesinthecapillarycirculation,thuspartiallycompensatingforthereductioninflowcausedbythemicroangiopathy.Intheinitialstagesofneuropathy,whenthemicroangiopathicchangesaredominant,thereisasymmetrichypothermiainthetoesandthedistalonethirdofthefoot.Severehypothermiamayappearas“thermicamputation”,generatedbyacombinationofobstructivemicroangiopathyandsympathetichyperactivitycausedbypartialnervedamage.,.,MICROANGIOPATHYANDNEUROPATHY,.,Aftertheonsetoftheneuropathicprocess,theskintemperatureincreasesThediabeticneuropathyaffectsthemicrocirculationbyincreasingthebloodflowthrougharteriovenousshunts,whicharenormallyunderthecontrolofsympatheticsystem.,.,E.Boyko(Skintemperatureintheneuropathicdiabeticfoot-2001)quotesastudyinwhichthemeanskintemperatureontheplantarfootisbetween33,2and33,5Camongdiabeticsubjectswitheitherpainfulorsensoryneuropathycomparedtoameanof27,8indiabeticsubjectwit