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THEINFRAREDIMAGING

OFTHEDIABETICFOOTZhi-jieXi,M.D.DepartmentofOrthopaedicsShanghaiGuanghuaHospitalofIntegratedTraditionalChineseandWesternMedicineTHEINFRAREDIMAGING

OFTH

ALITTLEHISTORYInfraredThermographyinDiabetesMellitusP.I.Branemark,S.E.Fagerberg,L.LangerandSave–Soderbergh,Diabetologia3,1967

16diabetics,12womenand4man,meanage28,averagediseaselength13years糖尿病足的紅外線診斷課件Theemissionovertoesandmetatarso-phalangealregionswasdistinctlydecreasedandgaveasharptransverseboundary.Littleornoreductionoftheemissionwasshownoverthedorsumofthefootandtibia.Asymmetricpatternswererecordedfromtheonlydiabeticwithlocalgangrene.Theemissionovertoesandmet糖尿病足的紅外線診斷課件糖尿病足的紅外線診斷課件DisturbancesinthearterialcirculationDetectionofareasathighriskforulcerationorre-ulcerationAssessmentoftissuesviability,amputationlevel,andtheintra-operativeskinflapviabilityDiagnosisofosteomyelitisEvaluationofthemedicaltreatmenteffectivenessAssessmentofmicroangiopathyandothersvascularchangescausedbytheneuropathyDisturbancesinthearterialcTheexaminationofthediabeticfootRoomtemperature:24CAcclimatizationtime:20minutesUndressedlegsPosition:OrthostatismorseatedwiththelowersextremitieshangingfreelyTheexaminationofthediabetiTheimagesaretakenatfixedcamera/objectdistancesfromthebothlegsintheanteriorview,thefootfromatopviewandthesolesHotspotisdefinedasanareaatleast0,5CwarmerthansurroundingsThethermalgradientrepresentsthedifferencebetweentheskintemperatureatthekneeandatthedorsumofthefoot.ThermalimagingofskinchangesonthefeetoftypeIIdiabetics–K.Ammer,P.Melnizky,O.Rathkolb,E.F.Ring-2001–23rdAnnualEMBSInternationalConferenceTheimagesaretakenatfixedChangesinthearterialcirculationEco-DopplerAngiographyThermographyChangesinthearterialcirculThe“macro-circulation”pathologylocalizesmoreoftenbelowthepoplitealfossa,thanattheleveloftheaortaoriliacvesselsTheinjuriesrespectthedistal(pedal)arteriesThechangesareusuallyasymmetric,thetibial–peronealtrianglebeingthemostcommonlyaffected.The“macro-circulation”patholThermographyisespeciallyusefultodifferentiatebetween“ischemicfoot”(cold)andthe“neuropathicfoot(warm).Detectingareasofcriticalischemia糖尿病足的紅外線診斷課件糖尿病足的紅外線診斷課件糖尿病足的紅外線診斷課件糖尿病足的紅外線診斷課件ARTERYOGRAPHYSevereatheromatosisaffectingtheentirelengthofthetibial-peronealtrunkARTERYOGRAPHY糖尿病足的紅外線診斷課件Neuropathic(40%)Neuro-ischemicIschemic(10%)ULCERATIONULCERATION糖尿病足的紅外線診斷課件糖尿病足的紅外線診斷課件Itwassuggestedthatexaminingthermographicpatterns,patientswithdiabetiscouldbescreenedforriskofulcerationandthathightemperaturewerepredictiveofulceration.Inpatientswithdiabetesperipheralneuropathies,andnoadditionalpathology,thetemperatureoftherightandtheleftlowerextremitieswerenotdifferent.ItwassuggestedthatexamininInfrareddermalthermometryfortheHigh-RiskdiabeticfootD.Armstrong,L.Lavery,P.Liswood,W.Todd,J.Tredweell-PhysicalTherapy,77,2,february1997Allpatientswhoexperiencedulcerationorre-ulcerationduringthefollow-upperiodshowedelevatedskintemperaturegradients.InfrareddermalthermometryfoThepatientscanbemonitoredtopreventulcerations,highertemperatureshavingapredictiveroleforulcerationorre-ulceration(20-58%ofpatientsdevelopanotherulcerwithinoneyear)Wehavetokeepinmindthattheincreasedtemperatureindicatesthereisaproblemandwhereitis,NOTWHATITIS!ThepatientscanbemonitoredThetemperaturemonitoringisalsorecommendedinpatientswithCharcot’sfractures,inthepost-acutephase,aftertheinflammationhadsubsided.Thermographyisalsousefulindetectingsubtletemperaturechangesthatmaypersistinthepostacutephase;aprematurereactivationindicatingreoccurrence.

Thetemperaturemonitoringis糖尿病足的紅外線診斷課件InfraredimagingisasensitiveindicatorofthepresenceorabsenceofosteomyelitiscomplicatingthediabeticfootulcerationwhencomparedwithotherimagingmodalitiesImagingindiabeticfootulceration:ablindedcomparisonofinfraredimagingwithaplainfilmradiology,MRI,clinicalassessment,andhaematologicalandbiochemicalinvestigation-R.Harding,J.Jones,A.Griffiths,H.Morris–RoyalGwent&STWoolosHospital,Newport,Gwent,UKOSTEOMYELITISInfraredimagingisasensitivThetemperatureoninfraredimagingissignificantly

increasednotonlyaroundtheulcerbutalsointheentiresoleofthefootinpatientswithradiologicallyconfirmedosteomyelitis.Quantitativeinfraredimagingcanpointouttheosteomyelitisinstallation,reducingmorbidityandmortalitybyselectingthosepatientswhowillbenefitfromappropriateaggressiveantibiotictherapy.ThetemperatureoninfraredimTHERMOGRAPHYINTHEASSESSMENTOFTHEAMPUTATIONLEVELVIABILITYDiabeticfootamputation:theneedforanobjectiveassessmenttool(Wounds15(7):241-245,2003,Healthmanagementpublication)Thermographyandlatertheclearanceoftheradioisotopeweresuccessfullyusedtodeterminetheviabilityofskinflapsforbelowthekneeamputation.Thecombinationofthesetechniquesyieldedasuccessrateof93%fortransifibialamputation.(NinewellsHospital,Dundee,Scotland)THERMOGRAPHYINTHEASSESSMENTAmputationoftheischemiclimb:selectionoftheoptimumsitebythermography–V.A.Spence,W.F.Walker,I.M.Troup–VascularLaboratory,NinewellesHospitalandMedicalSchool,Dundee,Scotland

Resultsfrom104patientsdemonstratethatthethermographicmethodisareliableindicatorforthelevelofamajorlimbamputation.AmputationoftheischemiclimIRlacksinformationaboutthelocalanatomyandonlyindirectlyestimatethechangesinthecutaneousmicrocirculatorybloodsupply.Theobtaineddatabymergingbothimagingtechniques(IR&MRI)allowsthedeterminationoftheextentofanatomicandphysiologicalcompromise,thusleadingtoabetterandmoreadequatesurgicalinterventionIRlacksinformationabouttheMICROANGIOPATHYANDNEUROPATHYThesetwotopicscanbediscussedtogether,sincethemicroangiopathyofthevasanervorumcontributestotheneuropathypathogenesis,whichinturninduceschangesinthecapillarycirculation,thuspartiallycompensatingforthereductioninflowcausedbythemicroangiopathy.Intheinitialstagesofneuropathy,whenthemicroangiopathicchangesaredominant,thereisasymmetrichypothermiainthetoesandthedistalonethirdofthefoot.Severehypothermiamayappearas“thermicamputation”,generatedbyacombinationofobstructivemicroangiopathyandsympathetichyperactivitycausedbypartialnervedamage.

MICROANGIOPATHYANDNEUROPATHYMICROANGIOPATHYANDNEUROPATHYMICROANGIOPATHYANDNEUROPATHYAftertheonsetoftheneuropathicprocess,theskintemperatureincreasesThediabeticneuropathyaffectsthemicrocirculationbyincreasingthebloodflowthrougharteriovenousshunts,whicharenormallyunderthecontrolofsympatheticsystem.AftertheonsetoftheneuropaE.Boyko(Skintemperatureintheneuropathicdiabeticfoot-2001)quotesastudyinwhichthemeanskintemperatureontheplantarfootisbetween33,2and33,5Camongdiabeticsubjectswitheitherpainfulorsensoryneuropathycomparedtoameanof27,8indiabeticsubjectwithoutneuropathy.E.Boyko(SkintemperatureintThedynamicmeasurementsoftheplantarmeantemperaturecanbeusefulindetectingtheperfusionanomaliesduetoneuropathy.Theplantartemperaturemodificationsaretheresultofthecirculatoryinsufficiency,neuropathdisorders,skeletonmodifications,infectionsoranycombinationsofthesefactors.Thedynamicmeasurementsofth糖尿病足的紅外線診斷課件ComplicationsDeterminationofinfectioncomplicatedbecauseofsuperimposedneuropathicosteoarthropathyandperipheralvasculardiseaseNeuropathicdiseasecanleadtof/x,deformity,boneproduction,andhyperemiawhichcanmimicinfectiononMRIandscanningincreasingthefalsepositivesPeripheralvasculardiseasecanpreventcontrastmaterialortracerfromreachingsiteofconcernandleadtofalsenegativesComplicationsDeterminationofTHEINFRAREDIMAGING

OFTHEDIABETICFOOTZhi-jieXi,M.D.DepartmentofOrthopaedicsShanghaiGuanghuaHospitalofIntegratedTraditionalChineseandWesternMedicineTHEINFRAREDIMAGING

OFTH

ALITTLEHISTORYInfraredThermographyinDiabetesMellitusP.I.Branemark,S.E.Fagerberg,L.LangerandSave–Soderbergh,Diabetologia3,1967

16diabetics,12womenand4man,meanage28,averagediseaselength13years糖尿病足的紅外線診斷課件Theemissionovertoesandmetatarso-phalangealregionswasdistinctlydecreasedandgaveasharptransverseboundary.Littleornoreductionoftheemissionwasshownoverthedorsumofthefootandtibia.Asymmetricpatternswererecordedfromtheonlydiabeticwithlocalgangrene.Theemissionovertoesandmet糖尿病足的紅外線診斷課件糖尿病足的紅外線診斷課件DisturbancesinthearterialcirculationDetectionofareasathighriskforulcerationorre-ulcerationAssessmentoftissuesviability,amputationlevel,andtheintra-operativeskinflapviabilityDiagnosisofosteomyelitisEvaluationofthemedicaltreatmenteffectivenessAssessmentofmicroangiopathyandothersvascularchangescausedbytheneuropathyDisturbancesinthearterialcTheexaminationofthediabeticfootRoomtemperature:24CAcclimatizationtime:20minutesUndressedlegsPosition:OrthostatismorseatedwiththelowersextremitieshangingfreelyTheexaminationofthediabetiTheimagesaretakenatfixedcamera/objectdistancesfromthebothlegsintheanteriorview,thefootfromatopviewandthesolesHotspotisdefinedasanareaatleast0,5CwarmerthansurroundingsThethermalgradientrepresentsthedifferencebetweentheskintemperatureatthekneeandatthedorsumofthefoot.ThermalimagingofskinchangesonthefeetoftypeIIdiabetics–K.Ammer,P.Melnizky,O.Rathkolb,E.F.Ring-2001–23rdAnnualEMBSInternationalConferenceTheimagesaretakenatfixedChangesinthearterialcirculationEco-DopplerAngiographyThermographyChangesinthearterialcirculThe“macro-circulation”pathologylocalizesmoreoftenbelowthepoplitealfossa,thanattheleveloftheaortaoriliacvesselsTheinjuriesrespectthedistal(pedal)arteriesThechangesareusuallyasymmetric,thetibial–peronealtrianglebeingthemostcommonlyaffected.The“macro-circulation”patholThermographyisespeciallyusefultodifferentiatebetween“ischemicfoot”(cold)andthe“neuropathicfoot(warm).Detectingareasofcriticalischemia糖尿病足的紅外線診斷課件糖尿病足的紅外線診斷課件糖尿病足的紅外線診斷課件糖尿病足的紅外線診斷課件ARTERYOGRAPHYSevereatheromatosisaffectingtheentirelengthofthetibial-peronealtrunkARTERYOGRAPHY糖尿病足的紅外線診斷課件Neuropathic(40%)Neuro-ischemicIschemic(10%)ULCERATIONULCERATION糖尿病足的紅外線診斷課件糖尿病足的紅外線診斷課件Itwassuggestedthatexaminingthermographicpatterns,patientswithdiabetiscouldbescreenedforriskofulcerationandthathightemperaturewerepredictiveofulceration.Inpatientswithdiabetesperipheralneuropathies,andnoadditionalpathology,thetemperatureoftherightandtheleftlowerextremitieswerenotdifferent.ItwassuggestedthatexamininInfrareddermalthermometryfortheHigh-RiskdiabeticfootD.Armstrong,L.Lavery,P.Liswood,W.Todd,J.Tredweell-PhysicalTherapy,77,2,february1997Allpatientswhoexperiencedulcerationorre-ulcerationduringthefollow-upperiodshowedelevatedskintemperaturegradients.InfrareddermalthermometryfoThepatientscanbemonitoredtopreventulcerations,highertemperatureshavingapredictiveroleforulcerationorre-ulceration(20-58%ofpatientsdevelopanotherulcerwithinoneyear)Wehavetokeepinmindthattheincreasedtemperatureindicatesthereisaproblemandwhereitis,NOTWHATITIS!ThepatientscanbemonitoredThetemperaturemonitoringisalsorecommendedinpatientswithCharcot’sfractures,inthepost-acutephase,aftertheinflammationhadsubsided.Thermographyisalsousefulindetectingsubtletemperaturechangesthatmaypersistinthepostacutephase;aprematurereactivationindicatingreoccurrence.

Thetemperaturemonitoringis糖尿病足的紅外線診斷課件InfraredimagingisasensitiveindicatorofthepresenceorabsenceofosteomyelitiscomplicatingthediabeticfootulcerationwhencomparedwithotherimagingmodalitiesImagingindiabeticfootulceration:ablindedcomparisonofinfraredimagingwithaplainfilmradiology,MRI,clinicalassessment,andhaematologicalandbiochemicalinvestigation-R.Harding,J.Jones,A.Griffiths,H.Morris–RoyalGwent&STWoolosHospital,Newport,Gwent,UKOSTEOMYELITISInfraredimagingisasensitivThetemperatureoninfraredimagingissignificantly

increasednotonlyaroundtheulcerbutalsointheentiresoleofthefootinpatientswithradiologicallyconfirmedosteomyelitis.Quantitativeinfraredimagingcanpointouttheosteomyelitisinstallation,reducingmorbidityandmortalitybyselectingthosepatientswhowillbenefitfromappropriateaggressiveantibiotictherapy.ThetemperatureoninfraredimTHERMOGRAPHYINTHEASSESSMENTOFTHEAMPUTATIONLEVELVIABILITYDiabeticfootamputation:theneedforanobjectiveassessmenttool(Wounds15(7):241-245,2003,Healthmanagementpublication)Thermographyandlatertheclearanceoftheradioisotopeweresuccessfullyusedtodeterminetheviabilityofskinflapsforbelowthekneeamputation.Thecombinationofthesetechniquesyieldedasuccessrateof93%fortransifibialamputation.(NinewellsHospital,Dundee,Scotland)THERMOGRAPHYINTHEASSESSMENTAmputationoftheischemiclimb:selectionoftheoptimumsitebythermography–V.A.Spence,W.F.Walker,I.M.Troup–VascularLaboratory,NinewellesHospitalandMedicalSchool,Dundee,Scotland

Resultsfrom104patientsdemonstratethatthethermographicmethodisareliableindicatorforthelevelofamajorlimbamputation.AmputationoftheischemiclimIRlacksinformationaboutthelocalanatomyandonlyindirectlyestimatethechangesinthecutaneousmicrocirculatorybloodsupply.Theobtaineddatabymergingbothimagingtechniques(IR&MRI)allowsthedeterminationoftheextentofanatomicandphysiologicalcompromise,thusleadingtoabetterandmoreadequatesurgicalinterventionIRlacksinformationabouttheMICROANGIOPATHYANDNEUROPATHYThesetwotopicscanbediscussedtogether,sincethemicroangiopathyofthevasanervorumcontributestotheneuropathypathogenesis,whichinturninduceschangesinthecapillarycirculation,thuspartiallycompensatingforthereductioninflowcausedbythemicroangiopathy.Intheinitialstagesofneuropathy,whenthemicroangiopathicchangesaredominant,thereisasymmetrichypothermiainthetoesandthedistalonethirdofthe

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