Diabetes.ca | 1-800-BANTING (226-8464) WHAT’S THE LATEST IN DIABETES & FOOT CARE? Axel...

diabetes.ca | 1-800-BANTING (226-8464)

WHAT’S THE LATEST IN DIABETES & FOOT CARE?

Axel RohrmannPodiatrist

The time to act is NOW!

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KEY MESSAGE• Foot problems are a major cause of

morbidity & mortality in people with diabetes.

• Management of foot ulceration requires an interdisciplinary approach (glycaemic control, infection, vascular status, foot wear & wound care).

• Uncontrolled diabetes may result in immunopathy with a blunted cellular response to foot infection.

• Diabetes is a serious chronic disease.– prevalence estimated at 246 million globally in 2007.– 4th leading cause of death in most developed countries.

• 20% of diabetic hospitalizations are foot related.– 70% of all leg amputations happen to people living with

diabetes. (> 1 million / year or 1 every 30 seconds).

• Foot ulcers precede the majority of amputations.– In developed countries 1 in 6 diabetics will have an

ulcer

INTRODUCTION

Limb Loss Prognosis with Diabetes

2% of all persons with diabetes will need an amputation. 5496 amputations last year!

50% of amputees will lose the other limb in 3 to 5 years.

Up to 50% mortality five years after first amputation.

The situation can be changedPossible to reduce amputation rates

between 49% & 85%.Care strategy:

PreventionMulti-disciplinary treatmentAppropriate organization of careClose monitoringEducation (people with diabetes & health

care professionals)

Diabetes is a biochemical disease• “Diabetes mellitus is a biochemical disease,

but a large number of lower extremity complications of the disorder are due to

biomechanical dysfunction.” (Source: Payne, 1998.)

• Diabetics may have altered biomechanics; or

• Present with a complication of any pre-existing neurovascular or biomechanical dysfunction.

Social / cultural habits Mobility Deformities Vascular status Neurological status Skin lesions: ulcers, callus, blisters Footwear Compliance & understanding

Risk Factors for Ulceration

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Risk Identification & CategoriesWill risk identification & categorization

reduce the number of:

Primary ulcerations?Re-ulcerations?Amputations?

YES!

Foot Ulceration

• Approximately 85% of diabetes-related amputations start off with a foot ulcer that deteriorates, becomes infected & gangrenous!

Most foot ulceration CAN be avoided /prevented

The “At-Risk” Foot

2 types of risk:

1. At risk for ulceration

1. At risk for limb loss

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• Peripheral neuropathy– Sensory– Autonomic– Motor

• Risk factors for neuropathy include:High levels of glycaemia, elevated triglycerides, high BMI, smoking & hypertension.

Risk Factors for Ulceration

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Sensory Neuropathy

• Largest single risk factor for diabetic foot ulcers– Burning, tingling, ”pins & needles”, numbness

or “dead” feeling– Repeated unrecognized stress, pressure,

friction & shearing.– Lack sensation to feel foreign objects, heat

changes, discomfort or pain.

Risk Factors for Ulceration

Autonomic Neuropathy

• Impairs skin integrity, sweat regulation & blood flow.

• Leads to:– thick, dry cracked skin, fissures– callus build-up at pressure points

Risk Factors for Ulceration

Motor Neuropathy

• Loss of muscle tone in the foot

• Foot deformities:– Hammer toes– Claw toes

• Metatarsal heads become prominent

• Changes in pressure distribution & gait pattern

Photo used with permission from Dr.Axel Rohrmann, Podiatrist.

Risk Factors for Ulceration

Under diagnosis of neuropathy

• Fundamental problem in primary care.• Impedes early identification,

management & prevention of squeals .

Risk Factors for Ulceration

Elevated Pressures & Foot Deformity

• Pes Planus - flat foot• Pes Cavus- high arch• Charcot Foot- (significant

disruption of the bony architecture)

• Lesser toe deformities

Note also• Prayer sign - hands

Risk Factors for Ulceration

• Occur in presence of: peripheral sensory neuropathy, autonomic neuropathy and trauma.

• Presentation: painless, unilateral oedema, erythema, with or without foot deformity, bounding pedal pulses. Post tib dysfunction in later stages.

Photo used with permission from Dr.Axel Rohrmann, Podiatrist.

CHARCOT FOOT

Diabetic Neuropathic Osteoarthropathy• Occur in presence of peripheral sensory

neuropathy, autonomic neuropathy & trauma.• Presentation: painless, unilateral oedema,

erythema, with or without foot deformity, bounding pedal pulses. Post tibial dysfunction in later stages.

• Note: – Acute charcot can mimic cellulitis & DVT– Radiological findings can be normal at first– Strict immobilization of foot for management– Patient education, protective footwear to prevent

ulcerations

Calluses• Presence of callus in an insensitive foot is

highly predictive of subsequent foot ulceration.

• Breakdown of underlying tissues• Regular debridement • Pressure relief : insoles / moulded orthotics• Footwear

Calluses increase pressure on underlying tissue by 30%

Risk Factors for Ulceration

Photo used with permission from Axel Rohrmann, Podiatrist.

Risk Factors for Ulceration

Limited Joint Mobility– Hallux rigidus– Hallux limitus– Hammer toes– Claw toes

Limited joint mobility can cause increasedground reaction forces under weight-

bearing joints. This can lead to ulceration.

Photo used with permission from Dr. Axel Rohrmann, Podiatrist.

Previous Ulceration & Amputation• Skin texture • Scar tissue reduced tensile strength. • Pressure points

Risk Factors for Ulceration

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NEUROVASCULAR ASSESSMENT

Type 1 – 5 years post diagnosis.

Type 2 - When diagnosed & annually or as indicated by risk category.

What to look for & assess!

Dermatological:– Color– Temperature– Texture– Errythema– Edema– Lesions– Fissures– Callus– Ulcers– Nail disorders

Vascular:– Pedal pulses– digital hair– capillary

revascularization– Varicosities– ABI, TPI, PPG– Edema– Transcutaneous

oxygen concentrations

– Angiography – MRI

What to look for & assess!

Neurological:– 10g

Monofilaments– Reflexes– Vibration

perception– Proprioception

Biomechanical:– Gait– Joint mobility– Anomalies & limitations– Amputations– Foot wear– Hosiery

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DIABETIC FOOT ULCERS

Diagnose the aetiology!!!!

– neurovascular, biomechanical, trauma

Healing the wound

Diabetic wound healing is a complicated process that requires a definite plan based on scientific fact. A validated classification system can be the roadmap to get you there.

University of Texas wound classificationThis straightforward system grades wounds first with numbers 0 to

3 referring to depth: – 0 (pre- or post-ulcer with epithelialization), – 1 (superficial and not involving tendon, bone or capsule), – 2 (ulcer penetrates through to tendon or capsule), and – 3 (penetrating to bone or joint).

A second classification tier, A to D, refers to other burdens on the wound.– A indicates non-infected/non-ischemic, – B indicates infection, – C indicates ischemia, and – D indicates infection plus ischemia.

Evaluation & Management of Infection in DM Foot

• Assess whether or not infection is present.

• If present determine the depth & the nature of involvement (e.g. whether OM or un-drained pus is present).

Evaluation & Management of Infection in DM Foot

• Surgically debride all devitalised tissue, repeatedly if necessary.

• Obtain adequate & appropriate material for culture of aerobic & anaerobic organism.

Evaluation & Management of Infection in DM Foot

• Ensure that the patient with plantar or heel ulceration complies with strict non-weight bearing until complete healing has occurred.

• Modify risk factors for future infection whenever possible (e.g. foot deformity, improper footwear, poorly educated patient)

Evaluation & Management of Infection in DM Foot

Control hyperglycaemia* & other metabolic derangement

*Rayfield EJ, Ault MJ, Keusch GT, Brothers MS, Nechemias C, Smith H. Infection and diabetes: the case for glucose control. AM J Med 1982;72:439-450

Evaluation & Management of Infection in DM Foot

• Empiric anti-microbial treatment active against most commonly isolated pathogens and/or those seen on initial Gram’s stain.

• Modify regimen based on culture results.

• Ensure adequate vascular supply exist.

Follow up prevention

• Daily home foot examination by person with diabetes and/or care provider.

• Frequent visits to appropriate team member(s) to evaluate feet & shoes.

• Education of patient, family & healthcare providers.

• Appropriate footwear.• Treatment of non-ulcerative pathology.• TLC!

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You Can Make a Difference

Awareness & intervention can prevent many problems with the

diabetic foot.

New website

diabetes.ca

diabetes.ca | 1-800-BANTING (226-8464)

Thank you!

References