I also call this lecture… · Management and Treatment of the Diabetic Foot Most podiatrists have...

I also call this lecture…

My Background

GO BUCKS!!!

Cornerstone University – Grand Rapids, MI

Kent State University College of Podiatric Medicine (OCPM)

Florida Hospital East Orlando – 3 year surgical residency

Lower Extremity Trauma

Foot and Ankle Deformity Correction Surgery

Management and Treatment of the Diabetic Foot

Most podiatrists have extensive training in

Reconstructive foot and ankle surgery

Traumatic injuries of the foot/ankle/leg

Treatment of diabetic foot complications/wound care

Pertinent Pointers for Physical Exam

• Palpate pulses• Capillary fill time• Skin texture and turgor• Pedal hair growth

Vascular

• TcPO2 → < 25 mmHg = decreased wound healing• Arterial Doppler• Segmental Pressures and ABI's• Toe Pressures

Advanced Testing

Pertinent Pointers for Physical Exam

• Semmes Weinstein 10g monofilament for protective sensation – 1st, 3rd, and 5th toes and met heads, plantar arch, and heel

• Vibratory with 128Hz tuning fork - 1st MTP and medial malleolus

• Sharp/Dull sensation• Two point discrimination• Light touch• Proprioception of great toe position

Neurological

• EMG/NCV• ENFD biopsy

Advanced Testing

Pertinent Pointers for Physical Exam

• ROM and EQUINUS• Toe and forefoot deformities most risky• Bone spurs and pressure points

Musculoskeletal

• X-ray• MRI• CT• Bone scan/WBC scan

Advanced Testing

Pertinent Pointers for Physical Exam

• Hyperkeratotic lesions with intradermal hemorrhage = stage 0 ulcer• Ulcerations evaluated by inspecting for erythema, edema, malodor,

purulence, and warmth• Some melanomas mimic diabetic foot ulcers

Dermatologic

• Skin/tissue biopsy• Fluid cultures• Superficial wound cultures are inappropriate

Advanced Testing

Charcot Neuroarthropathy

red, hot, swollen

Eichenholtz Classification

Prefragmentation (Stage 0) – initial inflammation

Acute or Fragmentation (Stage I) – fracture and collapse

Coalescence (Subacute) (Stage II) – bony resorption

Consolidation (Stage III) – return of stable, usually collapsed, foot

Charcot Treatment

Acute and subacute stages (0,I,II) • NWB activity/offloading• Until inflammation and swelling resolve• Total Contact Cast or CAM boot• Bisphosponates

Coalescence stage (III) • Initiate WB• Accommodative orthotics• Rocker bottom shoe• Charcot Restraint Orthotic Walker (CROW

boot)

Charcot

Gout

RED, HOT, SWOLLEN FOOT

(my cell is 239-703-5000 ;-)

So how should I treat my patients with peripheral neuropathy???

Should you work it up?

If patient is diabetic?

Usually assume DPN ~90% of PN is caused by DM

If suspicion of infectious process or nutritional deficiency, treat appropriately and symptoms may

resolve

If not diabetic, absolutely!

Peripheral Neuropathy Etiology

D – iabetes

A – lcoholism

N – utritional = Vitamin B1, B6, B12, E

G – uillan-Barre

T – oxic = Drugs, Lead, Arsenic

HE – reditary = Charcot-Marie Tooth, Refsum'sdz, Friedrich's Ataxia

R – ecurrent = Chronic inflammatory demyelinating polyneuropathy

A – myloidosis

P – orphyria

I – nfection = HIV, leprosy, mononucleosis, Lyme, diptheria, untreated syphilis

S – ystemic = Uremic syndrome, SLE, hypothyroid, Sjogren's

T – umors = paraneoplastic, multiple myeloma

Diabetic Peripheral Neuropathy

IRREVERSIBLE

Prevention = tight glycemic control

• “Intensive treatment” à increased mortality risk (ACCORD study)

HTN, hyperlipidemia, elevated BMI, and smoking MAY contribute to DPN

Clinical trials focusing on disease modification have failed because we lack knowledge on the pathophysiology of DPN

Gerstein HC, et al. Effects of Intensive Glucose Lowering in Type 2 Diabetes. N Engl J Med 2008; 358:2545-2559

My Treatment Protocol(Level V Evidence)

Mild• Mild numbness or burning in

toes

• No treatment or topical analgesics

Moderate• Partial or complete numbness

which includes forefoot• Mild constant dysesthesias

• Diabetic shoes and inserts• Low dose pharmacotherapy +

Vitamin supplementation

Severe• Constant pain, loss of motor

function, profound numbness

• Pharmacotherapy + Vitamin supplementation

• Physical medicine (PT, TENS, Ultrasound, Massage)

• DM shoes and custom inserts a MUST

• Experimental (Electronic signal transfer, Anodyne)

Bril V, et al. Evidence Based Guideline: Treatment of Painful Diabetic Neuropathy. Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2011 May 17; 76(20): 1758-1765

Robbins JM. Mortality Rates and Diabetic Foot Ulcers. J AM Podiatr Med Assoc 98(6): 489-493, 2008.

5 Year Mortality Rates

If you don’t already…

Refer to Your Favorite

Podiatrist!

l Several studies have demonstrated decreased morbidity and mortality when podiatric surgeons are involved in the care of diabetic patients with and without ulcerations

l A 2011 study demonstrated that during the 2 years following the onset of an initial DFU, podiatric care lowered the cost of treatment under commercial plans by $13,474 and by $3624 on Medicare plans.

l Podiatrists reduce hospitalizations secondary to ulcer/infection, reduce the formation of DFU's, and reduce amputation rates

l We save limbs, but also subsequently save lives per the mortality statistics previously mentioned

Remember that foot ulcer ALONE increases risk of mortality in diabetic population by 37% - Do not underestimate the

morbidity and mortality of a foot ulceration

Patients with DM and one of these systemic comorbidities should see a podiatrist at least every 3 months

3. Renal disease2. CHF1. Liver disease

Look for callouses, bony deformities, or areas of irritation on every diabetic foot

Calluses with intradermal

hemorrhage may be ulcerated – Refer

immediately

Equinus increases forefoot loading

pressure, early heel off, increased shear,

prolonged stance phase

swflfootankle@gmail.com