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diabetes.ca | 1-800-BANTING (226-8464)
WHAT’S THE LATEST IN DIABETES & FOOT CARE?
Axel RohrmannPodiatrist
The time to act is NOW!
123
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
9
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
13
• Peripheral neuropathy– Sensory– Autonomic– Motor
• Risk factors for neuropathy include:High levels of glycaemia, elevated triglycerides, high BMI, smoking & hypertension.
Risk Factors for Ulceration
14
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
diabetes.ca | 1-800-BANTING (226-8464)
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
diabetes.ca | 1-800-BANTING (226-8464)
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!
diabetes.ca | 1-800-BANTING (226-8464)
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