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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