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The diabetic foot Mollie Donohoe and Zoe Boulton
07 Feb 2014
• Current situation - amputations
• Cases
• Assessment of diabetic foot
• The role of the podiatrist
Evolution and the diabetic foot
Increasing numbers
Fashion victims
Why need to improve diabetic foot care
• Diabetic foot disease accounts for more hospital bed days than all other diabetes complications.
• 100 people a week lose a lower limb because of diabetes in the UK.
• 1 in 20 people with diabetes will develop a foot ulcer in one year.
• 80% of people die within 5 years after amputation.
NHS Atlas of VariationAmputation in Type 2 Diabetes
Percentage of people in the National Diabetes Audit (NDA)
having major lower limb amputations five years prior to the end of the
audit period by PCT1 January 2009 to 31 March 2010
NHS Expenditure – Ulceration and Amputation in Diabetes
• In 2010-11 the NHS spent an estimated £639 million to £662 million a year on diabetic foot care
• Equivalent to £1 in in every £150 of total NHS spending
Primary, Com-munity, Outpa-tient Care and A
& E £307m. - £324m.
Inpatient Care - Ulceration £213m.
Amputation £119m. - £125m.
Why it is so important?
• 80% of people die within five years of having foot ulcers or amputations
• Cost to the NHS
80% 49% 20% 17%
Amputation / Foot Ulcer
ColonCancer
ProstateCancer
Breast Cancer
But …
... up to 80 per cent of amputations are potentially preventable
Targets - NICE
Structured education at time of diagnosis and on ongoing basis (A)
(A) Directly based on evidence from metanalysis of RCTs/at least one RCT
Impact of foot ulcers on quality of life
Health related quality of life (SF-6D) scores for people with diabetic foot ulcers and other long-term conditions, and for healthy people aged 75+ (Source: Jeffcoate et al. (2009), Brazier et al. (2004), Davison et al.(2009)) •Diabetic foot ulcer QOL rated lower than osteoarthritis, COPD, dialysis•SF-6D or EQ-5D are building blocks for QALY estimation
Old PCT boundaries
Devon PCT
Torbay PCT
Plymouth PCT
PCT major amputation rates – YHPHO 2012
1.6
1.01.8
England 1.0
1.3
NEW Devon CCG northern locality NEW Devon CCG
eastern locality
NEW Devon CCG western locality
South Devon and Torbay CCG
New CCG boundaries(also reflect catchment areas)
NEW = North East West
NEW CCG amputation ratesYHPHO 2012
1.6
England 0.9
Calculating rates per catchment area
CCGs are the “externally visible” unit of healthcare• YHPHO has calculated amputation rates by CCG• NEW Devon CCG includes catchment areas of 3 hospitals
Shane Coe obtained the required data• Information analyst for NHS Devon• Used YHPHO methodology• Calculated amputation rates by CCG and locality
New CCG boundaries(also reflect catchment areas)
1.41.3
2.0
1.2
Thanks to Shane Coe – NEW Devon CCG
1.2
England 0.9
Devon is an outlier…
…because it’s the biggest
Ethnicity• White – risk = 1.0• S Asian – risk = 0.25• Black – risk = 0.62
Age• 2% increase per year
Confounding factors?
We are 20 years ahead of the country
(Sidmouth 2075)
Confounding factors?
Holman, Diabetologia 2012; 55: 1919.
Amputation rates in diabetic and non-diabetic patients correlate strongly – r=0.43, p=0.0005
The South Western Region
• High rate of diabetic foot disease in South West
Legacy effect 50% older migrants
Older population25% >65
longer survival
Rural occupation
White 94.1%
Interpret all data with caution
Atlas of Variation is not a scientific document• Some implausible data• Inadequate adjustment for confounders• Health service “units” are not helpful• Successfully achieved headlines
There is lots of room to improve, and we need to• Pan-Devon problem – perhaps pan-SW• Improvements need to cross primary and secondary care
RCA of Major Amputations in Diabetic Patients Jan 2012-13
• 16 patients - 22 amputations• 6 patients had 2 amputations same leg
• 3 patients out of area– 2 Somerset with ESRF – 1 Torbay (patient choice)
• 5 patients under renal physicians: 4 on dialysis
• 2 patients diagnosed with diabetes when admitted
Problems identified so far
• Only 50% of patients known to Diabetic foot clinic
• 5/16 (31%) solely under vascular as inpatient (no involvement from diabetes team)
• 4/16 (25%) of amputees had ESRF
• 5/13 (38%) not referred to podiatry post amputation
• 2/16 (12%) frequent DNA
Problems identified so far
• 5/8 (62%) documented given education in foot clinic.
• 2/16 (13%) had previous care in another area – no record of prior podiatric care.
• 1/16 (6%) critical event was ulcer which developed when patient previous inpatient.
• 16/16 (100%) had no inpatient podiatric care
Inpatient foot care
The Touch Test
The Touch Test• Up to 15% of inpatients have diabetes mellitus at any one time (1)
• 33% had feet examined (14% RD&E).• Robust screening method
–Accurate–Simple–Acceptable–Cost effective•Touch test performs consistently and favourably compared with Monofilament.
(1) National Diabetes Inpatient Survey 2009
Testing for neuropathy• The Ipswich Touch Test (IpTT)
A simple and novel method to identify inpatients with diabetes at risk of foot ulceration Diabetes Care, 34, July 2011
n = 2653 hospitals18 examiners 4 physicians, 9 podiatrists, 5 medical students>2 of 6 insensate areas signifying at risk feet
IpTT MFSensitivity 76% 81%Specificity 90% 91%
Concordance IpTT v MF Very good (k=0.85, p<0.0001)Inter observer reproducibility Good (k=0.68, p<0.001)
Results
• Prevalence of neuropathy = GP:11.4% ,DM:16.6%
• Compared to MF as “gold standard”• IpTT : 88.9% sensitivity (PPV 94%)
: 99.28% specificity (NPV 98%)• Overall accuracy 98.1%• Concordance: excellent agreement between
IpTT + monofilament (k=0.9, p<0.001)• Inter operator reproducibility N= 27 IpTT Good (K=0.51, p=0.006) MF Less good (K=0.44, p=0.01)
MANAGEMENT OF PAINFUL NEUROPATHY
• Is the pain neuropathic?• What is the dominant unpleasant
symptom?• When are the symptoms worse?• Does the patient have important fears or
beliefs about the pain?• What are patient’s expectations?
Painful diabetic peripheral neuropathy
Amitriptyline (unlicensed)
Start at 10mg, titrate to max. tolerated over 8/52
GabapentinDay 1 300mg odDay 2 300mg bdDay 3 300mg tdsMax 1800mg daily
8/52 trial
Pregabalin75mg bd
Increase to150mg bd
over 3-7 days8/52 trial
Duloxetine60mg od
Max 60mg bd8/52 trial
Discuss/refer – options capsaicin, GTN, lignocaine patches
Start tramadol meantime
CASES
Sausage toe - Osteomyelitis
HISTORY
Mrs C: Age 22Type 1 DM of 20
years° Smoker° AlcoholPT shop assistant.C/O severe pain left foot 2/12
History stubbing toe left toe 3/12 ago
HbA1c 78, Chol 5.1, Creatinine 100, CRP 10, Urate 317
Mrs C
Left foot warmer than right
Monofilament 3/6
All peripheral pulses felt
Left foot medial protrusion of inner long arch
Differential diagnosis
?
Charcot /SprainInfection: osteomyelitis: CellulitisGoutDVT
One month later
Bones in foot
Mr P
Mr A
• Type 1 diabetes (HBA1c 51 , creat 85 chol 4 ,proliferative retinopathy )
• Developed neuropathic fracture of talus and navicular + cuboid when playing squash 2010
• Treated with off loading but continued to exercise fluctuating temp difference
• 2012 : S/B orthopaedics – stop squash • 2013 : L mid foot fusion with bone grafting . 5*C difference
between feet • 2014 Recommenced cycling competitively
Mr A
Mr D
• Type 1 DM
• CKD4
• Proliferative retinopathy
• Biphasic pulses
• Foot ulcer healed R 2nd met head.
• Hot foot
CHARCOT’S JOINT/NEUROARTHROPATHY
• Relatively painless progressive arthropathy of single or multiple joints, caused by an underlying neurological deficit.
• Simultaneous presence of bone and joint destruction, fragmentation and remodelling.
DEMOGRAPHICS
• 0.1 - 5% in patients with diabetic peripheral neuropathy.
• Age 20 - 70 + years (50 - 60 > common)• History of long-standing diabetes.• Bi-lateral in about 15%.
• Joints: tarso-metatarsal 60% (mid foot) metatarsophalangeal 20%
ankle 10%
Patterns of bone and joint destruction Sanders LJ, Frykberg RG: Diabetic Neuropathic osteoarthropathy; The Charcot foot: the high risk foot in diabetes mellitus, New York 1991, Churchill Livingstone
Radiographic Staging (Eichenholtz, 1966)
• I Developmental (acute) stage
• II Coalescence (quiescent) stage
• III Consolidation (resolution) stage
Eichenholtz Classification
• Stage I - Developmental (acute)
–Hyperemia due to autonomic neuropathy weakens bone and ligaments
–Diffuse swelling, joint laxity, subluxation, frank dislocation, fine periarticular fragmentation, debris formation
Radiographs
• Stage I
Eichenholtz Classification
• Stage II - Coalescence (quiescent)–Absorption of osseous debris, fusion of
larger fragments–Dramatic sclerosis– Joints become less mobile and more stable–Aka the “hypertrophic”, or “subacute”
phase of Charcot
Radiographs
• Stage II
Eichenholtz Classification
• Stage III - Consolidation (resolution)
–Osseous remodelling – for clinical purposes, stage I is regarded as
the acute phase, while stages II and III are regarded as the chronic or quiescent phase
Radiographs
• Stage III
PATHOPHYSIOLOGY• Initiating event: trivial injury/unnoticed
repetitive minor trauma minor or periarticular or major fracture.
• Susceptible feet: peripheral neuropathy loss of protective sensation.
: >Inflammatory cytokines (TNF-α): Autonomic neuropathy >blood flow with
osteopenia.: Increased osteoclastic activity bone
resorbtion.
An algorithm depicting a basic approach to the Charcot foot
Cycle of pathophysiology of Charcot osteoarthropathy
RANKL pathway in the pathophysiology of Charcot arthropathy
The Role of RANKL in Charcot neuroarthropathy
TREATMENT
• Non-weight bearing: rest
aircast
shoes• Bisphosphonates - PAMIDRONATE• Watch other foot
• Surgery - trimming of bony exostos - arthrodesis
Maggot Therapy
FEET FIRST