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diabetes.ca | 1-800-BANTING (226-8464)
WHAT’S THE LATEST IN DIABETES & FOOT CARE?
Axel RohrmannPodiatrist
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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.
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• 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
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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.
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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)
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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.
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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?
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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
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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 includeHigh levels of glycaemia, elevated triglycerides, high BMsmoking & 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
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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
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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
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Under diagnosis of neuropathy
• Fundamental problem in primary care.• Impedes early identification,
management & prevention of squeals .
Risk Factors for Ulceration
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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
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• 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.
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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
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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
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Photo used with permission from Axel Rohrmann, Podiatrist.
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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.
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Photo used with permission from Dr. Axel Rohrmann, Podiatrist.
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Previous Ulceration & Amputation• Skin texture • Scar tissue reduced tensile strength. • Pressure points
Risk Factors for Ulceration
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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.
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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
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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
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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.
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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.
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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).
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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.
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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)
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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
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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.
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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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diabetes.ca | 1-800-BANTING (226-8464)
You Can Make a Difference
Awareness & intervention can prevent many problems
with the diabetic foot.
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New website
diabetes.ca
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diabetes.ca | 1-800-BANTING (226-8464)
Thank you!
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References