WHAT’S THE LATEST IN
DIABETES & FOOT CARE?
Axel Rohrmann
Podiatrist
diabetes.ca | 1-800-BANTING (226-8464)
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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INTRODUCTION
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Diabetes is a serious chronic disease.
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20% of diabetic hospitalizations are foot related.
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prevalence estimated at 246 million globally in 2007.
4th leading cause of death in most developed countries.
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.
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In developed countries 1 in 6 diabetics will have an ulcer
Limb Loss Prognosis with Diabetes
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2% of all persons with diabetes will need an
amputation.
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5496 amputations last year!
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50% of amputees will lose the other limb in 3
to 5 years.
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Up to 50% mortality five years after first
amputation.
The situation can be changed
 Possible to reduce amputation rates between
49% & 85%.
 Care strategy:
 Prevention
 Multi-disciplinary treatment
 Appropriate organization of care
 Close monitoring
 Education (people with diabetes & health care
professionals)
Diabetes is a biochemical disease
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“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.)
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Diabetics may have altered biomechanics; or
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Present with a complication of any pre-existing
neurovascular or biomechanical dysfunction.
Risk Factors for Ulceration
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Social / cultural habits
Mobility
Deformities
Vascular status
Neurological status
Skin lesions: ulcers, callus, blisters
Footwear
Compliance & understanding
Risk Identification & Categories
Will risk identification & categorization reduce the
number of:
Primary ulcerations?
Re-ulcerations?
Amputations?
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Foot Ulceration
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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
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At risk for limb loss
Risk Factors for Ulceration
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Peripheral neuropathy
– Sensory
– Autonomic
– Motor
Risk factors for neuropathy include
High levels of glycaemia, elevated triglycerides, high BM
smoking & hypertension.
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Risk Factors for Ulceration
Sensory Neuropathy
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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.
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Risk Factors for Ulceration
Autonomic Neuropathy
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Impairs skin integrity, sweat regulation
& blood flow.
Leads to:
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thick, dry cracked skin, fissures
callus build-up at pressure points
Risk Factors for Ulceration
Motor Neuropathy
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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
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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
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Prayer sign - hands
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Occur in presence of: peripheral sensory
neuropathy, autonomic neuropathy and trauma.
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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
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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:
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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
Risk Factors for Ulceration
Calluses
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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%
Photo used with permission from Axel Rohrmann, Podiatrist.
Risk Factors for Ulceration
Limited Joint Mobility
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Hallux rigidus
Hallux limitus
Hammer toes
Claw toes
Limited joint mobility can cause increased
ground reaction forces under weight-bearing
joints. This can lead to ulceration.
Photo used with permission from Dr. Axel Rohrmann, Podiatrist.
Risk Factors for Ulceration
Previous Ulceration & Amputation
Skin texture
• Scar tissue reduced tensile strength.
• Pressure points
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NEUROVASCULAR ASSESSMENT
Type 1 – 5 years post diagnosis.
Type 2 - When diagnosed & annually
or as indicated by risk category.
diabetes.ca | 1-800-BANTING (226-8464)
What to look for & assess!
Dermatological:
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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:
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10g Monofilaments
Reflexes
Vibration perception
Proprioception
Biomechanical:
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Gait
Joint mobility
Anomalies & limitations
Amputations
Foot wear
Hosiery
DIABETIC FOOT ULCERS
Diagnose the aetiology!!!!
– neurovascular, biomechanical, trauma
diabetes.ca | 1-800-BANTING (226-8464)
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 classification
This straightforward system grades wounds first with numbers 0
to 3 referring to depth:
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0
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3
(pre- or post-ulcer with epithelialization),
(superficial and not involving tendon, bone or capsule),
(ulcer penetrates through to tendon or capsule), and
(penetrating to bone or joint).
A second classification tier, A to D, refers to other burdens on
the wound.
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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
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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
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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
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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.
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Follow up prevention
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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!
You Can Make a Difference
Awareness & intervention
can prevent many problems
with the diabetic foot.
diabetes.ca | 1-800-BANTING (226-8464)
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Thank you!
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References