PREVENTION OF DIABETIC FOOT COMPLICATIONS

Dr. Shahzad Alam Shah

MBBS;FCPS
Assistant Professor of Laparoscopic Surgery Fatima Jinnah Medical College/ Sir Ganga Ram Hospital Lahore

Diabetic Foot ?

Diabetic Foot Presentatations

Callus Formation Pre-ulceration Ulceration Ischemia Infection Gangrene Deformities

FOOT ULCERS IN DIABETES

Precipitate 85% of amputations: Rule of 15 15% of diabetes patients Foot ulcer in lifetime 15% of foot ulcers
15% of foot ulcers

Osteomyelitis
Amputation

Clinical Care of the Diabetic Foot, 2005

AMPUTATIONS IN DIABETES
Tragic: Rule of 50
50% of amputations transfemoral/transtibial level

50% of patients
50% of patients

2nd amputation in 5y
Die in 5y
Clinical Care of the Diabetic Foot, 2005

PATHOGENESIS OF DIABETIC FOOT ULCER AND AMPUTATION

Sensory Joint Neuropathy Mobility Protective sensation Foot pressure Minor trauma recognition Motor Neuropathy Autonomic Neuropathy Sweating 2 dry skin Fissure PAD

Muscle atrophy and 2 foot deformities Foot pressure esp. over bony prominences

Ischemia

Healing

Callus

Pre-ulcer ULCER Minor Trauma: Mechanical Chemical Thermal

Infection AMPUTATION Interdigital Maceration (Moisture, Fungus)

OTHER RISKS FOR DIABETIC FOOT ULCER/AMPUTATION

Failure to adequately care for the feet:
Inadequate patient education Inadequate patient motivation
Depression, anxiety, anger more common in diabetes

Physical disability
Cannot see feet 2 to retinopathy Cannot reach feet 2 to obesity, age (?50% of patients)

Limited access to podiatry services

CAUSAL PATHWAYS FOR FOOT ULCERS

NEUROPATHY DEFORMITY MINOR TRAUMA - Mechanical (shoes) - Thermal - Chemical ULCER Diabetes Care 1999; 22:157

% Causal Pathways Neuropathy: 78% Minor trauma: 79% Deformity: 63% Behavioral issues ? POOR SELFFOOT CARE

DETECTING FEET-AT-RISK
History:
Prior amputation Prior foot ulcer PAD: known or claudication at < 1 block

Exam:
Major foot deformities PAD
Absent DP and PT pulses Prolonged venous filling time Reduced Ankle-Brachial Index (ABI)

Pre-ulcerative cutaneous pathology

Arch Intern Med 1998; 158:157

PHYSICAL EXAMINATION OF THE FEET IN PERSONS WITH DIABETES

SENSORY NEUROPATHY IN DIABETES

Loss of protective sensation in feet
Sensory loss sufficient to allow painless skin injury

Major risk factor for foot ulcer in diabetes Detect with 5.07/10g Semmes-Weinstein monofilament
Prevalence of insensate feet to 10g monofilament:
Age > 40y: 30% of diabetic patients Age > 60y: 50% of diabetic patients

Up to 50% have no neuropathic symptoms

Diabetes Care 2006; 29(Suppl 1):S24 Diabetes Care 2004; 27:1591

PAD IN DIABETES
Prevalence (ABI < 0.9): 20-30%
10-20% in type 2 diabetes at Dx 30% in diabetics age 50y 40-60% in diabetics with foot ulcer

Complications:
Claudication and functional disability Increases risk for concurrent CAD and CVD Delays ulcer healing
Increases amputation risk Not increase foot ulcer risk

EXAM TO DETECT PAD IN DIABETES

Venous filling time
Technique:
Sitting: ID pedal vein bulging above skin Supine: Elevate leg to 45 for 1 min Sitting: time to pedal vein bulging above skin

EXAM TO DETECT PAD IN DIABETES

Ankle Brachial Index

INTERPRETATION OF THE ABI

ABI 0.91-1.30 0.71-0.90 0.41-0.70 0.40 >1.30

Normal Mild obstruction *Moderate obstruction *Severe obstruction **Poorly compressible 2 to medial Ca++

*Poor ulcer healing with ABI 0.50 **Further vascular evaluation needed

MOTOR NEUROPATHY AND FOOT DEFORMITIES

Hammer toes
Claw toes Prominent metatarsal heads Hallux valgus Collapsed plantar arch

Hammer Toes

Claw Toes

From Levin and Pfeifer, The Uncomplicated Guide to Diabetes Complications, 2002

Hallux Valgus

From Levin and Pfeifer, The Uncomplicated Guide to Diabetes Complications, 2002

From Boulton, et al Diabetic Medicine 1998, 15:508

PRE-ULCER CUTANEOUS PATHOLOGY

Neuropathy inappropriate footwear:
Persistent erythema after shoe removal Callus Callus with subcutaneous hemorrhage: pre-ulcer

Autonomic neuropathy and secondary dry skin:

Fissure ulceration Augment callus formation

Poor self-care of the feet:

Interdigital maceration with fungal infection Nail pathology

RISK-STRATIFIED FOOTCARE MANAGEMENT FOR DIABETES PATIENTS

HIGH RISK: CATEGORY 1-3 PATIENTS

Annual comprehensive foot exam

Inspect feet at every visit

Podiatry care Intensive patient education

Detect/manage barriers to foot care

Therapeutic footwear, if needed

BASIC FOOT CARE CONCEPTS

Daily foot inspection
May require mirror, magnification, or caregiver Educate patient to recognize/report ASAP:
Persistent erythema Enlarging callus Pre-ulcer (callus with hemorrhage)

BASIC FOOT CARE CONCEPTS

Commitment to self-care:
Wash/dry daily
Avoid hot water; dry thoroughly between toes

Lubricate daily (not between toes) Debride callus/corn to reduce plantar pressure 25%
Avoid sharp instruments, corn plasters

No self-cutting of nails if:

Neuropathy, PAD, poor vision

BASIC FOOT CARE CONCEPTS

Protective behaviors:
Avoid temperature extremes No walking barefoot/stocking-footed Appropriate exercise if sensory neuropathy
Bicycle/swim > walking/treadmill

Inspect shoes for foreign objects Optimal footwear at all times

THERAPEUTIC FOOTWEAR: GOALS

Inappropriate footwear:
Contributes to 21-76% of ulcers/amputations

Optimal footwear should:

Protect feet from external injury Reduce plantar pressure, shock and shear forces Accommodate, stabilize, support deformities Suitable for occupation, home, leisure
Diab Metab Res Rev 2004; 20(Suppl1):S51

Diabetes Care 2004; 27:1832

Dr. Shahzad Alam Shah

MBBS;FCPS
Assistant Professor of Laparoscopic Surgery Fatima Jinnah Medical College/ Sir Ganga Ram Hospital Lahore