Prevention of Amputation Carolyn Wareham Podiatry Diabetes Specialist Practitioner

1-4% of people with diabetes will develop an ulcer per year (Leese at al, 2011; TRIEPodD-UK, 2012). Approximately 58% of DFU patients will become clinically infected. (Eurodiale study group 3) The number of diabetes-related amputations in England has now reached an all-time high of 20 a day (Diabetes UK 2016) 1-4% of people with diabetes will develop an ulcer per year Leese et al According to a study published by the Eurodiale study group 3, approximately 58% of DFU patients will become clinically infected. Amputation rate is on the rise: Public Health England data suggests there are about 7,370 amputations a year, compared to the previous figure of 7,042, according to Diabetes UK. So to begin these are some of the latest statistics which do not give a very optimistic outlook for our patients with Diabetes.

Individuals with diabetic foot ulcers have a 50% chance of mortality in 5 years (Young 2012) Early diagnosis and early intervention by an MDT approach can achieve good outcomes (Edmonds2009) Studies have shown that individuals with diabetic foot ulcers have a 50% chance of mortality in 5 years ( Young 2012) However research has shown that with early diagnosis and intervention within a multidisciplinary team can achieve good outcomes but it’s a huge challenge for us as health professionals. I am now going to present 2 case studies which demonstrate successful MDT working

Case Study One Red Hot swollen Foot Anyone have a guess at the diagnosis? Yes it is a Charcot of the left midfoot. Charcot is a chronic and progressive condition affecting the bones and joints of the feet, it is seen in patients with Diabetes and severe neuropathy. The pathogenesis is still not fully understood but the main predisposing factor is neuropathy which can be subdivided into sensory, motor and autonomic neuropathy which all have a part to play in the development of Charcot neuroarthropathy. Autonomic neuropathy results in increase blood flow to the foot with increased bone resorption, osteopenia and increases the likelihood of fracture. Sensory neuropathy results in loss of feeling in the foot so the person will be unaware of any trauma to the foot, such as a fracture and will continue to walk on the affected foot resulting in repeated micro trauma and further damage to the foot. Motor neuropathy leads to deformity resulting in the typical neuropathic foot. High medial longitudinal arch, clawed toes with prominent metatarsal heads. This results in altered pressures on certain parts of the foot again increasing the risk of damage. Reported in an article in the Diabetic foot and ankle in 2013 the prevalence of Charcot may be as much as 13% of patients with diabetes. This can be a devastating condition and unless diagnosed early enough can lead to defomrity, ulceration, infection and ultimately amputation. This is why it is important that with any red hot swollen foot to consider Charcot until proven otherwise. Charcot is often misdiagnosed for other conditions such as infection, peripheral vascular disease and gout. There are several stages to the process of CAN. The acute stage when the foot may be red hot and swollen but no radiological evidence to suggest a CHARCOT. It is at this stage that we want to see the patient. If we consider it’s a charcot and x ray does not confimr this then we would refer the pt for an MRI. The following stage include localised osteopenia, bony fragmentation, and destruction, followed by subluxation and dislocation and joint collapse. And the foot can become deformed very quickly. The final stage us when the destructive stage slows down and the bones and joints start to heal with bony fusion and new bone formation. The result is a stable but often deformed foot. this can take any time form a year to 18 months to Treatment is to offload the affected foot either in an Aircast or a total contact cast until the foot stabilises, This patient was treated in a TCC with limted weight bearing for ??? And then an aircast. The foot was stable in ???? Unfortunately with patients A. he had established deformity which resulted in reccuring ulceration on the plantar aspect of the foot. Mr N was treated as part of the mDT and was seen by Podiatry, Diabetes Consultant, Orthotic department and Orthoapedics..

Case Study One Learning Points Any red hot swollen foot to consider Charcot until proven otherwise. Urgent referral to MDT. Early diagnosis helps prevent deformity. A diagnosis of Charcot is a life changing event for the patient. R This was carried out on 26th July 2016. This photo was taken a week ago. The wound is healing well with healthy granulation tissue. Once this has healed Mr A can go back into surgical footwear and hopefully the foot will not ulcerate again.

Case Study 2 Complex Foot Ulceration

Case Study 2

Learning Points Early referral to podiatry and the MDT is essential. Good MDT working prevents major amputation. Patients with a history of a foot ulcer have a 50% risk of re-ulceration. People with diabetes have a 50% risk of reulceration within 1 year ( Maciejewski et al 2004)

Diabetic Foot Community clinics Clinics MDT Foot clinics Diabetic Foot Community clinics Clinics All of our 25 clinics across Hertfordshire see patients with Diabetes at both increased and high risk Many of these patients will have an ulcer. In the year 2013/2014 there were approximately 2500 patients with Diabetic foot ulcers seen by Podiatry. Our guidelines suggest that if the ulcer is not improving in 6 weeks or is deteriorating the patient can be referred into the Diabetic foot care clinics. These clinics are led by Podiatrists who work within the MDT with a specialist interest in Diabetes. These patients may alternate/rotate have their care jointly between the MDT and DFCC. 5 MDT clinics WGH- 6 appt slots HHGH - 10 appt slots Lister - 16 appt slots QE2 - 10 appt slots HCH - 2 appt slots MDT capacity is currently limited West Hertfordshire 16 appointments per week East Hertfordshire 28 appointments per week When people with a foot attack get rapid access for treatment by a specialist multi-disciplinary team this has been shown to promote faster healing and fewer amputations, saving money and lives.

The Multidisciplinary Diabetes Team Diabetologist Paediatric Consultant Practice Nurse Diabetes Specialist Nurse District Nurse The Patient G.P. Dieticians Tissue Viability Nurses Orthotist We are all part of that multidisciplinary team and each have a role for the care of these complex patients Podiatrists Orthopaedic Surgeon Pharmacist Radiologist Microbiologist Vascular Surgeon

Increased Diabetic Feet Your feet have been assessed as being at increased risk of developing diabetic foot complications. Podiatry Head Office: 01582 711544 (Mon – Fri 08.30 – 16.30) Diabetic Foot Emergencies: New pain or throbbing Foot hotter than usual New redness or swelling New / increased discharge or smell Unexplained increase in blood glucose Flu like symptoms (hot / shivery)   If you notice any of the above, contact your GP straight away. Explain that you have a diabetic emergency. Outside of normal hours, call the Out of Hours GP or go to A&E.

Urgent referrals to NHS Podiatry Ulceration +/- infection Red Hot Foot Fax to HCT Podiatry Have we answered your burning questions Evaluation Tel 01582 711544 Fax 01582 765537 www.hct.nhs.uk/our-services/podiatry-service/

Non urgent referrals to NHS Podiatry On going specialist foot care Callus and corns in people at risk Nail care for those at risk Tel 01582 711544 Fax 01582 765537 www.hct.nhs.uk/our-services/podiatry-service/ The NHS provides a comprehensive service for those who’s feet are at risk. Don’t attempt to treat corns and callus with blades or medicated corn plaster If people require on going podiatry care – nails hard skin corns or if Complete application form from HCT website and send to podiatry

Charcots foot Condition affecting the bones, joints and soft tissue in the foot and ankle Occurs in patients with diabetic neuropathy Acute localised inflammation initially which leads to varying degrees and patterns of bone destruction, subluxation, dislocation and deformity Despite neuropathy a lot of patients report of pain

Typical early clinical features are swollen, erythematous and warm foot Early in the course often misdiagnosed as cellulitis, DVT or gout Usually (but not always) peripheral circulation is preserved with patients having bounding pulses Most common deformity is the rocker-bottom foot deformity

Investigations Imaging – Foot X-ray should be the first imaging modality Can show early changes but could be entirely normal despite clinical features of Charcots Later on MRI foot or a nuclear medicine bone scan quite helpful to aid the diagnosis, MRI preferable in particular if there is an ulcer.

Treatment Offloading in a total contact cast is the mainstay of treatment Alternative is aircast boot Offloading continued till temperature difference between feet is less than 2 degrees Little evidence to support use of pharmacological therapies and we don’t use it Surgical management – in a small subset of patients

An algorithm depicting the basic approach to the Charcot foot An algorithm depicting the basic approach to the Charcot foot. *Osteomyelitis can be difficult to distinguish from the Charcot foot.