1. diabetes.ca | 1-800-BANTING (226-8464) WHAT’S THE LATEST IN DIABETES & FOOT CARE? Axel Rohrmann Podiatrist

2. The time to act is NOW! 1 2 3

3. 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.

4. Diabetes is a serious chronic disease. – prevalence estimated at 246 million globally in 2007. – 4 th 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

5. 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.

6. 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)

7. 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.

8.  Social / cultural habits  Mobility  Deformities  Vascular status  Neurological status  Skin lesions: ulcers, callus, blisters  Footwear  Compliance & understanding Risk Factors for Ulceration

9. 9 Risk Identification & Categories Will risk identification & categorization reduce the number of:  Primary ulcerations?  Re-ulcerations?  Amputations? YES!

10. 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

11. The “At-Risk” Foot 2 types of risk: 1. At risk for ulceration 1. At risk for limb loss

13. 13 Peripheral neuropathy – Sensory – Autonomic – Motor Risk factors for neuropathy include: High levels of glycaemia, elevated triglycerides, high BMI, smoking & hypertension. Risk Factors for Ulceration

14. 14 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

15. 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

16. 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

17. Under diagnosis of neuropathy Fundamental problem in primary care. Impedes early identification, management & prevention of squeals. Risk Factors for Ulceration

18. 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

19. 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.

20. 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

22. 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

23. Photo used with permission from Axel Rohrmann, Podiatrist.

24. Risk Factors for Ulceration Limited Joint Mobility – 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.

25. Photo used with permission from Dr. Axel Rohrmann, Podiatrist.

26. Previous Ulceration & Amputation Skin texture Scar tissue reduced tensile strength. Pressure points Risk Factors for Ulceration

27. 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.

28. 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

29. What to look for & assess! Neurological: – 10g Monofilaments – Reflexes – Vibration perception – Proprioception Biomechanical: – Gait – Joint mobility – Anomalies & limitations – Amputations – Foot wear – Hosiery

30. diabetes.ca | 1-800-BANTING (226-8464) DIABETIC FOOT ULCERS Diagnose the aetiology!!!! – neurovascular, biomechanical, trauma

31. 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.

32. University of Texas wound classification This 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.

33. 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).

34. 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.

35. 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)

36. 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

37. 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.

38. 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!

39. diabetes.ca | 1-800-BANTING (226-8464) You Can Make a Difference Awareness & intervention can prevent many problems with the diabetic foot.

40. New website diabetes.ca

41. diabetes.ca | 1-800-BANTING (226-8464) Thank you!

42. References