The Diabetes FootDr Natasha H Patel FRCP

GSTT NHS Foundation Trust

The

Pathophysiology

Social / cultural habits

Mobility

Deformities

Vascular status

Neurological status

Skin lesions: ulcers, callus, blisters

Footwear

Compliance & understanding

Risk Factors for Ulceration

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

The “At-Risk” Foot

2 types of risk:

1. At risk for ulceration

1. At risk for limb loss

Peripheral neuropathy

Sensory

Autonomic

Motor

Risk factors for neuropathy include:

High levels of glycaemia, elevated triglycerides, high BMI, smoking & hypertension.

Risk Factors for Ulceration

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

Risk Factors for UlcerationAutonomic Neuropathy

Impairs skin integrity, sweat regulation & blood flow.

Leads to:

– thick, dry cracked skin, fissures

– callus build-up at pressure points

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

Risk Factors for Ulceration

Foot assessment-neuropahty What to check?

- 10g Monofilament (Bailey/Owen Mumford)

- Test sites

- Tell patient result!

Diagnosis of neuropathy means greatly increased chance of developing foot ulcer due to inability to sense pain

Under diagnosis of neuropathy

Impedes early identification, management & prevention of squeals .

Risk Factors for Ulceration

Elevated Pressures & Foot Deformity

Pes Planus - flat foot

Pes Cavus- high arch

Charcot Foot-(significant disruption of the bony architecture)

Lesser toe deformitiesNote also

Prayer sign - hands

Risk Factors for Ulceration

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.

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

Charcot foot - diagnosis

REFER TO FOOT CLINIC

X-ray – not as useful in early stages but gives a baseline

HbA1c, Hb, ESR & CRP

Rule out infection, DVT, etc

Gold Standard : MRI

Charcot Foot - treatment

TOTAL CONTACT PLASTER CAST – gold standard

Time in cast varies – couple of months to 18 months

Transition to Aircast, then custom footwear

Can take 3 years

Prevent by good BG control, lessen complications, education

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

Photo used with permission from Axel Rohrmann, Podiatrist.

Previous Ulceration & Amputation

• Skin texture

• Scar tissue reduced tensile strength.

• Pressure points

Risk Factors for Ulceration

The two main pulses in the feet are then checked are to ensure that there is a sufficient blood supply to the feet

• The dorsalis pedis pulse is located on the dorsum of the foot running along the lateral side of the first metatarsal

shaft at approximately the mid-point

• The posterior tibial pulse is usually located just behind the medial malleolus at the level of the ankle joint

Image source: Diabetic Foot Screening App – College of Podiatry

Foot Assessment - Vascular

Questions to ask yourself when checking the vascular status of an individual:

Are there are other signs of poor circulation (discolouration, temperature, thin atrophic shiny

skin) anywhere about the foot and toes?

Are there symptoms of cramping when walking (intermittent claudication)?

If there is evidence of chronic limb-threatening limb ischaemia or

necrosis, send your patient for an urgent vascular assessment within

the Multi-Disciplinary Foot Clinic:

Chronic limb-threatening ischaemia symptoms:

Cold foot/lower limb

Foot or leg with a bluish (cyanotic) tinge

Rest pain

Dependent redness (rubor)

Evidence of gangrene

Ischaemic ulceration

Severe Infection:

Abscess

Cellulitis

Neuropathic Feet

Neuro-Ischaemic Feet

Risk Stratification

Xxxxx DIABETES FOOT CARE PATHWAYFOR PATIENTS WITH ACTIVE FOOT DISEASE

Adapted from the D-Foot Fast-track Pathway for foot ulceration – February 2018

Active foot tissue damage

• Any foot Ulceration• Acute Charcot foot• Any foot Infection• Foot Necrosis

Refer to specialist foot team within

24hrs

A&E If acutely unwell and septicIn-put from In-patient MDfT

Xxxxx Podiatry ServiceIf house bound

Xxxxx MDfT Foot Clinic If not septic nor housebound

Xxxxx footClinic Review

within48 hrs *

Weekly f/up if +ve Infection2 weekly for non-infective Charcot foot f/up as required

Step down to xxxxIf Wound area <1cm2 plus

SINBAD score <3

In-patient Foot Team ReferralWithin 24hrs If admitted

AC

TIV

EFO

OT

DIS

EASE

Foot Care within Specialist Foot Team

• Triage of referrals within 24 hrs *

• MDfT review within 48 hrs *

• “One-stop” case reviews

• Coordinate OPAT Care

1. Xxxxx MDfT Clinic (name of hospital)

Tel: xxxxxxPlus via eRS form on EMISEmail: @nhs.net

2. A&E if septic and/or out of hours

3. Xxxxx Podiatry if patient is housebound

Tel:Referral via single point referral system

Current and active foot tissue damage

• Any foot Ulceration

• Acute Charcot foot (hot/swollen/painful foot)

• Necrosis

• Any foot Infection

• deformity/lesions

Step-up back to xxxxxxMDfT

If poor progression at 6wks f/up

Healed patients without complex

procedures

Step down to xxxxFor 3monthly FPT f/up as a High Risk Patient

Escalation to tertiary xxx MDfTPatients needing complex procedures Both in-patient and out-patient review

Re-evaluation of standard of care if

Poor progression at 6 weeks follow-up

Referral via nhs.net

* Working

days

Insert logo here

Managing Infection

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).

Antibiotic Treatment

First Line

Co-amoxiclav 625mg tds po

If penicillin allergy

Clindamycin 450mg tds PO

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.

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.

Pictures

Acute Foot Problems

Acute Foot Problems

Acute Foot Problems

Acute Foot Problems

Acute Foot Problems – possible

examples

Blisters Callus with tissue

breakdown underneath

Ingrowing toenail Accidental trauma –

stubbing toe, cuts/grazes

ANYTHING INFECTED

Awareness & intervention can prevent many problems

with the diabetic foot.

The NDFA

- National Diabetes

Foot Audit

43

2b. Results: OutcomesMajor amputations

Table 2.2: Major amputations within 6 months of first expert assessment,England and Wales, 2015-189 (rounded1)

Severe ulcers are four times

as likely to lead to major

amputation (above the ankle)

than less severe ulcers.

Notes: 1, 9. Please refer to list of

footnotes in the Footnote section.

Please see Glossary for

explanation of terms.Patient having…

All ulcers

(24,200 patients)

Less severe ulcer

SINBAD 0-2

(13,210 patients)

Severe ulcer

SINBAD 3+

(10,995 patients)

Number Per cent Number Per cent Number Per cent

One or more

major amputation

(above the ankle)

385 1.6 90 0.7 * 295 2.7 *

* = statistically significant at the 0.05 level (Less severe vs Severe). n = not statistically significant

24,200patients

assessed

385 had

major

ampu-

tationWithin 6

months

i

44

2b. Results: OutcomesMajor amputations

Table 2.2: Major amputations within 6 months of first expert assessment,England and Wales, 2015-189 (rounded1)

Severe ulcers are four times

as likely to lead to major

amputation (above the ankle)

than less severe ulcers.

Notes: 1, 9. Please refer to list of

footnotes in the Footnote section.

Please see Glossary for

explanation of terms.Patient having…

All ulcers

(24,200 patients)

Less severe ulcer

SINBAD 0-2

(13,210 patients)

Severe ulcer

SINBAD 3+

(10,995 patients)

Number Per cent Number Per cent Number Per cent

One or more

major amputation

(above the ankle)

385 1.6 90 0.7 * 295 2.7 *

* = statistically significant at the 0.05 level (Less severe vs Severe). n = not statistically significant

24,200patients

assessed

385 had

major

ampu-

tationWithin 6

months

i

2b. Results: OutcomesFoot disease-related admissions

45

Table 2.3: Foot disease-related admissions10 within 6 months of first expert

assessment: length of stay12, by ulcer severity, by network England and Wales, 2015-189 (rounded1)

Notes: 1, 9, 10, 11, 12. Please refer to list of footnotes in the Footnote section. Please see Glossary for explanation of terms.

Ulcer

severity

Number

of

patients

Number of

hospital

admissions

Number

of bed

days11

Length of stay12

Median Mean

Less severe (SINBAD 0-2) 1,540 2,205 22,255 8.0 13.7

Severe (SINBAD 3+) 3,690 6,230 71,370 10.0 16.3

All ulcers 5,230 8,435 93,625 9.0 15.6

NDFA patients had over

90,000 hospital bed days

related to foot disease

within 6 months

Three quarters of

bed days were for

patients with severeulcers

Context

NDFA case

ascertainment of

10-20 per cent

means that the total

number of bed days

across the NHS

could be 5 to 10

times that reported

in the audit.

i

Patients with

severeulcers were

almost twice

as likely to diewithin 1 year

46

2b. Results: OutcomesMortality

Table 2.4: Deaths after first expert assessment17, by ulcer severity, England and Wales, 2017-1813 (rounded1)

Mortality17

within …

Number

of ulcers

Number

of

patients

Traced15 patients Deceased patients

Number Per cent Number Per cent

12 weeks 15,370 14,120 14,070 99.6 505 3.6

24 weeks 14,615 13,475 13,430 99.7 875 6.5

1 year 5,355 5,165 5,150 99.7 525 10.2

Mortality17

within …

Traced

patients14,15

Less severe

SINBAD 0-2

Deceased patientsTraced

patients14,15

Severe

SINBAD 3+

Deceased patients

Number Per cent Number Per cent

12 weeks 8,015 210 2.6 6,475 300 4.6

24 weeks 7,635 360 4.7 6,165 525 8.5

1 year 2,860 205 7.2 2,345 325 13.9

Notes: 1, 13, 14, 15, 17. Please refer to list of footnotes in the Footnote section. Please see Glossary for explanation of terms.

1 in 10

patients diewithin 1 year

of expert

assessment

i

2b. Results: Outcomes Commentary

RecommendationsTo minimise the severity of diabetic foot ulcers at first

expert assessment:

Patients with poor circulation (peripheral artery

disease or ischaemia) or loss of feeling (neuropathy)

should seek advice from their GP or usual diabetes

carer about how to prevent foot ulcers.

Patients with new foot ulcers should seek quick

referral from a healthcare professional to a local

specialist diabetes foot care service.

Providers should ensure that people with diabetic foot

ulcers are referred promptly for early specialist

assessment, in line with NICE guidance.

Commissioners should ensure that NICE-

recommended structures of care are in place.47NDFA team

The audit has consistently found

that ulcer severity is strongly

associated with worse patient

outcomes, including:

• Lower healing rates.

• More/longer hospital admissions.

• Higher major amputation rates

(above the ankle).

• Higher mortality rates.

The NDFA survival curves show that

1 in 7 people with severe ulcers die

within one year of assessment,

rising to almost 1 in 4 for those with

ischaemia.

i

Reducing

cardiovascular

mortality

Smoking – NDFA data – risk factor for non

healing ulcers, amputations and death

Statins – Atorvastatin 40mg/80mgWhen statin use of any dose was examined in a meta analysis of 18 RCTs in

the past 11 years, statin therapy increased the odds of adverse events

compared with placebo by 39% (P ¼ .008) but also reduced the risk of

cardiovascular events by 26% (P < .001).29 A meta-analysis of four RCTs

conducted in 2007 by the same authors examined intensive-dose therapy vs

moderate-dose therapy and found that intensive-dose therapy was associated

with a significant reduction in cardiovascular death.

(http://dx.doi.org/10.1016/j.jvs.2016.08.094)

Anti-coagulation (next slide)

Glycaemic Control

The COMPASS study of people at high risk of ischaemic

events showed that:3

For patients with CAD, the combined primary endpoint

of ischaemic stroke, myocardial infarction, death from

CV disease was reduced by 1.4% in patients taking

rivaroxaban and aspirin compared to aspirin alone.

For patients with PAD, acute limb ischaemia as a

composite of secondary outcomes- ischaemic stroke,

myocardial infarction or CV death reduced by 1.4%

compared to aspirin alone.

However, the combination increased the risk of

bleeding compared to aspirin monotherapy: 1.2%

increased risk of major bleeding, 0.8% increase in

gastro-intestinal (GI) bleeding, but 0.1% increased risk of

fatal bleeding/symptomatic intra-cerebral haemorrhage

(ICH) and 0.3% increased risk of fatal bleeding/

symptomatic bleeding into a critical organ.

Symptomatic confirmed peripheral

artery disease (PAD)2 eg. claudication,

atypical leg pain, tissue loss, gangrene,

ulcerated legs/feet

Dosing: The recommended dose is

2.5mg twice daily with food. It must be

co-administered with aspirin 75mg daily.4,5

In South London, rivaroxaban plus

aspirin is recommended, within its

marketing authorisation and unless contra-

indicated, as an option for preventing

atherothrombotic events in adults with

symptomatic peripheral artery disease

(PAD) or a confirmed diagnosis of

coronary artery disease (CAD), who are

at high risk of ischaemic events.1