The diabetic foot
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  • NHS spending on ulceration and amputation in diabetes is substantial. In 2010-11 we estimate that the NHS spent between £639 million and £662 million on diabetic foot care. Almost half of this money was spent in primary, community and outpatient care. Much of this care was not pro-actively commissioned for the diabetic foot, or recognised by commissioners as relating to diabetic foot problems.
  • A reminder why it is so importantPoint 1: There is an 80% likelihood of people dying within five years of having foot ulcers or amputationsThe risk is more than people who have colon, prostate and breast cancerNUMBERS: In England there are approx 6,000 amputations a year and in Scotland 450 a year.UK wide - 120 amputations a week during 2010Stark contrast: Troops in Afghanistan suffered 76 in the whole of 2010 (Source: Defence Analytical Services & Advice) Point 2: Cost to the NHS In England it is estimated that between £600m - £700m is spent each year on foot ulcers and amputations. £60m – £70m spent annual on foot ulcers and amputations in Scotland. This is an expensive and serious problem.

The diabetic foot Presentation Transcript

  • 1. The diabetic foot Mollie Donohoe and Zoe Boulton 07 Feb 2014 • Current situation - amputations • Cases • Assessment of diabetic foot • The role of the podiatrist
  • 2. Evolution and the diabetic foot Increasing numbers Fashion victims
  • 3. Why need to improve diabetic foot care • Diabetic foot disease accounts for more hospital bed days than all other diabetes complications. • 100 people a week lose a lower limb because of diabetes in the UK. • 1 in 20 people with diabetes will develop a foot ulcer in one year. • 80% of people die within 5 years after amputation.
  • 4. NHS Atlas of Variation Amputation in Type 2 Diabetes Percentage of people in the National Diabetes Audit (NDA) having major lower limb amputations five years prior to the end of the audit period by PCT 1 January 2009 to 31 March 2010
  • 5. NHS Expenditure – Ulceration and Amputation in Diabetes Amputation £119m. £125m. Inpatient Care Ulceration £213m. Primary, Comm unity, Outpatie nt Care and A & E £307m. £324m. • In 2010-11 the NHS spent an estimated £639 million to £662 million a year on diabetic foot care • Equivalent to £1 in in every £150 of total NHS spending
  • 6. Why it is so important? • 80% of people die within five years of having foot ulcers or amputations 80% 49% 20% Amputation / Foot Ulcer Colon Cancer Prostate Cancer • Cost to the NHS 17% Breast Cancer
  • 7. But … ... up to 80 per cent of amputations are potentially preventable
  • 8. Targets - NICE Structured education at time of diagnosis and on ongoing basis (A) (A) Directly based on evidence from metanalysis of RCTs/at least one RCT
  • 9. Impact of foot ulcers on quality of life Health related quality of life (SF-6D) scores for people with diabetic foot ulcers and other long-term conditions, and for healthy people aged 75+ (Source: Jeffcoate et al. (2009), Brazier et al. (2004), Davison et al.(2009)) •Diabetic foot ulcer QOL rated lower than osteoarthritis, COPD, dialysis •SF-6D or EQ-5D are building blocks for QALY estimation
  • 10. Old PCT boundaries Devon PCT Torbay PCT Plymouth PCT
  • 11. PCT major amputation rates – YHPHO 2012 1.6 1.3 1.8 1.0 England 1.0
  • 12. New CCG boundaries (also reflect catchment areas) NEW Devon CCG northern locality NEW Devon CCG eastern locality NEW = North East West NEW Devon CCG western locality South Devon and Torbay CCG
  • 13. NEW CCG amputation rates YHPHO 2012 1.6 England 0.9
  • 14. Calculating rates per catchment area CCGs are the “externally visible” unit of healthcare •YHPHO has calculated amputation rates by CCG •NEW Devon CCG includes catchment areas of 3 hospitals Shane Coe obtained the required data •Information analyst for NHS Devon •Used YHPHO methodology •Calculated amputation rates by CCG and locality
  • 15. New CCG boundaries (also reflect catchment areas) 1.3 1.4 2.0 1.2 Thanks to Shane Coe – NEW Devon CCG 1.2 England 0.9
  • 16. Devon is an outlier…
  • 17. …because it’s the biggest
  • 18. Confounding factors? Ethnicity •White – risk = 1.0 •S Asian – risk = 0.25 •Black – risk = 0.62 Age •2% increase per year
  • 19. We are 20 years ahead of the country (Sidmouth 2075)
  • 20. Confounding factors? Amputation rates in diabetic and nondiabetic patients correlate strongly – r=0.43, p=0.0005 Holman, Diabetologia 2012; 55: 1919.
  • 21. The South Western Region White 94.1% Legacy effect 50% older migrants Older population 25% >65 Rural occupation longer survival •High rate of diabetic foot disease in South West
  • 22. Interpret all data with caution Atlas of Variation is not a scientific document •Some implausible data •Inadequate adjustment for confounders •Health service “units” are not helpful •Successfully achieved headlines There is lots of room to improve, and we need to •Pan-Devon problem – perhaps pan-SW •Improvements need to cross primary and secondary care
  • 23. RCA of Major Amputations in Diabetic Patients Jan 2012-13 • 16 patients - 22 amputations • 6 patients had 2 amputations same leg • 3 patients out of area – 2 Somerset with ESRF – 1 Torbay (patient choice) • 5 patients under renal physicians: 4 on dialysis • 2 patients diagnosed with diabetes when admitted
  • 24. Problems identified so far • Only 50% of patients known to Diabetic foot clinic • 5/16 (31%) solely under vascular as inpatient (no involvement from diabetes team) • 4/16 (25%) of amputees had ESRF • 5/13 (38%) not referred to podiatry post amputation • 2/16 (12%) frequent DNA
  • 25. Problems identified so far • 5/8 (62%) documented given education in foot clinic. • 2/16 (13%) had previous care in another area – no record of prior podiatric care. • 1/16 (6%) critical event was ulcer which developed when patient previous inpatient. • 16/16 (100%) had no inpatient podiatric care
  • 26. Inpatient foot care
  • 27. The Touch Test
  • 28. The Touch Test • Up to 15% of inpatients have diabetes mellitus at any one time (1) • 33% had feet examined (14% RD&E). • Robust screening method – – – – • Accurate Simple Acceptable Cost effective Touch test performs consistently and favourably compared with Monofilament. (1) National Diabetes Inpatient Survey 2009
  • 29. Testing for neuropathy • The Ipswich Touch Test (IpTT) A simple and novel method to identify inpatients with diabetes at risk of foot ulceration Diabetes Care, 34, July 2011 n = 265 3 hospitals 18 examiners 4 physicians, 9 podiatrists, 5 medical students >2 of 6 insensate areas signifying at risk feet Sensitivity Specificity IpTT MF 76% 81% 90% 91% Concordance IpTT v MF Very good (k=0.85, p<0.0001) Inter observer reproducibility Good (k=0.68, p<0.001)
  • 30. Results • Prevalence of neuropathy = GP:11.4% ,DM:16.6% • Compared to MF as “gold standard” • IpTT : 88.9% sensitivity (PPV 94%) : 99.28% specificity (NPV 98%) • Overall accuracy 98.1% • Concordance: excellent agreement between IpTT + monofilament (k=0.9, p<0.001) • Inter operator reproducibility N= 27 IpTT Good (K=0.51, p=0.006) MF Less good (K=0.44, p=0.01)
  • 31. MANAGEMENT OF PAINFUL NEUROPATHY • Is the pain neuropathic? • What is the dominant unpleasant symptom? • When are the symptoms worse? • Does the patient have important fears or beliefs about the pain? • What are patient’s expectations?
  • 32. Painful diabetic peripheral neuropathy Amitriptyline (unlicensed) Start at 10mg, titrate to max. tolerated over 8/52 Gabapentin Day 1 300mg od Day 2 300mg bd Day 3 300mg tds Max 1800mg daily 8/52 trial Pregabalin 75mg bd Increase to 150mg bd over 3-7 days 8/52 trial Duloxetine 60mg od Max 60mg bd 8/52 trial Discuss/refer – options capsaicin, GTN, lignocaine patches Start tramadol meantime
  • 33. CASES
  • 34. Sausage toe - Osteomyelitis
  • 35. HISTORY Mrs C: Age 22 Type 1 DM of 20 years ° Smoker ° Alcohol PT shop assistant. C/O severe pain left foot  2/12 History stubbing toe left toe 3/12 ago HbA1c 78, Chol 5.1, Creatinine 100, CRP 10, Urate 317
  • 36. Mrs C Left foot warmer than right Monofilament 3/6 All peripheral pulses felt Left foot medial protrusion of inner long arch
  • 37. Differential diagnosis ? Charcot /Sprain Infection: osteomyelitis: Cellulitis Gout DVT
  • 38. One month later
  • 39. Bones in foot
  • 40. Mr P
  • 41. Mr A • Type 1 diabetes (HBA1c 51 , creat 85 chol 4 ,proliferative retinopathy ) • Developed neuropathic fracture of talus and navicular + cuboid when playing squash 2010 • Treated with off loading but continued to exercise fluctuating temp difference • 2012 : S/B orthopaedics – stop squash • 2013 : L mid foot fusion with bone grafting . 5*C difference between feet • 2014 Recommenced cycling competitively
  • 42. Mr A
  • 43. Mr D • Type 1 DM • CKD4 • Proliferative retinopathy • Biphasic pulses • Foot ulcer healed R 2nd met head. • Hot foot
  • 44. CHARCOT’S JOINT/NEUROARTHROPATHY • Relatively painless progressive arthropathy of single or multiple joints, caused by an underlying neurological deficit. • Simultaneous presence of bone and joint destruction, fragmentation and remodelling.
  • 45. DEMOGRAPHICS • 0.1 - 5% in patients with diabetic peripheral neuropathy. • Age 20 - 70 + years (50 - 60 > common) • History of long-standing diabetes. • Bi-lateral in about 15%. • Joints: tarso-metatarsal 60% (mid foot) metatarsophalangeal 20% ankle 10%
  • 46. Patterns of bone and joint destruction Sanders LJ, Frykberg RG: Diabetic Neuropathic osteoarthropathy; The Charcot foot: the high risk foot in diabetes mellitus, New York 1991, Churchill Livingstone
  • 47. Radiographic Staging (Eichenholtz, 1966) • I Developmental (acute) stage • II Coalescence (quiescent) stage • III Consolidation (resolution) stage
  • 48. Eichenholtz Classification • Stage I - Developmental (acute) – Hyperemia due to autonomic neuropathy weakens bone and ligaments – Diffuse swelling, joint laxity, subluxation, frank dislocation, fine periarticular fragmentation, debris formation
  • 49. Radiographs • Stage I
  • 50. Eichenholtz Classification • Stage II - Coalescence (quiescent) – Absorption of osseous debris, fusion of larger fragments – Dramatic sclerosis – Joints become less mobile and more stable – Aka the “hypertrophic”, or “subacute” phase of Charcot
  • 51. Radiographs • Stage II
  • 52. Eichenholtz Classification • Stage III - Consolidation (resolution) – Osseous remodelling – for clinical purposes, stage I is regarded as the acute phase, while stages II and III are regarded as the chronic or quiescent phase
  • 53. Radiographs • Stage III
  • 54. PATHOPHYSIOLOGY • Initiating event: trivial injury/unnoticed repetitive minor trauma minor or periarticular or major fracture. • Susceptible feet: peripheral neuropathy loss of protective sensation. : >Inflammatory cytokines (TNF-α) : Autonomic neuropathy >blood flow with osteopenia. : Increased osteoclastic activity bone resorbtion.
  • 55. An algorithm depicting a basic approach to the Charcot foot
  • 56. Cycle of pathophysiology of Charcot osteoarthropathy
  • 57. RANKL pathway in the pathophysiology of Charcot arthropathy
  • 58. The Role of RANKL in Charcot neuroarthropathy
  • 59. TREATMENT • Non-weight bearing: rest aircast shoes • Bisphosphonates - PAMIDRONATE • Watch other foot • Surgery - trimming of bony exostos - arthrodesis
  • 60. Maggot Therapy
  • 61. FEET FIRST