The diabetic foot
Mollie Donohoe and Zoe Boulton
07 Feb 2014

• Current situation - amputations

• Cases
• Assessment of d...
Evolution and the diabetic foot

Increasing numbers

Fashion victims
Why need to improve diabetic foot care
• Diabetic foot disease accounts for more hospital
bed days than all other diabetes...
NHS Atlas of Variation
Amputation in Type 2 Diabetes
Percentage of people in the
National Diabetes Audit (NDA)
having majo...
NHS Expenditure –
Ulceration and Amputation in Diabetes
Amputation
£119m. £125m.

Inpatient Care Ulceration
£213m.

Primar...
Why it is so important?
• 80% of people die within five years of having
foot ulcers or amputations
80%

49%

20%

Amputati...
But …

... up to 80 per cent of
amputations are potentially
preventable
Targets - NICE
Structured education at time of diagnosis and on ongoing basis (A)

(A)

Directly based on evidence from me...
Impact of foot ulcers on
quality of life

Health related quality of life (SF-6D) scores for people with diabetic foot ulce...
Old PCT boundaries

Devon PCT

Torbay PCT
Plymouth PCT
PCT major amputation rates –
YHPHO 2012

1.6
1.3

1.8

1.0
England 1.0
New CCG boundaries
(also reflect catchment areas)
NEW Devon CCG
northern locality

NEW Devon CCG
eastern locality

NEW = N...
NEW CCG amputation rates
YHPHO 2012

1.6

England 0.9
Calculating rates per catchment area

CCGs are the “externally visible” unit of healthcare
•YHPHO has calculated amputatio...
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
Devon is an outlier…
…because it’s the biggest
Confounding factors?

Ethnicity
•White – risk = 1.0
•S Asian – risk = 0.25
•Black – risk = 0.62
Age
•2% increase per year
We are 20 years ahead of the country

(Sidmouth 2075)
Confounding factors?

Amputation rates in
diabetic and nondiabetic patients
correlate strongly –
r=0.43, p=0.0005

Holman,...
The South Western Region

White
94.1%

Legacy
effect
50%
older
migrants

Older
population
25% >65

Rural occupation

longe...
Interpret all data with caution
Atlas of Variation is not a scientific document
•Some implausible data
•Inadequate adjustm...
RCA of Major Amputations in Diabetic Patients
Jan 2012-13
• 16 patients - 22 amputations
• 6 patients had 2 amputations sa...
Problems identified so far
• Only 50% of patients known to Diabetic foot clinic
• 5/16 (31%) solely under vascular as inpa...
Problems identified so far
• 5/8 (62%) documented given education in foot clinic.
• 2/16 (13%) had previous care in anothe...
Inpatient foot care
The Touch Test
The Touch Test
• Up to 15% of inpatients have diabetes mellitus at any one time (1)
• 33% had feet examined (14% RD&E).
• ...
Testing for neuropathy
• The Ipswich Touch Test (IpTT)
A simple and novel method to identify inpatients with diabetes at r...
Results
• Prevalence of neuropathy = GP:11.4% ,DM:16.6%
• Compared to MF as “gold standard”
• IpTT
: 88.9% sensitivity (PP...
MANAGEMENT OF
PAINFUL NEUROPATHY
• Is the pain neuropathic?
• What is the dominant unpleasant
symptom?
• When are the symp...
Painful diabetic peripheral neuropathy
Amitriptyline (unlicensed)
Start at 10mg, titrate to max. tolerated over 8/52
Gabap...
CASES
Sausage toe - Osteomyelitis
HISTORY
Mrs C:

Age 22
Type 1 DM of 20 years
° Smoker
° Alcohol
PT shop assistant.
C/O severe pain left foot  2/12
Histor...
Mrs C

Left foot warmer than right

Monofilament 3/6
All peripheral pulses felt
Left foot medial protrusion of inner
long ...
Differential diagnosis
?

Charcot
/Sprain
Infection: osteomyelitis: Cellulitis
Gout
DVT
One month later
Bones in foot
Mr P
Mr A
• Type 1 diabetes (HBA1c 51 , creat 85 chol 4 ,proliferative
retinopathy )
• Developed neuropathic fracture of talus ...
Mr A
Mr D
• Type 1 DM
• CKD4
• Proliferative retinopathy
• Biphasic pulses
• Foot ulcer healed R 2nd met head.
• Hot foot
CHARCOT’S
JOINT/NEUROARTHROPATHY

• Relatively painless progressive arthropathy
of single or multiple joints, caused by an...
DEMOGRAPHICS
• 0.1 - 5% in patients with diabetic peripheral
neuropathy.
• Age 20 - 70 + years (50 - 60 > common)
• Histor...
Patterns of bone and joint destruction
Sanders LJ, Frykberg RG: Diabetic Neuropathic osteoarthropathy; The Charcot foot: t...
Radiographic Staging
(Eichenholtz, 1966)

• I Developmental (acute) stage
• II Coalescence (quiescent) stage
• III Consoli...
Eichenholtz Classification
• Stage I - Developmental (acute)
– Hyperemia due to autonomic neuropathy
weakens bone and liga...
Radiographs
• Stage I
Eichenholtz Classification
• Stage II - Coalescence (quiescent)
– Absorption of osseous debris, fusion of
larger fragments...
Radiographs
• Stage II
Eichenholtz Classification
• Stage III - Consolidation (resolution)
– Osseous remodelling
– for clinical purposes, stage I...
Radiographs
• Stage III
PATHOPHYSIOLOGY
• Initiating event: trivial injury/unnoticed
repetitive minor trauma minor or periarticular
or major fract...
An algorithm depicting a basic approach to the Charcot foot
Cycle of pathophysiology of Charcot osteoarthropathy
RANKL pathway in the pathophysiology of
Charcot arthropathy
The Role of RANKL in Charcot neuroarthropathy
TREATMENT
• Non-weight bearing: rest
aircast
shoes
• Bisphosphonates - PAMIDRONATE
• Watch other foot
• Surgery
- trimming...
Maggot Therapy
FEET
FIRST
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
The diabetic foot
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

    1. 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. 2. Evolution and the diabetic foot Increasing numbers Fashion victims
    3. 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. 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. 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. 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. 7. But … ... up to 80 per cent of amputations are potentially preventable
    8. 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. 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. 10. Old PCT boundaries Devon PCT Torbay PCT Plymouth PCT
    11. 11. PCT major amputation rates – YHPHO 2012 1.6 1.3 1.8 1.0 England 1.0
    12. 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. 13. NEW CCG amputation rates YHPHO 2012 1.6 England 0.9
    14. 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. 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. 16. Devon is an outlier…
    17. 17. …because it’s the biggest
    18. 18. Confounding factors? Ethnicity •White – risk = 1.0 •S Asian – risk = 0.25 •Black – risk = 0.62 Age •2% increase per year
    19. 19. We are 20 years ahead of the country (Sidmouth 2075)
    20. 20. Confounding factors? Amputation rates in diabetic and nondiabetic patients correlate strongly – r=0.43, p=0.0005 Holman, Diabetologia 2012; 55: 1919.
    21. 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. 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. 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. 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. 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. 26. Inpatient foot care
    27. 27. The Touch Test
    28. 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. 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. 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. 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. 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. 33. CASES
    34. 34. Sausage toe - Osteomyelitis
    35. 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. 36. Mrs C Left foot warmer than right Monofilament 3/6 All peripheral pulses felt Left foot medial protrusion of inner long arch
    37. 37. Differential diagnosis ? Charcot /Sprain Infection: osteomyelitis: Cellulitis Gout DVT
    38. 38. One month later
    39. 39. Bones in foot
    40. 40. Mr P
    41. 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. 42. Mr A
    43. 43. Mr D • Type 1 DM • CKD4 • Proliferative retinopathy • Biphasic pulses • Foot ulcer healed R 2nd met head. • Hot foot
    44. 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. 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. 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. 47. Radiographic Staging (Eichenholtz, 1966) • I Developmental (acute) stage • II Coalescence (quiescent) stage • III Consolidation (resolution) stage
    48. 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. 49. Radiographs • Stage I
    50. 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. 51. Radiographs • Stage II
    52. 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. 53. Radiographs • Stage III
    54. 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. 55. An algorithm depicting a basic approach to the Charcot foot
    56. 56. Cycle of pathophysiology of Charcot osteoarthropathy
    57. 57. RANKL pathway in the pathophysiology of Charcot arthropathy
    58. 58. The Role of RANKL in Charcot neuroarthropathy
    59. 59. TREATMENT • Non-weight bearing: rest aircast shoes • Bisphosphonates - PAMIDRONATE • Watch other foot • Surgery - trimming of bony exostos - arthrodesis
    60. 60. Maggot Therapy
    61. 61. FEET FIRST
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