Diabetic foot lecture 2010

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Lecture on Diabetic Foot Problems

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  • Say may ask questions during presentation. Speak slowly.
  • RCTs evaluating education for people with diabetes, aimed at preventing diabetic foot ulceration, are mostly of poor methodological quality. Weak evidence suggests that patient education may reduce foot ulceration and amputations, especially in high-risk patients. Foot care knowledge and behaviour of patients seem positively influenced by patient education in the short term.
  • Prevention 4 RCTs of pressure relieving interventions were identified. Interventions for the prevention of diabetic foot ulcers indicated that in-shoe orthotics are of benefit. The relative merits of different in-shoe orthotics are unclear; cushioning and pressure redistribution appear of equal benefit. Other pressure relieving interventions such as running shoes have not been adequately evaluated and removable casts (Scotchcast or Hope) or foam inlays do not appear to have been evaluated at all in randomised controlled studies. Treatment 1 RCT of total contact casting indicated that it was effective in the treatment of diabetic ulcers although the evidence was limited .
  • Topical negative pressure therapy for treating chronic wounds Topical negative pressure (TNP) therapy is the application of negative pressure across a wound to aid wound healing. The pressure is thought to aid the drainage of excess fluid, reduce infection rates and increase localised blood flow. TNP is also known as vacuum assisted closure (VAC) and sealed surface wound suction. Seven trials compared TNP with either moistened gauze dressings or other topical agents and found no difference in effects. One very small, poor quality trial (7 wounds) showed a reduction in wound volume and depth in favour of TNP. There is no valid or reliable evidence that topical negative pressure increases chronic wound healing.
  • There is evidence to suggest that hydrogel increases the healing rate of diabetic foot ulcers compared with gauze dressings or standard care and larval therapy resulted in significantly greater reduction in wound area than hydrogel. More research is needed to evaluate the effects of a range of widely used debridement methods and of debridement per se.
  • 12 Weeks Sheehan 2003 Diabetes Care
  • Bring Semmes Weinstein tester and vibration tester
  • Affects C Fibers and A delta (small ones first)
  • Bring in pressure stat
  • Before and after
  • Bring DM shoe with inserts
  • Diabetic foot lecture 2010

    1. 1. Diabetic Foot Complications – Current treatments and advanced therapies in treating the diabetic foot Don Pelto, DPM Central Massachusetts Podiatry, PC Worcester, MA
    2. 2. Objectives <ul><li>Participants will understand incidence and economic impact of diabetic foot infections </li></ul><ul><li>Participants will define the risk factors leading to diabetic foot infections </li></ul><ul><li>Participants will learn to diagnose an “at risk” diabetic foot </li></ul><ul><li>Participants will understand current treatments and advanced therapies in the standard of care/treatment for diabetic foot ulcers </li></ul>
    3. 3. Case Study M.S. <ul><li>CC: Chronic ulceration right foot </li></ul><ul><li>PMH: DM-2, HTN, Restless Leg Syndrome </li></ul><ul><li>PSH: Unremarkable </li></ul><ul><li>NKDA </li></ul><ul><li>Meds: Glucophage, Humalog, Miripex, Lisinopril </li></ul>
    4. 4. Diabetic Foot Ulcers <ul><li>One of the most common complications of diabetes </li></ul><ul><li>Annual incidence 1% to 4% 1-2 </li></ul><ul><li>Lifetime risk 15% to 25% 3-4 </li></ul><ul><li>~15% of diabetic foot ulcers result in lower extremity amputation 3,5 </li></ul><ul><li>~85% of lower limb amputations in patients with diabetes are preceded by ulceration 6-7 </li></ul><ul><li>Peripheral neuropathy is a major contributing factor in diabetic foot ulcers 1-7 </li></ul>1. Reiber and Ledoux. In The Evidence Base for Diabetes Care. Williams et al, eds. Hoboken, NJ: John Wiley & Sons; 2002:641–665. 2. Boulton et al. NEJM. 2004;351:48. 3. Sanders. J Am Podiatry Med Assoc. 1994;84:322. 4. Boulton et al. Lancet. 2005;366:1719. 5. Ramsey et al. Diabetes Care 1999;22:382. 6. Pecoraro et al. Diabetes Care. 1990;13:513. 7. Apelqvist and Larsson. Diabetes Metab Res Rev. 2000:16:S75.
    5. 5. Costs to Treat a Diabetic Foot Ulcer Over a 2-Year Period Following Detection Ramsey et al. Diabetes Care. 1999;22:382. Cost analyses based on percent change in the medical component of the US consumer price index.
    6. 6. 5-Year Mortality Rates Armstrong DG, Wrobel J, Robbins JM. Guest Editorial: are diabetes-related wounds and amputations worse than cancer? Int Wound J. 2007;4(4):286–287
    7. 7. The Diabetic Foot – Risk Factors The Comprehensive Diabetic Foot Exam <ul><li>Dermatological Considerations </li></ul><ul><li>Nerve Considerations </li></ul><ul><li>Osseous Considerations </li></ul><ul><li>Vascular Considerations </li></ul><ul><li>Shoegear Considerations </li></ul>Pinzur et al. Foot & Ankle International. 2005;26:1:113-119. Guidelines for diabetic footcare. Valk GD, Kriegsman DMW, Assendelft WJJ. Patient education for preventing diabetic foot ulceration. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD001488. DOI: 10.1002/14651858.CD001488.pub2.
    8. 8. Current and Advanced Treatments for Wounds
    9. 9. Dermatological Considerations <ul><li>Dry Skin </li></ul><ul><li>Fungal Infection </li></ul><ul><li>Callus </li></ul><ul><li>Interdigital lesions </li></ul><ul><li>Ingrown Nail </li></ul><ul><li>Ulceration </li></ul>
    10. 10. Dermatological Considerations <ul><li>Dry Skin </li></ul><ul><li>Fungal Infection </li></ul><ul><li>Callus </li></ul><ul><li>Interdigital lesions </li></ul><ul><li>Ingrown Nail </li></ul><ul><li>Ulceration </li></ul>
    11. 11. Dermatological Considerations <ul><li>Dry Skin </li></ul><ul><li>Fungal Infection </li></ul><ul><li>Callus </li></ul><ul><li>Interdigital lesions </li></ul><ul><li>Ingrown Nail </li></ul><ul><li>Ulceration </li></ul>
    12. 12. Dermatological Considerations <ul><li>Dry Skin </li></ul><ul><li>Fungal Infection </li></ul><ul><li>Callus </li></ul><ul><li>Interdigital lesions </li></ul><ul><li>Ingrown Nail </li></ul><ul><li>Ulceration </li></ul>
    13. 13. Dermatological Considerations <ul><li>Dry Skin </li></ul><ul><li>Fungal Infection </li></ul><ul><li>Callus </li></ul><ul><li>Interdigital lesions </li></ul><ul><li>Ingrown Nail </li></ul><ul><li>Ulceration </li></ul>
    14. 14. Dermatological Considerations <ul><li>Dry Skin </li></ul><ul><li>Fungal Infection </li></ul><ul><li>Callus </li></ul><ul><li>Interdigital lesions </li></ul><ul><li>Ingrown Nail </li></ul><ul><li>Ulceration </li></ul>
    15. 15. Dermatological Considerations <ul><li>Dry Skin </li></ul><ul><li>Fungal Infection </li></ul><ul><li>Callus </li></ul><ul><li>Interdigital lesions </li></ul><ul><li>Ingrown Nail </li></ul><ul><li>Ulceration </li></ul>
    16. 16. Dermatological Considerations <ul><li>Dry Skin </li></ul><ul><li>Fungal Infection </li></ul><ul><li>Callus </li></ul><ul><li>Interdigital lesions </li></ul><ul><li>Ingrown Nail </li></ul><ul><li>Ulceration </li></ul>
    17. 17. Dermatological Considerations <ul><li>Dry Skin </li></ul><ul><li>Fungal Infection </li></ul><ul><li>Callus </li></ul><ul><li>Interdigital lesions </li></ul><ul><li>Ingrown Nail </li></ul><ul><li>Ulceration </li></ul>Spencer SA. Pressure relieving interventions for preventing and treating diabetic foot ulcers. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD002302. DOI: 10.1002/14651858.CD002302.
    18. 18. Dermatological Treatments <ul><li>Callus </li></ul><ul><ul><li>Diabetic shoes </li></ul></ul><ul><li>Ulceration </li></ul><ul><ul><li>VAC </li></ul></ul><ul><ul><li>Debridement </li></ul></ul><ul><ul><li>Dermal Skin Substitute </li></ul></ul><ul><ul><li>Platelet Rich Plasma </li></ul></ul>Spencer SA. Pressure relieving interventions for preventing and treating diabetic foot ulcers. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD002302. DOI: 10.1002/14651858.CD002302.
    19. 19. Dermatological Treatments <ul><li>Callus </li></ul><ul><ul><li>Diabetic shoes </li></ul></ul><ul><li>Ulceration </li></ul><ul><ul><li>VAC </li></ul></ul><ul><ul><li>Debridement </li></ul></ul><ul><ul><li>Dermal Skin Substitute </li></ul></ul><ul><ul><li>Platelet Rich Plasma </li></ul></ul>Ubbink DT, Westerbos SJ, Evans D, Land L, Vermeulen H. Topical negative pressure for treating chronic wounds. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD001898. DOI: 10.1002/14651858.CD001898.pub2.
    20. 20. Dermatological Treatments <ul><li>Callus </li></ul><ul><ul><li>Diabetic shoes </li></ul></ul><ul><li>Ulceration </li></ul><ul><ul><li>VAC </li></ul></ul><ul><ul><li>Debridement </li></ul></ul><ul><ul><li>Dermal Skin Substitute </li></ul></ul><ul><ul><li>Platelet Rich Plasma </li></ul></ul>Edwards J, Stapley S. Debridement of diabetic foot ulcers. Cochrane Database of Systematic Reviews 2010, Issue 1.
    21. 21. Dermatological Treatments <ul><li>Callus </li></ul><ul><ul><li>Diabetic shoes </li></ul></ul><ul><li>Ulceration </li></ul><ul><ul><li>VAC </li></ul></ul><ul><ul><li>Debridement </li></ul></ul><ul><ul><li>Dermal Skin Substitute </li></ul></ul><ul><ul><li>Platelet Rich Plasma </li></ul></ul>
    22. 22. Dermatological Treatments <ul><li>Callus </li></ul><ul><ul><li>Diabetic shoes </li></ul></ul><ul><li>Ulceration </li></ul><ul><ul><li>VAC </li></ul></ul><ul><ul><li>Debridement </li></ul></ul><ul><ul><li>Dermal Skin Substitute </li></ul></ul><ul><ul><li>Platelet Rich Plasma </li></ul></ul>
    23. 23. Dermatological Treatments <ul><li>Callus </li></ul><ul><ul><li>Diabetic shoes </li></ul></ul><ul><li>Ulceration </li></ul><ul><ul><li>VAC </li></ul></ul><ul><ul><li>Debridement </li></ul></ul><ul><ul><li>Dermal Skin Substitute </li></ul></ul><ul><ul><li>Platelet Rich Plasma </li></ul></ul>
    24. 24. Nerve Considerations <ul><li>Neuropathy </li></ul><ul><li>Semmes Weinstein 5.07 monofilament (10g) </li></ul><ul><li>EMG and NCV </li></ul>
    25. 25. Nerve Treatments <ul><li>Neuropathy </li></ul><ul><ul><li>Medication Oral </li></ul></ul><ul><ul><li>Topical Medication </li></ul></ul><ul><ul><li>ENFB (Epidermal Nerve Fiber Biopsy) </li></ul></ul>
    26. 26. Musculoskeletal Considerations <ul><li>Foot Deformities </li></ul><ul><li>Plantar Pressure </li></ul><ul><li>Charcot Joint </li></ul>
    27. 27. Musculoskeletal Considerations <ul><li>Foot Deformities </li></ul><ul><li>Plantar Pressure </li></ul><ul><li>Charcot Joint </li></ul>
    28. 28. Musculoskeletal Considerations <ul><li>Foot Deformities </li></ul><ul><li>Gait Evaluation </li></ul><ul><li>Plantar Pressure </li></ul><ul><li>Charcot Joint </li></ul>
    29. 29. Musculoskeletal Treatments <ul><li>Foot Deformities </li></ul><ul><ul><li>Preventative foot surgery </li></ul></ul>
    30. 30. Vascular Considerations <ul><li>Pulses </li></ul><ul><li>Capillary filling time </li></ul><ul><li>Color changes </li></ul><ul><li>Edema </li></ul><ul><li>Temperature </li></ul>
    31. 31. Vascular Considerations <ul><li>Pulses </li></ul><ul><ul><li>Revascularization </li></ul></ul><ul><ul><li>Silverhawk </li></ul></ul><ul><ul><li>Vascular flaps </li></ul></ul>
    32. 32. Shoegear Considerations <ul><li>Type of shoe </li></ul><ul><li>Fit </li></ul><ul><li>Lining Wear </li></ul><ul><li>Insoles, Orthoses </li></ul><ul><li>Socks </li></ul>
    33. 33. Shoegear Modifications <ul><li>Diabetic extra-depth shoes </li></ul><ul><li>Diabetic socks </li></ul><ul><li>Multi-density inserts </li></ul>
    34. 34. Thank You Don Pelto, DPM Central Massachusetts Podiatry, PC Worcester, MA 508.757.4003 [email_address]

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