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Diabetic foot 2015
- 1. Think Feet! Diabetic FootProtection Service Tallaght Hospital, Dublin, Ireland Sean Tierney
- 2. Vascular surgery @Tallaght “…the enormity of the global burden of diabetic foot disease…this much neglected, but potentially devastating, complication of a disease that is reaching epidemic proportions…Someone, somewhere, loses a leg because of diabetes every 30 seconds of everyday…” Lancet 2005; 366:1674
- 3. Vascular surgery @Tallaght The diabetic foot – natural history • Diabetes – 3.5% population – 5% of total healthcare spend – 10% of hospital admissions • Foot burden – 2.5–10% incident ulcers/yr – .25-1.8% amputations/yr – x 8 amputation risk – 9/1000 diabetic have a foot ulcer at one time
- 4. Vascular surgery @Tallaght • 50% of amputations are above knee • 50% of patients require a second major amputation within 5 years • 50% of patients dead within 5 years Clinical Care of the Diabetic Foot, 2005 Implications
- 6. Vascular surgery @Tallaght Neuropathy http://goo.gl/oOQG4q High glucose x time • Sorbitol accumulation • Protein glycation • Oxidative stress • Micro-ischaemia
- 7. Vascular surgery @Tallaght Neuopathy http://goo.gl/oOQG4q 0 20 40 60 80 100 0 25 Yrs %
- 8. Vascular surgery @Tallaght Clawing of the toes Risk Level Foot Ulcer %/yr % in clinics (diabetes clinics) 3: Prior amputation Prior ulcer 28.1% 18.6% 7% 2: Insensate and foot deformity or absent pedal pulses 6.3% 10% 1: Insensate 4.8% 17%-30% 0: All normal 1.7% 66% Diabetes Care. 2001;24:1442 Diabetes Metab. 2003;29:261
- 9. Vascular surgery @Tallaght Clawing of the toes Risk Level Foot Ulcer %/yr % in clinics (diabetes clinics) 3: Prior amputation Prior ulcer 28.1% 18.6% 7% 2: Insensate and foot deformity or absent pedal pulses 6.3% 10% 1: Insensate 4.8% 17%-30% 0: All normal 1.7% 66% Diabetes Care. 2001;24:1442 Diabetes Metab. 2003;29:261
- 10. Vascular surgery @Tallaght Other foot deformity • Claw toes • Hammer toes • Hallux valgus • Pes Cavus • Toe amputations • Charcot
- 11. Vascular surgery @Tallaght Autonomic neuropathy & Callous
- 12. Vascular surgery @Tallaght Arterial supply Poitier et al, Eur J Vasc Endovasc 2011 • PAOD prevalence 9.5% - 13.6% • (~ 50% with ulcer) • distal > proximal • Medial artery calcification more common
- 13. Vascular surgery @Tallaght Mechanism of ulceration Neuropathy Deformity Trauma Ulcer
- 14. Vascular surgery @Tallaght Vascular disease Neuropathy Deformity Trauma UlcerHealing
- 15. Vascular surgery @Tallaght Vascular disease Neuropathy Deformity Trauma UlcerHealing Limb loss Ischaemia Infection
- 16. Vascular surgery @Tallaght Risk assessment for foot ulceration Structural Skin and soft tissue Innervation Perfusion
- 17. Vascular surgery @Tallaght Semmes-Weinstein monofilament • Loss of – protective sensation in feet – proprioception – vibration – Pain • Asymptomatic – 50% of insensate patients have no symptoms Sensory neuropathy Diabetes Care. 2006;2 9: S24 Diabetes Care. 2004; 27: 1591
- 18. Vascular surgery @Tallaght • Demonstrate on forearm or hand • Place monofilament perpendicular & bow into C-shape for 1 second • 4 sites/foot • Avoid – Heel (does not predict ulcer) – calluses, scars, and ulcers Sensory neuropathy Diabetes Care. 2006;2 9: S24 Diabetes Care. 2004; 27: 1591
- 19. Vascular surgery @Tallaght Sensory neuropathy • -ve predictive value = 90%-98% • +ve predictive value = 18%-36% J Fam Pract. 2000;49:S30 Diabetes Care. 1992;15:1386
- 20. Vascular surgery @Tallaght Ipswich Touch test • If ≥2 (of 6) missed • Sensitivity 77% • Equivalent to SWMF Rayman G. Diabetes Care. Jul 2011; 34(7): 1517–1518.
- 21. Vascular surgery @Tallaght Foot assessment in diabetics Structural Skin and soft tissue Innervation Perfusion
- 22. Vascular surgery @Tallaght Vascular assessment in diabetics Clinical assessment Peripheral pulses Ankle brachial pressure indices Toe (brachial) pressure indices Tissue oximetry
- 23. Vascular surgery @Tallaght Palpating pulses
- 24. Vascular surgery @Tallaght Is palpation of pulses reliable? DP only PT only Both Sensitivity 64 70 73 Specificity 81 83 92 NPV * 91 92 94 PPV 43 49 81 Accuracy 77 81 95 absent pulses • Negative predictive value of palpable pulses in excluding PAOD is 94% (vs ABI <0.9 as gold standard) Armstrong et al. Can J Cardiol 2010
- 25. Vascular surgery @Tallaght Risk based ulcer prevention Risk Level Foot Ulcer %/yr % in clinics (diabetes clinics) 3: Prior amputation Prior ulcer 28.1% 18.6% 7% 2: Insensate and foot deformity or absent pedal pulses 6.3% 10% 1: Insensate 4.8% 17%-30% 0: All normal 1.7% 66%
- 26. Vascular surgery @Tallaght Risk based ulcer prevention Risk Level Foot Ulcer %/yr % in clinics (diabetes clinics) 3: Prior amputation Prior ulcer 28.1% 18.6% 7% 2: Insensate and foot deformity or absent pedal pulses 6.3% 10% 1: Insensate 4.8% 17%-30% 0: All normal 1.7% 66% Education Annual community screening
- 27. Vascular surgery @Tallaght Risk based ulcer prevention Risk Level Foot Ulcer %/yr % in clinics (diabetes clinics) 3: Prior amputation Prior ulcer 28.1% 18.6% 7% 2: Insensate and foot deformity or absent pedal pulses 6.3% 10% 1: Insensate 4.8% 17%-30% 0: All normal 1.7% 66% Education Regular podiatry & screening
- 28. Vascular surgery @Tallaght Risk based ulcer prevention Risk Level Foot Ulcer %/yr % in clinics (diabetes clinics) 3: Prior amputation Prior ulcer 28.1% 18.6% 7% 2: Insensate and foot deformity or absent pedal pulses 6.3% 10% 1: Insensate 4.8% 17%-30% 0: All normal 1.7% 66% Regular podiatry & screening Footwear & insoles
- 29. Vascular surgery @Tallaght Active ulcer
- 30. Vascular surgery @Tallaght Active ulcer ? infection ? ischaemia
- 31. Vascular surgery @Tallaght Active ulcer • Debride • Xray • ? Bone scan • ? MRI • Offload – TCC – Removable cast • Reassess • Footwear
- 32. Vascular surgery @Tallaght Infection • Clinical rather than microbiology Osteomyelitis • Probes to bone • MRI ? • Bony destruction
- 33. Vascular surgery @Tallaght Infection • Antibiotics • Sliding scale • Surgical Debridement • Drainage • Minor amputation
- 34. Vascular surgery @Tallaght Infection • Multiple procedures • VAC closure • Offloading
- 35. Vascular surgery @Tallaght Where is the patient on the spectrum? Normal pulses Impalpable pulses
- 36. Vascular surgery @Tallaght Other clinical signs • Colour • Temperature • Hair loss • Shiny Skin Inconsistent & unreliable
- 37. Vascular surgery @Tallaght Beurger’s test - 1
- 38. Vascular surgery @Tallaght Beurger’s test - 2 60o <120s
- 39. Vascular surgery @Tallaght Beurger’s test - 3 <120s
- 40. Vascular surgery @Tallaght Beurger’s test Insall et al, J R Soc Med 1989
- 41. Vascular surgery @Tallaght Ankle brachial index
- 42. Vascular surgery @Tallaght ABI in Diabetes Poitier et al, Eur J Vasc Endovasc 2011
- 43. Vascular surgery @Tallaght ABI in Diabetes Poitier et al, Eur J Vasc Endovasc 2011
- 44. Vascular surgery @Tallaght Toe pressures
- 45. Vascular surgery @Tallaght Toe pressure P>SBP
- 46. Vascular surgery @Tallaght Toe pressure measurements • Less affected by medial calcification • (neuropathy, CRF) • false positive results rare • absolute toe pressure of <30 mmHg = critical ischemia • Probably not required in routine assessment Brooks B, Dean R, Patel S, Wu B, Molyneaux L, Yue DK: TBI or not TBI: that is the question. Is it better to measure toe pressure than ankle pressure in diabetic patients? Diabetic Medicine 2001, 18(12):528-532.
- 47. Vascular surgery @Tallaght Tissue oxygenation
- 48. Vascular surgery @Tallaght Tissue oximetry & healing Londahl et al. Diabetolgia 2011
- 49. Vascular surgery @Tallaght Tissue oximetry (summary) • tissue hypoxia is defined as “a TcPO2 <40 mm Hg” • associated with reduced likelihood of amputation healing • in critical limb ischemiaTcPO2 typically < 30 mm Hg Oxygen response • TcPO2 increases by > 40 mm Hg on 100% O2 usually associated with subsequent healing Fife et al. Undersea and Hyperbaric Medicine. 2009
- 50. Vascular surgery @Tallaght Choices Structural & neuropathy Offload Ischaemia Revascularisation Infection Drain, debride, ABx
- 51. Vascular surgery @Tallaght Foot Protection Clinic Nason et al. Ir J Med Sci 2013
- 52. Vascular surgery @Tallaght Vascular Intervention
- 53. Vascular surgery @Tallaght Pedal Bypass surgery • 1998-2008 • N= 28 (4 asynchronous bilateral) • M:F = 5:1 • Mean age 63y (37 – 92) • Autologous vein used in all patients Good et al Ir J Med Sci 2010
- 54. Vascular surgery @Tallaght Pedal Bypass surgery Good et al Ir J Med Sci 2010 Proximal site • Popliteal (n=28) Distal sites • Dorsalis paedis (n=13) • Plantar artery (n= 15)
- 55. Vascular surgery @Tallaght Pedal Bypass surgery Primary graft patency 0 20 40 60 80 100 0 6 12 18 24 30 36 42 48 54 60 Time after surgery (months) Graftpatencyasapercentage Primary patency Good et al Ir J Med Sci 2010
- 56. Vascular surgery @Tallaght Primary & Secondary graft patency 0 20 40 60 80 100 0 6 12 18 24 30 36 42 48 54 60 Time after surgery (months) Graftpatencyasapercentage Primary Secondary Pedal Bypass surgery Good et al Ir J Med Sci 2010
- 57. Vascular surgery @Tallaght Pedal Bypass surgery 0 20 40 60 80 100 0 6 12 18 24 30 36 42 48 54 60 Limbsurvivalasapercentage Time after surgery (months) Limb Salvage Good et al Ir J Med Sci 2010
- 58. Vascular surgery @Tallaght Patient Survival after Popliteo-pedal bypass 0 20 40 60 80 100 0 6 12 18 24 30 36 42 48 54 60 Time after surgery (months) Survivalasapercentage Pedal Bypass surgery Good et al Ir J Med Sci 2010
- 59. Vascular surgery @Tallaght Meta-analysis (pop pedal bypass) • N=1,2320 (79 studies) • @ 5 years • 1o patency 63% • 2o patency 71% • Limb salvage 78% • * 5 yr mortality ~50% Albers et al J Vasc Surg. 2006 43:498-503. *Hinchcliffe et al Diabetes Metab Res Review 2012
- 60. Vascular surgery @Tallaght Innovation
- 61. Vascular surgery @Tallaght Tibial artery disease
- 62. Vascular surgery @Tallaght Tibial artery disease
- 63. Vascular surgery @Tallaght Tibial artery disease
- 64. Vascular surgery @Tallaght Tibial angioplasty - results • Jan 2010-June 2013 • 61 limbs in 53 patients (41 male, median age 73) • Rest pain /tissue loss) • Infrapopliteal disease extent: TASC D • Co-morbidities – 36/53 Diabetic – 31/53 Smoker – 18/53 Chronic kidney disease stage 4-5 O Connor et al ASGBI 2014
- 65. Vascular surgery @Tallaght Tibial angioplasty – results 2 • Technical success 81.3% (49/61 limbs) • 55% (29/53) > one tibial vessel treated • 24% (13/53) proximal lesion (SFA or Pop) treated synchronously • Adjuvant procedures: – Minor amputation or debridement :12/61 limbs – Mechanical thrombectomy(Rotoarex): 6/61 limbs – Intra-op thrombolysis: 6/61 limbs O Connor et al ASGBI 2014
- 66. Vascular surgery @Tallaght Tibial angioplasty - followup • Mean follow up 17months (1-42) • Major Amputation rate 10% (6/61 limbs) • Revascularisation required in 12 pts – 8 repeat angioplasty – 4 distal bypass • Overall survival at 3 years: 72% • Amputation free survival at 3 years : 64% • Poor survival associated with chronic kidney disease O Connor et al ASGBI 2014
- 67. Vascular surgery @Tallaght Tibial angioplasty – meta-analysis • N = 2653 • Technical success = 90% • @ 3 years • 1o patency 49% • 2o patency 63% • Limb salvage 80% • Survival 68% Romiti et al J Vas Surg 2008
- 68. Vascular surgery @Tallaght Tibial angioplasty – meta-analysis • N = 2653 • Technical success = 90% • @ 3 years • 1o patency 49% • 2o patency 63% • Limb salvage 80% • Survival 68% Romiti et al J Vas Surg 2008 vs Bypass (@5 years) 63% 71% 78% 50% Albers et al J Vasc Surg. 2006 43:498-503.
- 69. Vascular surgery @Tallaght Tallaght data Nason et al. Ir J Med Sci 2013
- 70. Vascular surgery @Tallaght Amputations AKA BKA 0 2 4 6 8 10 12 Study Period Control Period Nason et al. Ir J Med Sci 2013
- 71. Vascular surgery @Tallaght Length of stay 15 days 12 days Nason et al. Ir J Med Sci 2013
- 72. Vascular surgery @Tallaght Total bed days used 2842 2485 Bed Days Used Control Period Study Period 13% Nason et al. Ir J Med Sci 2013
- 73. Vascular surgery @Tallaght Total bed days used 2842 2485 Bed Days Used Control Period Study Period €300,000 *€ 890 per dayNason et al. Ir J Med Sci 2013
- 74. Vascular surgery @Tallaght Think feet… think vascular
- 75.