An example of locality guidelines for the management of the diabetic neuropathy and the diabetic foot.

1. THE DIABETIC FOOT
Dr Samer Al-sabbagh
Consultant Diabetologist
East & North Hertfordshire NHS Trust

2. Outline
• Epidemiology of Diabetes, foot ulceration and LEA
• Foot ulcers and LEA
• Risk factors of foot ulceration
• Prevention of foot ulceration
• The MDT foot team and NICE
• Classifications of foot ulcers
• Management of diabetic foot ulcers
• Charcot’s neuroarthropathy

3. •Diabetes is one of the biggest health
challenges facing the UK today
•In 2010, 2.3 million people in the UK were
registered as having diabetes, while the
number of people estimated as having either
type 1 or type 2 diabetes was 3.1 million
•By 2030 it is estimated that more than 4.6
million people will have
diabetes (Diabetes UK, 2010)

4. Major Complications of Diabetes
Microvascular Macrovascular
A Leading
Peripheral Nervous System Brain and Cerebral Circulation
Cause of Death (Cerebrovascular disease)
(Neuropathy)
Heart and Coronary Circulation
Kidney (Nephropathy)
(Coronary heart disease)
Eyes (Retinopathy)
Diabetes
Lower Limbs
(Peripheral vascular disease)
Diabetic Foot
Diabetic Foot
(Ulceration and amputation) Reduced Life
(Ulceration and amputation)
Expectancy
Amos AF, et al. Diabet Med. 1997;14(Suppl 5):S7-S85. Meltzer S, et al. CMAJ. 1998;20(Suppl 8):S1-
S29.

5. Foot ulceration
• Foot ulceration is common and occurs in both
type 1 and 2 DM
• Approximately 5-10% of patients with diabetes
have had past or present foot ulceration, and
1% have undergone amputation
• A large community study in the UK showed
annual incidence of ulceration of approximately
2%, this rises to 7% in those known diabetic
neuropathy

6. Identifying at risk feet – Deformed
toes

7. • Lower-extremity amputation (LEA) is one of
the complications of diabetes that is perhaps
most feared by patients with this disease (1)
and rightfully so.
• These LEAs are generally the end point of a
characteristic sequence of events: a foot
wound, usually a consequence of peripheral
neuropathy, becomes infected and does not
respond to treatment (2)
– (1) Singh N, Armstrong DG, Lipsky BA
Preventing foot ulcers in patients with diabetes. JAMA 2005;293:217–228pmid:15644549
(2) Reiber GE, Pecoraro RE, Koepsell TD
Risk factors for amputation in patients with diabetes mellitus: a case-control study.
Ann Intern Med 1992;117:97–105pmid:1605439

8. Patient with Diabetes
Risk factors for ulceration?
• Peripheral neuropathy
• Peripheral vascular disease
• Foot deformity
• Oedema
• Past ulcer history (high incidence up to50%)
• Other complication

9. • Although the factors associated with diabetic
people developing a foot ulcer are well
defined (1), risk factors for amputation are
less clear
• Studies have identified independent risk
factors that include
(in approximate order of odds ratio)
-A history of a foot ulcer (6)
(1) Singh N, Armstrong DG, Lipsky BA
Preventing foot ulcers in patients with diabetes. JAMA 2005;293:217–228pmid:15644549
(6)Krittiyawong S, Ngarmukos C, Benjasuratwong Y,et al Thailand diabetes registry project: prevalence
and risk factors associated with lower extremity amputation in Thai diabetics. J Med Assoc Thai
2006;89(Suppl. 1):S43–S48pmid:17715833

10. – limb ischemia, underlying bone involvement, the
presence of gangrene (e.g., a higher Wagner
grade), deep wounds
– older age, elevated inflammatory markers (7)
– Poor glycemic control (8)
– A specific ethnicity or geographical region (9,10)
– nephropathy (8), and retinopathy (6)
(7) Yesil S, Akinci B, Yener S, et al
Predictors of amputation in diabetics with foot ulcer: single center experience in a large Turkish
cohort. Hormones (Athens) 2009;8:286–295pmid:20045802
(8) Shojaiefard A, Khorgami Z, Larijani B
Independent risk factors for amputation in diabetic foot. Int J Diabetes Dev Ctries 2008;28:32–
37pmid:19902045
(9)Chaturvedi N, Stevens LK, Fuller JH, Lee ET, Lu M;
WHO Multinational Study of Vascular Disease in Diabetes. Risk factors, ethnic differences and
mortality associated with lower-extremity gangrene and amputation in diabetes. Diabetologia
2001;44(Suppl. 2):S65–S71pmid:11587052
(10)Gonsalves WC, Gessey ME, Mainous AG 3rd, Tilley BC
A study of lower extremity amputation rates in older diabetic South Carolinians. J S C Med Assoc
2007;103:4–7pmid:17763819

11. Peripheral neuropathy
• All three components of neuropathy; sensory,
motor and autonomic can contribute to
ulceration
• Chronic sensorimotor neuropathy is common,
affecting at least one third of older patients in
Western Countries
• Therefore, assessment of the foot ulcer risk
must always include careful foot examination,
whatever the history

12. Distal Symmetric Polyneuropathy is the most common form of
neuropathy
Prevalence of neuropathy in the Rochester diabetic
100 neuropathy study, 1986
90
80
70
60.4
Patients (%)
60
50 47.3
40
31.7
30
20
10 4.8
0
All Distal Carpal tunnel Autonomic
neuropathy polyneuropathy syndrome neuropathy
Adapted from Eastman, R.C., Neuropathy in Diabetes in Diabetes in America , pp. 339-348, 2nd Ed., 1995, NIH
Publication No. 95-1468

13. Prevalence of DPNP in Type 2 Diabetes1
26% of Type 2 patients had DPNP associated
with decreased quality of life
26% 80% of these patients report
moderate to severe pain
Type 2
Diabetics
1. Davies M, et al. Diabetes Care. 2006;29:1518—22.

14. NICE guideline for
Neuropathic Pain management - DPNP
1.11 - For people with painful
diabetic neuropathy, offer oral
duloxetine as first-line treatment. If
duloxetine is contraindicated, offer 1st Line – Duloxetine *
oral amitriptyline.
1.13 - For people with painful
diabetic neuropathy:
− if first-line treatment was with
duloxetine, switch to amitriptyline or
pregabalin, or combine with
pregabalin
2nd Line – Switch to Amitriptyline * *
− if first-line treatment was with or Pregabalin
amitriptyline, switch to or combine
with pregabalin....
“1.14 - If satisfactory pain reduction
is not achieved with second-line
treatment:
• refer the person to a specialist 3rd Line – Refer to specialist Pain
pain service and/or a condition-
specific service” Centre
NICE. Neuropathic pain. CG96. London:
*
If Contraindicated – Use Amitriptyline * *
NICE; March 2010 (www.nice.org.uk) **
Not licensed for DPNP

15. Autonomic neuropathy
• Sympathetic autonomic neuropathy affecting
the lower limbs results in reduced sweating,
dry skin, and development of cracks and
fissures.
• In the absence of large vessel arterial disease,
there may be increased blood flow to the
foot, with arteriovenous shunting leading to
the warm but at risk foot

16. Identifying at risk feet –very dry
skin

17. Peripheral Vascular Disease
• PVD itself in isolation rarely causes ulceration
• Combination of PVD and minor trauma can
lead to ulceration
• Minor injury and subsequent infection
increase the demand for blood supply beyond
the circulatory capacity, and ischaemic
ulceration and risk of amputation develop
• Early identification of PVD is essential

18. PVD
• The presence of a Dorsalis Pedis and Posterior
Tibial pulse is the simplest and most reliable
indicator of significant ischaemia
• Doppler derived ankle pressure can be
misleadingly high in longstanding DM
• Noninvasive studies together with
arteriography often leads to bypass surgery
• Distal bypass surgery is often performed with
good short term and long term results in limb
salvage

19. Past Foot Ulceration, Foot Surgery
& Other Diabetic Complications
• More than 50% of patients with new foot
ulcers give a past ulcer history
• Patients with retinopathy and renal
dysfunction are at increased risk for foot
ulceration

20. Callus, Deformity and high foot
pressures
• Motor neuropathy with imbalance of the
flexor and extensor muscles in the foot
commonly results in foot deformity with
prominent metarsal heads and clawing of the
toes
• In turn, the combination of the proprioceptive
loss due to neuropathy and the prominence of
metatarsal heads leads to increases in the
loads and pressures under the diabetic foot

21. Identifying at risk feet –clawed
toes

22. Identifying at risk feet- Plantar
Callosity

23. Prevention of Foot Ulceration and
Amputation
• The most important message to practitioners
is to have the patient remove the shoes and
socks and to look at the feet for risk factors
( presence of callus, deformity, muscle
wasting, and dry skin)
• That diabetic foot ulceration is largely
preventable is not disputed; small, mostly
single-center studies have shown that
relatively simple interventions can reduce
amputations by up to 80%

24. Prevention of foot ulceration
A simple neurologic examination that might
include a modified neuropathy disability score
is recommended; in the large UK community
study
Abbott CA, Carrington AL, Ashe H, et al:
The North-West diabetes foot care study: incidence of, and risk fac
Diabetic Med 2002; 20:277-384

25. • this simple clinical exam was the best
predictor of foot ulcer risks Absence of
the ability to perceive pressure from a
10-g monofilament, inability to perceive
a vibrating 128-Hz tuning fork over the
hallux, and absent ankle reflexes all have
been shown to be predictors of foot
ulceration
• Bowker JH, Pfeifer MA, ed. Levin & O'Neal's The Diabetic Foot, 7th ed. St Louis: Mosby; 2006
• Boulton AJM, Vileikyte L, Kirsner RS: Neuropathic diabetic foot ulcers. N Engl J
Med 2004; 251:48-55
• Boulton AJM: The diabetic foot: from art to science. Diabetologia 2004; 47:1343-1353

27. The Diabetic Foot Care Team
• Patients identified as being at high risk for
foot ulceration should be managed by a team
of specialists with interest and expertise in the
diabetic foot. The podiatrist generally takes
responsibility for follow-up and care of the
skin and nails and, together with the specialist
nurse or diabetes educator, provides foot care
education

28. • The orthotist, or shoe fitter, is invaluable for
advising about and sometimes designing
footwear to protect high-risk feet, and these
members of the team should work closely
with the diabetologist and the vascular and
orthopedic surgeons
• Patients with risk factors for ulceration
require preventive foot care education and
frequent review
Boulton AJM:
Why bother educating the multidisciplinary team and the patient? The example of prevention of low
Patient Educ Counsel 1995; 26:183-188

29. Diabetic foot problems
Inpatient management of diabetic
foot problems

30. Multidisciplinary foot care team
Each hospital should have a care pathway for patients with diabetic
foot problems who require inpatient care1.
The multidisciplinary foot care team should consist of
healthcare
professionals with the specialist skills and competencies
necessary to
deliver inpatient care for patients with diabetic foot problems.
The multidisciplinary foot care team should normally include a
diabetologist, a surgeon with the relevant expertise in managing
diabetic foot problems, a diabetes nurse specialist, a podiatrist and
a tissue viability
nurse, and the team should have access to other specialist
services required to deliver the care outlined in this guideline.

31. The multidisciplinary foot care team should:
assess and treat the patient’s diabetes, which should include
interventions to minimise the patient’s risk of cardiovascular events,
and any interventions for pre-existing chronic kidney disease or anaemia
(please refer to ‘Chronic kidney disease’ [NICE clinical guideline 73] and
‘Anaemia management in people with chronic kidney disease’ [NICE
clinical guideline 114])
assess, review and evaluate the patient’s response to initial medical,
surgical and diabetes management
•assess the foot, and determine the need for specialist wound care,
debridement, pressure off-loading and/or other surgical
interventions
•assess the patient’s pain and determine the need for treatment
and access to specialist pain services

32. •perform a vascular assessment to determine the need
for further interventions
•review the treatment of any infection
•determine the need for interventions to prevent the
deterioration and
•development of Achilles tendon contractures and other
foot deformities
•perform an orthotic assessment and treat to prevent
recurrent disease of the foot
•have access to physiotherapy
•arrange discharge planning, which should include making
arrangements for the patient to be assessed and their care
managed in primary and/or community care, and followed
up by specialist teams.

33. Initial examination and assessment
Remove the patient’s shoes, socks, bandages and dressings
and examine
their feet for evidence of:
•neuropathy
•ischaemia
•ulceration
•inflammation and/or infection
•deformity
•Charcot arthropathy.
•Document any identified new and/or existing diabetic foot
problems.
•Obtain urgent advice from an appropriate specialist if any of
the following
are present:
-Fever or any other signs or symptoms of -systemic sepsis.
-Clinical concern that there is a deep-seated infection (for
example
palpable gas).
-Limb ischaemia.

34. Care: within 24 hours of a patient with diabetic foot
problems being
admitted to hospital, or the detection of diabetic foot
problems (if the
patient is already in hospital)
Refer the patient to the multidisciplinary foot care team
within 24 hours of
the initial examination of the patient’s feet. Transfer the
responsibility of
care to a consultant member of the multidisciplinary foot
care team if a
diabetic foot problem is the dominant clinical factor for
inpatient care

35. WAGNER DIABETIC FOOT ULCER CLASSIFICATION
SYSTEM
Modified from Oyibo S, Jude EB, Tarawneh I,
et al: A comparison of two diabetic foot ulcer classification
systems: the Wagner and the 2001;24:84-88.
Grade Description
0 No ulcer, but high-risk foot (e.g.,
deformity, callus, insensitivity)
1 Superficial full-thickness ulcer
2 Deeper ulcer, penetrating
tendons, no bone involvement
3 Deeper ulcer with bone
involvement, osteitis
4 Partial gangrene (e.g., toes,
forefoot)
5 Gangrene of whole foot

36. TABLE 32-15 -- UNIVERSITY OF TEXAS WOUND
CLASSIFICATION SYSTEMModified from Armstrong DG, Lavery LA, Harkless LB.
Validation of a diabetic wound classification system. Diabet Med 1998;14:855-859.
Stage Grade 0 Grade 1 Grade 2 Grade 3
A Preulcer or Superficial ulcer Deep ulcer to Wound
postulcer lesion tendon or penetrating
capsule bone or joint
No skin break
B + Infection + Infection + Infection + Infection
C + Ischemia + Ischemia + Ischemia + Ischemia
D + Infection and + Infection and + Infection and + Infection and
ischemia ischemia ischemia ischemia

38. Management of diabetic foot ulcers
Basically, a diabetic foot ulcer will heal if the
following conditions are satisfied
• Arterial inflow is adequate.
• Infection is treated appropriately.
• Pressure is removed from the wound and
the immediate surrounding area
(1)The most common cause of nonhealing of
neuropathic foot ulcers is the failure to remove
pressure from the wound and immediate
surrounding area

39. • The lack of pain permits pressure to be put
directly onto the ulcer and results in
nonhealing
• A patient who walks on a plantar wound
without limping must have neuropathy
• (2)The next most common error is
inappropriate management of infection
• (3)Another common error is the failure to
appreciate ischemic symptoms
• (4)Finally, inappropriate wound debridement
is another reason for slow healing or
nonhealing of a diabetic foot ulcer

40. Neuropathic Foot Ulcer without Osteomyelitis
(Wagner Grades 1, 2; University of Texas Grades
1a, 2a)
• TCC or a removable Scotch cast boot
• The TCC was recognized as the gold standard for off-
loading a foot wound in the 1999 consensus
statement on diabetic foot wounds by the American
Diabetes Association
• randomized, controlled trial in which Armstrong and
colleagues compared three off-loading techniques
and found that the TCC was associated with the
shortest healing time

41. • In neuropathic ulcers with a good peripheral
circulation, antibiotics are not indicated unless there
are clear clinical signs of infection, including
prominent discharge, local erythema, and cellulitis
• The presence of any of these features in Wagner's
grade 1 or 2 ulcers would warrant reclassification in
the University of Texas system to 1b or 2b. In such
cases, deep wound swabs should be taken and
broad-spectrum oral antibiotic treatment started
Either an Amoxicillin–Clavulanic acid combination
(Augmentin) or clindamycin. The antibiotic might
need to be altered when sensitivity results become
available

42. Neuroischemic Ulcers (Wagner Grades 1, 2;
University of Texas Grades 1c, 1d)
• Principles are similar to those for neuropathic ulcers
with the following important exceptions:
• Total contact casts are not usually recommended for
management of neuroischemic ulcers although
removable casts and pneumatic cast boots (Aircast)
may be used
• Antibiotic therapy is usually recommended for all
neuroischemic ulcers
• Investigation of the circulation (including noninvasive
assessment and, when required, arteriography with
appropriate subsequent surgical management or
angioplasty) is indicated

43. Osteomyelitis (Wagner Grade 3; University of
Texas Grades 3b, 3d)

44. Osteomyelitis (Wagner Grade 3; University of
Texas Grades 3b, 3d)
• Osteomyelitis is a serious complication of foot
ulceration and may be present in as many as 50% of
diabetic patients with moderate to severe foot
infections
• If the physician can probe down to bone in a deep
ulcer, the presence of osteomyelitis is strongly
suggested
• Plain radiographs are indicated in any nonhealing
foot ulcer and are useful in the diagnosis of
osteomyelitis in more than two thirds of patients,
although it should be kept in mind that the radiologic
changes may be delayed

45. • MRI, bone scans, or an 111In-labeled white blood cell
scan can be useful in diagnosing bone infection
• Although the treatment of osteomyelitis is
commonly surgical and involves resecting the
infected bone, there have been reports of successful
long-term treatment with antibiotics that treat the
underlying bacterium, most commonly
Staphylococcus aureus. Thus, agents such as
clindamycin (which penetrates bone well) or
flucloxacillin are often used
• IV Tazocin 4.5g tds for inpatient could be used for
severe cases, ciprofloxacin and Clindamycin is an
alternative

46. Infection severity Clinical manifestation
Uninfected Wound lacking purulence or any manifestations of inflammation
Mild Presence of 2 or more manifestations of inflammation
(purulence, or erythema, pain, tenderness, warmth,
or induration), but any cellulitis/erythema extends 2 or less cm
around the ulcer, and infection is limited to the skin or superficial
subcutaneous tissues; no other
local complications or systemic illness.
Moderate Infection (as above) in a patient who is systemically well and
metabolically stable but which has 1 or more of the following
characteristics: cellulitis extending >2 cm, lymphangitic streaking,
spread beneath the superficial fascia, deep-tissue abscess,
gangrene, and involvement of muscle, tendon, joint or bone
Severe Infection in a patient with systemic toxicity or metabolic instability
(eg fever, chills, tachycardia, hypotension, confusion, vomiting,
leukocytosis, acidosis, severe hyperglycaemia, or azotemia)

47. East and Antibiotic Usage Flow Chart
North Hert
Mild PO coamoxiclav 625mg TDS
PO Clindamycin (if penicillin allergic) 300mg qds
Duration of treatment 7-10 days (initially)
Discharge and arrange out patient follow up with the Diabetic
Podiatry Clinic (should be seen in the following week)
Moderate iv coamoxiclav 1.2 gm TDS (plus clindamycin 600mg qds may be added if there is
bone involvement on the advice of Consultant
Diabetologist or Consultant Microbiologist)
Or (if penicillin allergy)
IV teicoplanin 400mg once daily (after 3 loading doses of 400mg 12 hrly) + IV
metronidazole 500mg tds
Modify antibiotics according to culture results
and micro advice
Duration of treatment 2-4 weeks, 6 weeks if osteomyelitis
Start iv and switch to PO depending on the response
If gram negative infection is likely/suspected, add gentamicin (monitor levels
and renal functions)
Severe IV Tazocin 4.5 g tds plus gentamycin stat IV
Or penicillin allergic IV Teicoplanin 400mg od (after 3 loading doses of 400 mg 12
hourly ) + IV gentamycin 5mg/kg + IV metronidazole 500mg tds

48. Debridement

49. Gangrene (Wagner Grades 4, 5)
It is in this area that the team approach is most
important, with close collaboration among the diabetes
specialist, the vascular surgeon, and the radiologist

50. Gangrene (Wagner Grades 4, 5)
• Gangrene or areas of tissue death is always a serious
sign in the diabetic foot. However, localized areas of
gangrene, especially in the toes, without cellulitis,
spreading infection, or discharge, can occasionally be
left to spontaneously autoamputate
• The presence of more extensive gangrene requires
urgent hospital admission; treatment of infection,
often with multiple antibiotics; control of the
diabetes, usually with intravenous insulin; and
detailed vascular assessment

51. Charcot's Neuroarthropathy
• Charcot's neuroarthropathy is a rare and
disabling condition affecting the joints and
bones of the feet
• Permissive features for the development of
this condition include the presence of severe
peripheral neuropathy, together with
autonomic dysfunction, with increased blood
flow to the foot
• The peripheral circulation is usually intact

53. • In the Western world, diabetes is the most
common cause of a Charcot's foot, and
increased awareness of this condition can
enable earlier diagnosis and treatment to
prevent severe deformity and disability
• The actual pathogenesis of the Charcot
process is poorly understood
• the patient with peripheral insensitivity and
autonomic dysfunction with increased blood
flow to the foot is vulnerable to unrecognized
trauma that may be so trivial that the patient
cannot recall the event

54. Diagnosis of Charcot
• A unilateral swollen, hot foot is a patient
with neuropathy must be considered to be
Charcot's foot until proved otherwise
• Charcot's arthropathy can be diagnosed in
most patients by plain radiograph and a high
index of suspicion. Radiographs might reveal
bone and joint destruction, fragmentation,
and remodeling

56. • Management of the acute phase involves
immobilization, usually in a TCC
• Evidence suggests that treatment with
bisphosphonates, which reduce osteoclastic
activity, can reduce swelling, discomfort, and
bone turnover markers