PREVENTION OF DIABETIC FOOT COMPLICATIONS : PREVENTION OF DIABETIC FOOT COMPLICATIONS Dr. Shahzad Alam Shah MBBS;FCPS Assistant Professor of Laparoscopic Surgery Fatima Jinnah Medical College/ Sir Ganga Ram Hospital Lahore
Diabetic Foot ?: Diabetic Foot ?
Diabetic Foot Presentatations: Diabetic Foot Presentatations Callus Formation Pre-ulceration Ulceration Ischemia Infection Gangrene Deformities
FOOT ULCERS IN DIABETES: FOOT ULCERS IN DIABETES Precipitate 85% of amputations: “Rule of 15” 15% of diabetes patients Foot ulcer in lifetime 15% of foot ulcers Osteomyelitis 15% of foot ulcers Amputation Clinical Care of the Diabetic Foot , 2005
AMPUTATIONS IN DIABETES: AMPUTATIONS IN DIABETES Tragic: “Rule of 50” 50% of amputations transfemoral/transtibial level 50% of patients 2 nd amputation in 5y 50% of patients Die in 5y Clinical Care of the Diabetic Foot , 2005
Slide6: Sensory Joint Motor Autonomic PAD Neuropathy Mobility Neuropathy Neuropathy Protective Muscle atrophy and Sweating Ischemia sensation 2 ° foot deformities 2° dry skin Foot pressure Foot pressure Fissure Healing Minor trauma esp. over recognition bony prominences Callus Pre-ulcer ULCER Infection AMPUTATION Minor Trauma: Interdigital Maceration Mechanical (Moisture, Fungus) Chemical Thermal PATHOGENESIS OF DIABETIC FOOT ULCER AND AMPUTATION
OTHER RISKS FOR DIABETIC FOOT ULCER/AMPUTATION: OTHER RISKS FOR DIABETIC FOOT ULCER/AMPUTATION Failure to adequately care for the feet: Inadequate patient education Inadequate patient motivation Depression, anxiety, anger more common in diabetes Physical disability Cannot see feet 2 to retinopathy Cannot reach feet 2 to obesity, age (?50% of patients) Limited access to podiatry services
CAUSAL PATHWAYS FOR FOOT ULCERS: CAUSAL PATHWAYS FOR FOOT ULCERS % Causal Pathways NEUROPATHY Neuropathy: 78% Minor trauma: 79% DEFORMITY Deformity: 63% Behavioral issues ? MINOR TRAUMA - Mechanical ( shoes ) POOR SELF- - Thermal FOOT CARE - Chemical ULCER Diabetes Care 1999; 22:157
DETECTING FEET-AT-RISK: DETECTING FEET-AT-RISK History : Prior amputation Prior foot ulcer PAD: known or claudication at < 1 block Exam : Major foot deformities PAD Absent DP and PT pulses Prolonged venous filling time Reduced Ankle-Brachial Index (ABI) Pre-ulcerative cutaneous pathology Arch Intern Med 1998; 158:157
PHYSICAL EXAMINATION OF THE FEET IN PERSONS WITH DIABETES: PHYSICAL EXAMINATION OF THE FEET IN PERSONS WITH DIABETES
SENSORY NEUROPATHY IN DIABETES: SENSORY NEUROPATHY IN DIABETES Loss of protective sensation in feet Sensory loss sufficient to allow painless skin injury Major risk factor for foot ulcer in diabetes Detect with 5.07/10g Semmes-Weinstein monofilament Prevalence of insensate feet to 10g monofilament: Age > 40y: 30% of diabetic patients Age > 60y: 50% of diabetic patients Up to 50% have no neuropathic symptoms Diabetes Care 2006; 29(Suppl 1):S24 Diabetes Care 2004; 27:1591
PAD IN DIABETES: PAD IN DIABETES Prevalence (ABI < 0.9): 20-30% 10-20% in type 2 diabetes at Dx 30% in diabetics age 50y 40-60% in diabetics with foot ulcer Complications : Claudication and functional disability Increases risk for concurrent CAD and CVD Delays ulcer healing Increases amputation risk Not increase foot ulcer risk
EXAM TO DETECT PAD IN DIABETES: EXAM TO DETECT PAD IN DIABETES Venous filling time Technique: Sitting: ID pedal vein bulging above skin Supine: Elevate leg to 45 ° for 1 min Sitting: time to pedal vein bulging above skin
Slide15: EXAM TO DETECT PAD IN DIABETES Ankle Brachial Index
INTERPRETATION OF THE ABI: INTERPRETATION OF THE ABI ABI Normal 0.91-1.30 Mild obstruction 0.71-0.90 *Moderate obstruction 0.41-0.70 *Severe obstruction 0.40 **Poorly compressible >1.30 2 ° to medial Ca ++ *Poor ulcer healing with ABI 0.50 **Further vascular evaluation needed
MOTOR NEUROPATHY AND FOOT DEFORMITIES: MOTOR NEUROPATHY AND FOOT DEFORMITIES Hammer toes Claw toes Prominent metatarsal heads Hallux valgus Collapsed plantar arch
Slide18: From Levin and Pfeifer, The Uncomplicated Guide to Diabetes Complications , 2002 Hammer Toes Claw Toes
Slide19: From Levin and Pfeifer, The Uncomplicated Guide to Diabetes Complications , 2002 Hallux Valgus
Slide20: From Boulton, et al Diabetic Medicine 1998, 15:508
PRE-ULCER CUTANEOUS PATHOLOGY: PRE-ULCER CUTANEOUS PATHOLOGY Neuropathy inappropriate footwear: Persistent erythema after shoe removal Callus Callus with subcutaneous hemorrhage: “pre-ulcer” Autonomic neuropathy and secondary dry skin: Fissure ulceration Augment callus formation Poor self-care of the feet: Interdigital maceration with fungal infection Nail pathology
RISK-STRATIFIED FOOTCARE MANAGEMENT FOR DIABETES PATIENTS: RISK-STRATIFIED FOOTCARE MANAGEMENT FOR DIABETES PATIENTS
HIGH RISK: CATEGORY 1-3 PATIENTS: HIGH RISK: CATEGORY 1-3 PATIENTS Annual comprehensive foot exam Inspect feet at every visit Podiatry care Intensive patient education Detect/manage barriers to foot care Therapeutic footwear, if needed
BASIC FOOT CARE CONCEPTS: BASIC FOOT CARE CONCEPTS Daily foot inspection May require mirror, magnification, or caregiver Educate patient to recognize/report ASAP: Persistent erythema Enlarging callus Pre-ulcer (callus with hemorrhage)
BASIC FOOT CARE CONCEPTS: BASIC FOOT CARE CONCEPTS Commitment to self-care: Wash/dry daily Avoid hot water; dry thoroughly between toes Lubricate daily (not between toes) Debride callus/corn to reduce plantar pressure 25% Avoid sharp instruments, corn plasters No self-cutting of nails if: Neuropathy, PAD, poor vision
BASIC FOOT CARE CONCEPTS: BASIC FOOT CARE CONCEPTS Protective behaviors: Avoid temperature extremes No walking barefoot/ stocking - footed Appropriate exercise if sensory neuropathy Bicycle/swim > walking/treadmill Inspect shoes for foreign objects Optimal footwear at all times
THERAPEUTIC FOOTWEAR: GOALS: THERAPEUTIC FOOTWEAR: GOALS Inappropriate footwear: Contributes to 21-76% of ulcers/amputations Optimal footwear should: Protect feet from external injury Reduce plantar pressure, shock and shear forces Accommodate, stabilize, support deformities Suitable for occupation, home, leisure Diabetes Care 2004; 27:1832 Diab Metab Res Rev 2004; 20(Suppl1):S51
Slide48: Dr. Shahzad Alam Shah MBBS;FCPS Assistant Professor of Laparoscopic Surgery Fatima Jinnah Medical College/ Sir Ganga Ram Hospital Lahore Thanks