Diabetic Foot Ulcer

PREVENTION OF DIABETIC FOOT ULCERS
AND LOWER EXTREMITY AMPUTATION

Barry Stults, M.D.
Scott Clark, D.P.M
Thomas Miller, M.D.
University of Utah Medical Center
2006. American College of Physicians. All Rights Reserved.
CASE: Mr. M.C.

64 yr-old obese white male, not seen x 12 mo
Type 2 DM (15 yrs)
BP
(18 yrs)
Dyslipidemia (18 yrs)
CABG
(10 yrs ago)
Claudication (today; 25 yds)
Insulin/Metformin/Statin/ARB/Hctz/CCB/ASA
Sore on my left foot, Doc
CASE: Mr. M.C.

Clinical evaluation of heel ulcer:
Probe reached bone
Extensive subcutaneous abscess
MRI: extensive osteomyelitis
ABI: 0.2
Angiography: severe infrapopliteal, suprapopliteal obstruction
Not amenable to revascularization
Uncontrolled infection despite antibiotics/drainage
AMPUTATIONS IN DIABETES
Common:
Worldwide amputation 2 to diabetes q 30 sec.
U.S.A. 80,000 amputations/y (2002)
Higher rates in men, racial/ethnic minorities
Costly:
$60,000/amputation
$2 billion/y total costs
Lancet 2005; 366:1719
Diabetes Care 2004; 27:1598
Diabetes Care 2003;

26:495
AMPUTATIONS IN DIABETES
Tragic: Rule of 50
50% of amputations
transfemoral/transtibial level
50% of patients
2nd amputation in 5y
50% of patients
Die in 5y
Clinical Care of the Diabetic Foot, 2005
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

FOOT ULCERS IN DIABETES

Costly:
$30,000/ulcer
$9 billion/y total costs
Tragic:
Quality of life: ulcer patient amputation patient
Burden of non-weight-bearing as ulcer heals
Lifetime behavioral adaptations to prevent recurrence
Fear of recurrent ulcer/amputation
70% ulcer recurrence in 3y
Foot Ankle Int 2005; 26:32, 128
Clin Infect Dis 2004; 39(Suppl 2):S129
TEAM CARE REDUCES ULCERS/AMPUTATIONS
Five clinical trials:

Format: integrated, risk-stratified interventions
ID high-risk patients with exam:
Frequent follow-up to detect early problems

Educate/motivate self-care behaviors
Prophylactic nail/skin care by podiatry
Therapeutic footwear, if needed
Prompt, multidisciplinary Rx of ulcers

Lancet 2005; 366:1676
TEAM CARE REDUCES ULCERS/AMPUTATIONS
Efficacy of team care:

50-80% reductions in ulcers/amputations
Economic modeling studies of team care:

Cost-effective if 25-40% reduction in ulcer rate
Cost-saving if > 40% reduction in ulcer rate
Applicable only to high-risk patients

Lancet 2005; 366:1719
PATHOGENESIS OF DIABETIC FOOT ULCER AND AMPUTATION

Sensory
Joint
Neuropathy Mobility
Motor
Neuropathy
Autonomic
Neuropathy
Protective
sensation
Muscle atrophy and

2 foot deformities
Sweating
2 dry skin
Ischemia
Foot pressure
Minor trauma
recognition
Foot pressure
esp. over
bony prominences
Fissure
Healing
Callus
Pre-ulcer
ULCER
Minor Trauma:
Mechanical
Chemical
Thermal
PAD
Infection
AMPUTATION
Interdigital Maceration
(Moisture, Fungus)
OTHER RISKS FOR 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

Age Ageing 1992; 21:333
Diab Metab Res Rev 2004; 20(Suppl 1):S13
CAUSAL PATHWAYS FOR FOOT ULCERS

NEUROPATHY
DEFORMITY
MINOR TRAUMA
- Mechanical (shoes)
- Thermal
- Chemical
% Causal Pathways
Neuropathy:
78%
Minor trauma:
79%
Deformity:
63%
Behavioral issues
?
POOR SELFFOOT CARE
ULCER
DETECTING FEET-AT-RISK
History:
Prior amputation
Prior foot ulcer
PAD: known or claudication at < 1 block
Exam:
Insensate to 5.07/10g monofilament
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
RISK STRATIFY FOR FOOT ULCERATION

Foot Ulcer,
Risk Level
3: prior amputation
prior ulcer
% Office Patients
%/yr
(diabetes clinics)
28.1%
7%
18.6%
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
ANNUAL DIABETIC FOOT EXAMS

2000 Behavioral Risk Factor Surveillance System, CDC
Total
% with foot
exam in
past year
63
Private MedicaidInsurance Medicare

64
65
VA
Uninsured
84*
48*
*p < 0.01
Health Services Research 2005; 40:361
PHYSICAL EXAMINATION OF THE FEET

IN PERSONS WITH 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
UTILITY OF MONOFILAMENT TESTING

Predicts ulcer/amputation in 5 prospective studies:
NPV (normal sensing) = 90-98%
PPV (fail to sense) = 18-36%
Prospective 32 mo observational study:
80% of ulcers/100% of amputations in insensate feet
Superior predictive value to other tests:

Pin prick, cotton wisp, symptoms
? 128 Hz tuning fork?
ADA recommendation, 2006: also test vibration
Diabetes Care 2006; 29(Suppl 1):S25
J Fam Pract 2000; 49:S30
USING THE 5.07/10gm MF (Tool-Kit)

Demonstrate sensation on the
forearm or hand
Place monofilament
perpendicular to test site
Bow into C-shape for one
second
Test four sites/foot: Predicts
95% of ulcer formers vs. 8
sites
Heel testing does not
discriminate ulcer formers
Avoid calluses, scars, and
ulcers
USING THE 5.07/10g MF (Tool-Kit)

Minimize bias:
Test sites in random sequences
Test each site X3, sham test as 1 of 3
Do you feel it? Yes or No?

Retest site if patient fails (misses 2/3 responses)
Insensate at 1 site = insensate feet
Falsely insensate with edema, cold feet
Test annually when sensation normal
Use < 100x/d; replace if bent; replace q 3 mo.
Purchase calibrated MF (See Tool-Kit)

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
JACC 2006; 47:921
Diabet Med 2005; 22:1310
HX TO DETECT PAD IN DIABETES

Claudication at < 1 block suggests severe ischemia
Vascular Level Site of Pain
Aorto-iliac
Buttocks/Thigh
Femoral Calf
Tibioperoneal Foot/Ankle
Rest pain indicates critical ischemia
Toes and forefoot
Difficult to distinguish from neuropathic pain

Ischemic Rest Pain
Unilateral (usually)
Continuous; hs
With dependency
Absent DP/PT pulses
Neuropathic Pain
Bilateral (usually)
Wax/wane
No change with dependency
Variable DP/PT pulses
(After Pompogelli and Campbell, 2002)

Asymptomatic, severe PAD common in diabetes
Tibio-peroneal disease predominance:
Unrecognized ankle/foot claudication
No claudication
Sensory neuropathy blunts/eliminates pain sensation of

claudication and rest pain
EXAM TO DETECT PAD IN DIABETES

Pedal pulse exam:
Absent DP and PT: LR = 3.0-3.8 for severe PAD
Absent DP or PT not predict PAD
Non-palpable DP (8%) or PT (3%) in normals
Present DP and PT not R/O PAD!

30% with PAD have one palpable pulse (collaterals)
High PAD suspicion vascular testing
Claudication, foot ulcer
JAMA 2006; 295:536

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
J Clin Epidemiol 1997; 50:659

Venous filling time
Filling time > 20 sec predicts ABI < 0.5
Sensitivity = 22%; Specificity = 94%; LR = 3.9
J Clin Epidemiol 1997; 50:659
OTHER EXAM FINDINGS FOR PAD

Helpful:
Femoral bruit (LR = 4.75.7)
Unilateral cool extremity
Not predictive of PAD:

Atrophic skin
Hair loss
Capillary refill > 5 sec
Diabetes Med 2005; 22:1310 Arch Intern Med 1998; 158:1357
VASCULAR LAB TO DETECT PAD

Ankle/Brachial BP Index or ABI Testing
Screening: 2004 ADA recommendation
Consider at age 50 and q 5 yr
Screen earlier if multiple CVD risks
Diagnosis:
Claudication, absent DP/PT pulses, foot ulcer
Limitations:
Underestimate severity if medial artery Ca++
Consider pulse volume recording, systolic toe BP, vascular
consultation if uncertain about PAD
Diabetes Care 2004; 27(Suppl 1): S15-S35
INTERPRETATION OF THE ABI
Normal
Mild obstruction
*Moderate obstruction
*Severe obstruction
**Poorly compressible
2 to medial Ca++
ABI
0.91-1.30
0.71-0.90
0.41-0.70
0.40
>1.30
*Poor ulcer healing with ABI 0.50

**Further vascular evaluation needed
MOTOR NEUROPATHY AND FOOT DEFORMITIES

Hammer toes
Claw toes
Prominent metatarsal heads
Hallux valgus
Collapsed plantar arch
Hammer
Toes
Claw Toes
From Levin and Pfeifer, The Uncomplicated Guide

to Diabetes Complications, 2002
Hallux
Valgus
From Levin and Pfeifer, The Uncomplicated

Guide to Diabetes Complications, 2002
From Boulton, et al Diabetic Medicine 1998, 15:508

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
LOW RISK: CATEGORY 0 PATIENTS

Annual comprehensive foot examination
Questionnaire completed by patient in waiting room
Examination form with decision-support
(See Tool-Kit)
Every visit visual inspection if higher risk

Racial/ethnic minorities; alcoholism; homeless
Basic education: self-management, appropriate

footwear
Brief counseling
Written handout
JAMA 2005; 293:217
HIGH RISK: CATEGORY 1-3 PATIENTS

Annual comprehensive foot exam
Inspect feet at every office visit
Podiatry care stratified to risk level
Intensive patient education
Detect/manage barriers to foot care
Therapeutic footwear, if needed

Nursing tasks to facilitate foot exams:
High Risk Feet stickers to each chart (Tool-Kit)
Remove patients shoes/socks
Increases % of foot exams in observational studies
Determine that patient can reach/see soles of feet

Stock 10g monofilament in each room
Consider training to perform 10g monofilament exam
Provide patient education forms

Literacy/language appropriate
J Gen Intern Med 2003; 18:258
www.ndep.nih.gov/diabetes/pubs/feet_kit_Eng.pdf

Regular prophylactic podiatry care:
Provide nail and skin care

Assess footwear needs
RCT: 48% RRR for recurrent ulceration
Optimal visit frequency not evidence-based:
Category 1 q 3-6 mo
Category 2 q 2-3 mo
Category 3 q 1-2 mo
J Fam Practice 2000; 49(Suppl):S30

Intensive patient education:
1 care clinician, podiatrist, educator contribute
Reinforce frequently low retention documented
Patient to demonstrate self-care knowledge
Questionnaires, tests are available (see Tool-Kit)
Utility:
? Reduced foot ulcer/amputation rates?
Cochrane Database Syst Rev 2005 Jan 25;(1)CD001488
Foot Ankle Int 2005; 26:38
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)

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

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
FOOT CARE EDUCATION TOOLS

Prevent diabetes problems: Keep your feet and skin healthy
Cartoons minimal text still simple
www.niddk.nih.gov or ndic@info.niddk.nih.gov
Take Care of Your Feet For a Lifetime booklet
Few cartoons more advanced
http://ndep.nih.gov/materials/pubs/feet/brochure/index.htm
Take Care of Your Feet For a Lifetime 1 page summary
www.ndep.nih.gov/diabetes/pubs/FootTips.pdf
FOOT CARE EDUCATION TOOLS

Diabetic Foot Care
American Orthopedic Foot and Ankle Society
Multilingual translation
Available in 20 languages
Reference:
Trepman E, et al. Foot and Ankle International
2005; 26:64-107.
EDUCATIONAL DEFICIENCIES:
HIGH RISK PATIENTS
558 high risk patients:
Deficiency
Not inspect feet regularly
Walk barefoot/stockings
Seldom/never test water temp.
Trim callus with sharp object
Not know to call ASAP for foot ulcer
Not know how to select footwear
From GE Reiber, 2003
% Deficient
50%
62%
40%
48%
58%
57%
BASIC FOOTWEAR EDUCATION

Avoid:
Pointed-toes
Slip-ons
Open-toes
High heels
Plastic
Black color
Too small
Favor:
Broad-round toes
Adjustable (laces, buckles,
Velcro)
Athletic shoes, walking shoes
Leather, canvas
White/light colors
between longest toe and
end of shoe
Diabetes Self-Management 2005; 22:33
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
Diab Metab Res Rev 2004; 20(Suppl1):S51
THERAPEUTIC FOOTWEAR: COMPONENTS

Padded socks (eg. CoolMax, Duraspun, others)
Cushion metatarsal heads, heels, and decrease plantar
pressure
White, seamless, absorbent acrylic fibers
Shoe inserts/insoles (closed-cell foam, viscoelastic)
Off-the-shelf
Custom-molded
Therapeutic shoes
Extra-depth extra-width
Rigid rocker outsoles
Custom-molded
FOOTWEAR RECOMMENDATIONS BY RISK LEVEL
Low Risk (0) Proper style/fit, cushioned stock shoes

Sensation (1)
Deep toe box shoes, cushioned insoles
Callosities, ulcer Hx Extra-depth stock shoes, custom-molded insole

Severe deformities Custom-molded extra-depth shoes and insoles,
rigid rocker outsoles
Modified from The Foot in Diabetes, 2000, p.136
THERAPEUTIC FOOTWEAR: EFFICACY

Decreases plantar pressure 50-70%
Uncertain reduction in ulcer rate:
1 prevention: no data
2 prevention: controversial reduction of ulcer recurrence
Analytic/descriptive studies
2 RCTs
decreases ulcers 50-75%

no benefit
Benefits vary with footwear use, risk level?

Severe foot deformity, prior toe/ray amputation?
MEDICARE COVERAGE OF THERAPEUTIC FOOTWEAR

Certify diabetic patient with foot-at-risk
1 care physician
Prescribe therapeutic footwear
D.P.M., D.O., M.D.
Prepare/fit therapeutic footwear
Pedorthist, orthotist, prosthetist, D.P.M.
www.cpeds.org
Foot Ankle Int 2005; 26:42
MEDICARE COVERAGE OF THERAPEUTIC FOOTWEAR

Medicare pays 80% of payment amount allowed:
Extra Depth shoes

Custom-made shoes
Diabetic Pre-fab Insoles
Diabetic Custom Insoles
Total Amount Amount Covered by

Allowed
Medicare
$132.00
$105.60
$396.00
$316.00
$67.00
$53.60
$67.00
$53.60
1 pair extra-depth shoes 3 pair insoles/y, or

1 pair extra-depth shoes with modification
2 pair insoles/y, or
1 pair custom-molded shoes 2 pair insoles/y

Diabetic Foot Ulcer

Încărcat de

Informații document

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Diabetic Foot Ulcer

Încărcat de

Drepturi de autor:

Formate disponibile

PREVENTION OF DIABETIC FOOT ULCERS

AND LOWER EXTREMITY AMPUTATION

2006. American College of Physicians. All Rights Reserved.

CASE: Mr. M.C.

CASE: Mr. M.C.

2006. American College of Physicians. All Rights Reserved.

2006. American College of Physicians. All Rights Reserved.

Diabetes Care 2004; 27:1598

Diabetes Care 2003;

2006. American College of Physicians. All Rights Reserved.

2006. American College of Physicians. All Rights Reserved.

FOOT ULCERS IN DIABETES

15% of foot ulcers

Clinical Care of the Diabetic Foot, 2005

FOOT ULCERS IN DIABETES

Clin Infect Dis 2004; 39(Suppl 2):S129

2006. American College of Physicians. All Rights Reserved.

TEAM CARE REDUCES ULCERS/AMPUTATIONS

Five clinical trials:

Frequent follow-up to detect early problems

Prompt, multidisciplinary Rx of ulcers

2006. American College of Physicians. All Rights Reserved.

TEAM CARE REDUCES ULCERS/AMPUTATIONS

Efficacy of team care:

Economic modeling studies of team care:

Applicable only to high-risk patients

Diabetes Care 2004; 27:901

2006. American College of Physicians. All Rights Reserved.

PATHOGENESIS OF DIABETIC FOOT ULCER AND AMPUTATION

Muscle atrophy and

2006. American College of Physicians. All Rights Reserved.

OTHER RISKS FOR ULCER/AMPUTATION

Limited access to podiatry services

Diabetes Care 2003; 29:495

Diab Metab Res Rev 2004; 20(Suppl 1):S13

2006. American College of Physicians. All Rights Reserved.

CAUSAL PATHWAYS FOR FOOT ULCERS

Pre-ulcerative cutaneous pathology

RISK STRATIFY FOR FOOT ULCERATION

2006. American College of Physicians. All Rights Reserved.

ANNUAL DIABETIC FOOT EXAMS

Private MedicaidInsurance Medicare

2006. American College of Physicians. All Rights Reserved.

PHYSICAL EXAMINATION OF THE FEET

2006. American College of Physicians. All Rights Reserved.

SENSORY NEUROPATHY IN DIABETES

Major risk factor for foot ulcer in diabetes

Up to 50% have no neuropathic symptoms

Diabetes Care 2004; 27:1591

2006. American College of Physicians. All Rights Reserved.

2006. American College of Physicians. All Rights Reserved.

2006. American College of Physicians. All Rights Reserved.

UTILITY OF MONOFILAMENT TESTING

Superior predictive value to other tests:

J Fam Pract 2000; 49:S30

Diabetes Care 1992; 15:1386

2006. American College of Physicians. All Rights Reserved.

USING THE 5.07/10gm MF (Tool-Kit)

USING THE 5.07/10g MF (Tool-Kit)

Do you feel it? Yes or No?

Purchase calibrated MF (See Tool-Kit)

Diabet Med 2005; 22:1310

Diabetes Care 2003; 26:3333

2006. American College of Physicians. All Rights Reserved.