Presentation on theme: "By Patrick A. DeHeer, DPM Hoosier Foot & Ankle"— Presentation transcript:
1 By Patrick A. DeHeer, DPM Hoosier Foot & Ankle Diabetic Foot ExamBy Patrick A. DeHeer, DPMHoosier Foot & Ankle
2 Lancet. 2005;366:1674“…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…”
4 24% of all DFU cases require inpatient care -Harrington et al. 2000 Presence of a DFU for 30 days or longer carries an 8-Fold risk for infection. – Lavery 2006The Hard FactsPatients who develop a foot infection have a 55.7 times greater risk of hospitalization that those who do not. –Lavery 2006$72,775 – Cost of a leg amputation/ per amputation procedure- Bureau of Labor Statistics, 2010Go through this slide to help them convince potential referring doctors that there is little time to waste. Stakes are high and risks are unacceptable.$20,300 – DFU inpatient cost per episode, Harrington et al. 2000
5 Costs to Treat a Diabetic Foot Ulcer Over a 2-Year Period Following Detection Diabetic foot ulcers result in a marked increase in healthcare costs. Ramsey and colleagues (1999) found that the direct, attributable cost over the first 2 years following the development of a DFU was approximately $28,000 (1995 US dollars). This slide displays these costs for 2000, 2005, and 2010 adjusted for medical care increases based on the percent change in the medical component of the US consumer price index.1 This initial 1995 cost analysis was based on retrospective data from a large staff-model HMO and compared diabetic patients with newly diagnosed DFU to age and sex-matched controls with diabetes and no DFU history. The higher costs for patients with DFU are attributed to the increased health service utilization by these patients compared with controls. DFU patients averaged 0.24 more emergency room visits, 22 more outpatient appointments, and 4.6 more hospital stays within the first year. Additionally the DFU group had a greater risk for osteomyelitis and amputation, which added to overall healthcare costs. 15 to 20% increase each year.1Source: Bureau of Labor Statistics, Consumer Price Index, Archived Consumer Price Index Detailed Report Information, 2009 CPI Index Detailed Report Tables, December Accessed March 3,Cost analyses based on percent change in the medical component of the US consumer price index.Ramsey et al. Diabetes Care. 1999;22:382.
6 Healing of Neuropathic Ulcers: Results of a Meta-analysis A 1999 meta-analysis by Margolis and colleagues evaluated the rate of neuropathic ulcer healing in 10 control groups from clinical trials. These control groups used standard good wound care, which included debridement and off-loading, and either saline-moistened gauze or placebo gel and gauze. A total of 622 patients were assessed; 172 in the 20-week end point group and 450 in the 12-week end point group.Weighted mean healing rates were 24.2% (95% CI 19.5–28.8%) for the 12-week end point and 30.9% (95% CI 26.6–35.1%) for the 20-week end point.These data provide clinicians with a realistic assessment of their chance of healing neuropathic ulcers over 20 weeks. Further, this emphasizes that even with good, standard wound care, the healing of neuropathic ulcers in patients with diabetes continues to be a challenge.These data provide clinicians with a realistic assessment of their chances of healing neuropathic ulcersEven with good, standard wound care, healing neuropathic ulcers in patients with diabetes continues to be a challengeMargolis et al. Diabetes Care. 1999;22:692.
7 Tragic “Rule of 50”50% of amputations - Transfemoral/Transtibial level50% of patients - 2nd amputation in 5 years50% of patients - Die in 5 yearsClinical Care of the Diabetic Foot, 2005
8 Tragic “Rule of 15”15% of diabetics will develop a foot ulcer in their lifetime15% of foot ulcers will develop osteomyelitis15% of foot ulcers will lead to an amputation
9 Pathways for Foot Ulcers NeuropathyFoot Deformities (from motor neuropathy)Minor traumaMechanical/Shoes (tight/ill-fitting)Thermal (heat inside shoes)Chemical (corn removal pads)Prospective studies have investigated the causal pathways leading to diabetic foot ulcer.The most common pathway involved a combination of sensory neuropathy, foot deformities secondary to motor neuropathy, and minor trauma caused by poor self-foot care practices.Sources of minor trauma included ill-fitting shoes, thermal trauma (hot water, sand, or pavement) and chemical trauma (over-the-counter corn plasters).ULCERDiabetes Care. 1999; 22:157
10 Patient Ulcer Risk 28.1% 18.6% 7% 6.3% 10% 4.8% 17%-30% 1.7% 66% Risk LevelFoot Ulcer%/yr% Office Patients(diabetes clinics)3: Prior amputation Prior ulcer28.1%18.6%7%2: Insensate and foot deformity or absent pedal pulses6.3%10%1: Insensate4.8%17%-30%0: All normal1.7%66%Diabetic patients can be stratified into one of four risk levels for subsequent foot ulceration.Risk level 3 patients with either a prior lower extremity amputation or foot ulcer are at greatest risk as their annual risk of foot ulceration is 18-28%; about 7% of office patients are at this level of risk.Risk level 2 patients are insensate to the 10g monofilament, and in addition, they have either major foot deformities or absent pedal pulses; annual risk of foot ulcer is about 6%.Risk level 1 patients are insensate to the 10g monofilament; annual risk of foot ulcer is 4.8%/year risk; they comprise 17-30% of the diabetic patients seen in the office practice.Note that risk level 0 patients who have no risk factors may still have an increased risk of foot ulceration of 1-2%/year.
11 History for the Diabetic Foot Chief ComplaintHPI –NLDOCATSMedicationsAllergiesPast Medical HistoryDiabetes – NIDDM/IDDMControl?How long?Family HistorySurgical HistoryAmputationRevascularizationSocial HistoryROS –CV – IC, edema, change in color or temperature of LE, PAD, venous diseaseNeuro – burning, numbness, paresthesia, neuropathy, weaknessMSK – amp, foot deformity, Charcot, injury, ambulatory, OA/RADerm – prior ulcer Hx, nail fungus, dry and cracking skin, local or systemic signs or symptoms of infection
12 Neurological Exam Deep Tendon Reflexes – Clonus Babinski Vibratory PatellarAchillesClonusBabinskiVibratorySharp/DullLoss of protective sensation – 5.07/10 g Semmes-Weinstein monofilament wire
14 Monofilament Wire Testing Test characteristics:Negative predictive value = 90%-98%Positive predictive value = 18%-36%Prospective observational study:80% of ulcers and 100% of amputations occur in insensate feetSuperior predictive value vs. other test modalitiesDemonstrate on forearm or handPlace monofilament perpendicular to test siteBow into C-shape for 1 secondTest 4 sites/footHeel testing does not predict ulcerAvoid calluses, scars, and ulcersJ Fam Pract. 2000;49:S30Diabetes Care. 1992;15:1386
15 Monofilament Wire Testing Insensate at 1 site = insensate feetFalsely insensate with edema, cold feetTest annually when sensation normalMonofilament< 100 times dayReplace if bentReplace every 3 months
16 Neurological Exam Diabetes Care. 2006;29(Suppl 1):S25 BiothesiometerBest predictor of foot ulcer risk128-Hz tuning fork at hallucesEquivalent to 10-g monofilamentNewly recommended by ADADiabetes Care. 2006;29(Suppl 1):S25Diabetes Res Clin Pract. 2005;70:8
17 Motor Neuropathy and Foot Deformities Hammer toesClaw toesProminent metatarsal headsHallux valgusCollapsed plantar arch
23 Equinus and the Diabetic Patient Grant et al JFAS1997Electron microscope investigation of the effects of diabetes on the Achilles tendonAll patients had diabetic neuropathy and had an ulcer or/and Charcot neuroarthropathy12 diabetic patients and 5 non-diabetic patientsChanges noted in diabetic patients –Increased packing density of collagen fibrilsDecreased fibrillar diameterAbnormal fibril morphology
24 Equinus and the Diabetic Patient Grant et al JFAS1997Foci in which collagen fibrils appeared twisted, curved, overlapping, and otherwise highly disorganized were common in specimens from most patients (11 of 12)Structural reorganization that may be the result of nonenzymatic glycation expressed over many yearsLeads to tightening of Achilles tendonThe fine structure of the Achilles tendon appears normal, consistent with the finding that the ultrastructural changes result from diabetes rather than neuropathy
25 Equinus and the Diabetic Patient Lavery, Armstrong, Boulton Study JAPMA 2002Relationship between in equinus and peak plantar pressures in diabetic patients1,666 patientsDefinition 0° AJ DF with KEPressure measured with force-plate gait analysis systemMean Age / (years)Men 50.3%Weight / (Kg)Diabetes duration /- 9.5 (years)
27 Lavery, Armstrong, Boulton Study JAPMA 2002 No statistical significant difference –WeightSex differenceAbsence or presence of neuopathyStatistical significant difference –Equinus patients had longer duration of diabetesEquinus prevalence in this population = 10.3%
28 Lavery, Armstrong, Boulton Study JAPMA 2002 “A high index of suspicion should lead to earlier surgical or nonsurgical treatment of these deformities. This increased vigilance, coupled with intervention, may lower the risk of ulceration and amputation in this high-risk population.”
29 Peripheral Artery Disease Prevalence (ABI < 0.9):10%-20% in type 2 diabetes at diagnosis30% in diabetics age 50 years40%-60% in diabetics with foot ulcerComplications:ClaudicationAssociated coronary and cerebral vascular diseaseDelayed ulcer healingAbsent pedal pulses predicts severe PADAbsence of a single pedal pulse does not predict PADPresence of pedal pulses does not rule out PAD!Hand held doppler – good initial evaluationMultiphasicMonophasicArch Intern Med. 1998;158:1357Diabetes Care. 2003;26:3333Diabet Med. 2005;22:1310Diabetes Care. 2003;26:3333
30 A much more useful noninvasive test to diagnose PAD in diabetes is the Ankle-Brachial Index (ABI). The (ABI) is performed with a handheld Doppler Flow meter to measure systolic blood pressure in both arms and in the DP and PT arteries. The ABI is calculated by dividing the highest pressure measured at the ankle by the highest brachial pressure.[PATRICK AND TED: DO NOT HAVE PERMISSION TO USE. REFERENCE IS:Norman PE, Eikelboom JW, Hankey GJ. Peripheral arterial disease: prognostic significance and prevention of atherothrombotic complications. Medical Journal of Australia 2004; 181: Figure 1, p.151Adapted from: Norman PE, Eikelboom JW, Hankey GJ. Peripheral arterial disease: prognostic significance and prevention of atherothrombotic complications. Medical Journal of Australia 2004; 181: Figure 1, p.151
31 Ankle-Brachial Index Screening: 2004 ADA recommendation Diagnosis: “Consider” at age 50 years and every 5 yearsDiagnosis:Claudication, absent DP/PT pulses, foot ulcerLimitations:Underestimates severity in calcified arteriesInterpretation ABINormalMild obstructionModerate obstruction*Severe obstruction* <0.40Poorly compressible** >1.302° to medial calcification*Poor ulcer healing with ABI < 0.50**Further vascular evaluation needed
32 Foot Care Based on Risk Factors Low RiskHigh RiskAnnual comprehensive foot examinationQuestionnaire completed by patientExaminationSelf-management and footwear educationBrief counselingWritten handoutAnnual comprehensive foot examInspect feet every office visitPodiatry care as neededIntensive patient educationDetect/manage barriers to foot careTherapeutic footwear, as needed
33 Foot Care Based on Risk Factors High Risk: Nursing TasksHigh Risk: Patient EducationPlace “High-Risk Feet” stickers on each chartRemove patient’s shoes/socksDetermine if patient can reach/see soles of feetStock 10-g monofilament in each roomConsider training to perform monofilament examProvide patient education formsReinforce frequently – low retentionPatient demonstrates self-care knowledgeEvidence:May reduce foot ulcer/amputation ratesCochrane Database Syst Rev Jan 25;(1)CD001488Foot Ankle Int. 2005;26:38J Gen Intern Med. 2003;18:258
34 Diabetic Foot Care High Risk: Podiatry Care Basic Foot Care Concepts Provide nail and skin careAssess footwear needsVisit frequency not evidence-basedEquinus managementDaily foot inspectionMay require mirror, magnification, or caregiverPatient able to recognize/report:Persistent erythemaEnlarging callusPre-ulcer (callus with hemorrhage)Diabetes Care. 2003;26:1691J Fam Practice. 2000;49(Suppl):S30
35 Diabetic Foot Care Basic Foot Protective Behaviors Basic Foot Care ConceptsBasic Foot Protective BehaviorsCommitment to self-careWash/dry dailyLubricate daily (not between toes)Debride callus/corn (low-risk patients)No self-cutting of nails if:NeuropathyPADPoor visionAvoid temperature extremesNo walking barefoot/stocking-footedAppropriate exercise for insensate feetInspect shoes for foreign objectsOptimal footwear at all times
36 Basic Footwear Education Avoid:Favor:Pointed toesSlip-onsOpen toesHigh heelsPlasticBlack colorToo smallBroad-round toesAdjustable (laces, buckles, Velcro)Athletic shoes, walking shoesLeather, canvasWhite/light colors½” between longest toe and end of shoeDiabetes Self-Management. 2005;22:33
37 Therapeutic Footwear Efficacy Protect feetReduce plantar pressure, shock, and shearAccommodate, stabilize, support deformitiesSuitable for occupation, home, leisurePadded socks (e.g., CoolMax, Duraspun, others)Shoe inserts/insoles (closed-cell foam, viscoelastic)Therapeutic shoesDecreases plantar pressure 50%-70%Uncertain reduction in ulcer rateDiabetes Care. 2004;27:1774
38 Thomson Rueters Study JAPMA 2011 Thomson Reuters Healthcare carried out the study utilizing its MarketScan Data Base examining claims from 316,527 patients with commercial insurance (64 year of age and younger) and 157,529 patients with Medicare and an employer sponsored secondary insurance.The study focused on one specific aspect of diabetic foot care: those patients who developed a foot ulcer. For those who developed a foot ulcer, the year preceding their development of a foot ulcer was examined to see if they had seen a podiatrist. Those who saw a podiatrist were compared to those who did not over a three year time period.A comparison was then made between those who had at least one visit to a podiatrist prior to developing the foot ulcer to those who had no podiatry care in the year prior to developing the foot ulceration.
39 Thomson Rueters Study JAPMA 2011 Average savings over a three-year time period (year before ulceration and two years after ulceration occurred):Commercial Insurance: Savings of $19,686 per patient if they had at least one visit to a podiatrist in the year preceding their ulcerationMedicare Insured: Savings of $4,271 per patientAmputation Rates:Commercial Insurance:Podiatry care amputation rate – 5.82%Non-podiatry care amputation rate – 8.49%Medicare Insured:Podiatry care amputation rate – 4.69%Non-podiatry care amputation rate – 6.04%
40 Duke Study – Health Services Research Medicare‐eligible patients with diabetes were less likely to experience a lower extremity amputation if a podiatrist was a member of the patient care team.Patients with severe lower extremity complications who only saw a podiatrist experienced a lower risk of amputation compared with patients who did not see a podiatrist.A multidisciplinary team approach that includes podiatrists most effectively prevents complications from diabetes and reduces the risk of amputations.
41 Thank You!!!! Any Question??? Patrick A. DeHeer, DPM Hoosier Foot & AnkleHoosierfootandankle.com