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1 Diabetic Foot For information on the authors and reviewers click here
WELCOME TO THE DIABETIC FOOT MODULE! “Nice pic, but why is this module important?” Well, in 2007, 246million people aged years were diagnosed with diabetes mellitus – a global epidemic affecting 6% of the adult population. 25% of these develop foot problems...that’s 61.5 million diabetic feet! And, worryingly, the prevalence of diabetes mellitus is expected to reach 333 million by 2025. The foot of a diabetic patient showing extensive tissue necrosis and infection For information on the authors and reviewers click here Page 1 of 67

2 How should you study this module?
We suggest that you start with the learning objectives and try to keep these in mind as you go through the module slide by slide. Print out the mark sheet. As you go along, write your answers to the questions on the mark sheet as best you can before looking at the answers. Award yourself marks as detailed on the mark sheet: one mark for each keyword (shown in the red text) in the short answer questions and for every correct answer in the True/False questions. Repeat the module until you have achieved a mark of > 80% (65/81) Finish with the formative multiple choice questionnaire to assess how well you have covered the materials as a whole. You should research any issue that you are unsure about. Look in your textbooks, access the on-line resources indicated at the end of the module and discuss with your peers and teachers. Finally , enjoy your learning! We hope that this module will be enjoyable to study and complement your learning about diabetic foot from other sources. Page 2 of 67

3 Learning Outcomes By the end of the module, you should be able to:
Discuss the global burden of the diabetic foot in both the developing and developed world List the causes of diabetic foot ulceration then fully assess for each one and their complications; using bedside examinations, blood tests, microscopy and radiology Discuss the management of diabetic foot ulcers using mechanical intervention (debridement, dressing and cast application) invasive treatment (larvae, antimicrobials and amputation) analgesia Offer advice to diabetic patients on proper foot care and footwear for prevention of foot problems Page 3 of 67

4 Epidemiology 1 2003 2025 Europe Africa Population Diabetes
“So how many people with diabetes are there?” Here are recent estimates of the disease burden due to diabetes and projections for the future. 2003 2025 Europe Africa Population Total Adult (20-79 yrs) 872 million 621 million 667 million 295 million 863 million 646 million 1107 million 541 million Diabetes No. of people Prevalence 48.4 million 7.8 % 7.1 million 2.4 % 65 million 19million 4.3 % Page 4 of 67 Source: International Diabetes Federation and The international Working Group on Diabetes joint publication 2006.

5 Epidemiology 2 “That’s a lot! How many of these get foot ulcers?”
Developed countries: 15% of people with diabetes get ulcers at least once in their lifetime Developing countries: the prevalence is even higher at 20%. “...and does amputation use vary from place to place?”  Yes!...see below; Incidence of minor and major amputations per 1000 people with diabetes Incidence per 1000 Population Year Mauritius 680 Hospital-oriented Tanzania 400 2002 Croatia 6.8 UK 2.6 Regional 1998 The Netherlands 3.6 Nationwide Page 5 of 67 Source: International Diabetes Federation and The international Working Group on Diabetes joint publication 2005.

6 Click the box for the correct answer
Epidemiology Quiz According to the above data; Which region has the most people with diabetes? Which region will see the greatest increase in diabetes prevalence by 2025 ? Which region has the greatest disease burden due to diabetic foot ? Click the box for the correct answer 1 2 3 Page 6 of 67

7 Epidemiology 3 “How does the diabetic foot affect individuals
and society?” Diabetic foot ulcers and their complications (explained later) are often painful. Patients often become dependent on others for mobility. As a result, patients suffer a loss of autonomy and reduced social function, making depression common. The cost of diabetic foot management is 12-15% of the total healthcare budget for diabetes in developed countries. This figure may as high as 40% in developing countries*. These figures do not account for the cost of the loss of potential working members to the economy and the social costs of the inability to support a family. *IDF/IWG joint publication on diabetic foot. Page 7 of 67

8 Pathophysiology “Well those diabetic feet are everywhere and causing
chaos! If we’re going to stop them, I would first like to know how diabetic foot ulcers occur…” Diabetic foot ulcers may have multiple causes, the prominent ones being; Peripheral neuropathy (nerve damage) Peripheral vascular disease (poor pedal blood supply) Trauma Acute: any injury to the foot such as burns or cuts Chronic: due to foot deformities (changes of foot shape that lead to ill-fitting shoes and, thereby, ulceration) Page 8 of 67

9 Stress on bones & joints
Pathophysiology Neuropathy Neuropathy Motor Sensory Autonomic Muscle wasting Foot weakness Postural deviation ↓ Proprioception, Unawareness of foot position Reduced sweating A-V Shunt* open Permanent Stress on bones & joints Plantar pressure Dry skin Increase foot Blood flow ↓ nociception Fissures and cracks Bulging foot veins, Warm foot Deformities, stress and shear pressures Callus formation Page 9 of 67 Trauma Ulcer Infection *Shunts: blood vessels that bypass capillaries and lead directly from arteries to veins

10 Peripheral arterial disease
Pathophysiology Peripheral Arterial Disease “Then how are blood vessels affected?”  High blood sugar expedites artherosclerosis giving peripheral vascular disease (reduction of blood supply to the foot).  The delivery of essential nutrients and oxygen to the foot is compromised leading to anaerobic infections and tissue necrosis. Peripheral arterial disease Artherosclerosis narrows or blocks the arterial lumen Foot ischaemia Foot ulcer Necrosis/ Gangrene Ischaemic toes due to artherosclerosis Infection Page 10 of 67 Artheroma plaque narrowing the arterial lumen

11 Pathophysiology Trauma
“Don’t people with diabetes feel trauma before it reaches ulceration stage?” No- that’s the problem! Acute trauma: abrasions and burns occur often due to the absence of nociception. Poor wound healing makes ulcerations more likely occur. Chronic trauma: reduced motor function results in a high arch. Together with decreased proprioception, this creates classical deformed foot shapes (explained later). These result in bony prominences which, when coupled with high mechanical pressure on the overlying skin, results in ulceration. Page 11 of 67

12 You have come to the end of the first section
End of Section 1 Well done! You have come to the end of the first section We suggest that you answer Question 1 to 4 to assess your learning so far. Please remember to write your answers on the mark sheet before looking at the correct answers! Page 12 of 67

13 Section 1 Quiz Question 1: write ‘T’ or ‘F’ on the answer sheet. When you have completed all 5 questions, click on the boxes and mark your answers. a Diabetic foot is a global health problem The prevalence of diabetes is falling The incidence of foot ulcers in people with diabetes is higher in developed than developing countries Diabetic foot amputation is commoner in developing countries than developed countries Post amputation mortality is higher in developed countries b c d Page 13 of 67 e

14 Section 1 Quiz Question 2: write ‘T’ or ‘F’ on the answer sheet. When you have completed all 4 questions, click on the boxes and mark your answers. a) Diabetic foot problems result in a higher cost to the economy in developing than developed countries b) Depression is common in diabetic foot patients c) Wound healing is slower in diabetes d) Artherosclerosis is common in diabetes patients a b c d Page 14 of 67

15 Peripheral neuropathy ……………………… Peripheral arterial disease …………………………
Section 1 Quiz Question 3: The 4 main causes of diabetic foot ulcers are; write the answers in your mark sheet. Peripheral neuropathy ……………………… Peripheral arterial disease ………………………… Click here for the answers

16 Stress on bones & joints
Section 1 Quiz Question 4: Study this flow chart and list 4 factors that predispose to diabetic foot ulceration. Write your answer in your mark sheet Neuropathy Click here for the answers Motor Sensory Autonomic Muscle wasting Foot weakness Postural deviation ↓ Proprioception, Unawareness of foot position Reduced sweating A-V Shunt* open Permanent Stress on bones & joints Plantar pressure Dry skin Increase foot Blood flow ↓ nociception Fissures and cracks Bulging foot veins, Warm foot Deformities, stress and shear pressures Callus formation Page 16 of 67 Ulcer Trauma Infection *Shunts: blood vessels that bypass capillaries and lead directly from arteries to veins

17 Assessment “How do we predict how bad a diabetic foot is then?” Foot assessment needs to be undertaken in all people with diabetes to evaluate the individual’s risk of foot complications and hence plan management. It can be undertaken by a podiatrist, junior doctor, specialised diabetes nurse or other trained nurses. The aim of the assessment is to examine each pathological cause that creates ulcers: 1) peripheral neuropathy peripheral arterial disease structural Page 17 of 67 But how do you assess the diabetic foot? Let me guess. As always start with the history and then the examination for each cause …?”- Bingo!

18 Assessment Peripheral Neuropathy
History burning, tingling, numbness of the foot and nocturnal leg pain indicate cutaneous sensory deficits Note that in ~35% of patients who are asymptomatic, neuropathy can be detected by examination Examination Inspect deformities such as claw toes, hair loss, muscle atrophy and a high medial longitudinal arch (giving prominent metatarsal heads) Test for reduced power and reflexes that are evidence of muscular motor deficits. Test sensation by skin pinprick (spinothalamic tracts), proprioception and vibration (dorsal columns) Claw toes Page 18 of 67 Prominent metatarsal heads and an ulcer

19 Assessment Monofilament for pressure sensation (pinprick sense)
Place a 10g nylon Semmes-Weinstein monofilament at a right angle to the skin Apply pressure until the monofilament buckles, indicating that a specific pressure has been applied. Inability to perceive the 10g of force applied by the monofilament is associated with clinically significant large fibre neuropathy and an increased risk of ulceration (sensitivity of 66 to 91%) Test 4 plantar sites on the forefoot (great toe and the base of 1st, 3rd and 5th metatarsals ) to identify 90% of patients with an insensate foot. Monofilament test Page 19 of 67

20 The sensitivity of this test for demonstrating a deficit is ~53%
Assessment Tuning Fork (vibration) Apply a vibrating 128 Hz tuning fork to the bony prominence of the big toe If the patient cannot feel the vibration, gradually move the fork upwards The sensitivity of this test for demonstrating a deficit is ~53% A biothesiometer is a portable device that measures the vibration perception threshold. A vibration threshold of more than 25V has a sensitivity of 83%. Tuning fork test Either an abnormal 10g monofilament test or a vibration threshold of more than 25V predicts foot ulceration with a sensitivity of 100% , hence the rationale for combining these two tests in clinical practice. Page 20 of 67

21 “So how do we know how well the blood is flowing?”
Assessment Peripheral Vascular Disease (PVD) “So how do we know how well the blood is flowing?” History : claudication (calf pain after walking a specific distance) that is relieved by rest. However this is uncommon in people with diabetes due the concomitant neuropathy. Examination: Palpate the foot for temperature (cool in PVD); palpate the dorsalis pedis pulse and, if absent, the posterior tibial pulse. Test for Bergers angle (at which leg turns white) and reactive hyperaemia (leg turns bright red on declining back to the ground). Page 21 of 67 Palpation of the dorsalis pedis pulse Palpation of the posterior tibial pulse

22 Doppler being used to detect the dorsalis pedis pulse
Assessment Investigations: ankle brachial pressure index Measure the blood pressure (BP) in the arm using a sphygmanometer Measure the blood pressure in the foot. Place a BP cuff around the calf and detect the dorsalis pedis pulse using a small hand-held doppler. Inflate the cuff and slowly deflate until the pulse appears. The ankle brachial pressure index (ABPI) is the ratio of the ankle systolic pressure to brachial systolic pressure. ABPI is usually >1 but in the presence of peripheral vascular disease is <1. Normal ABPI effectively excludes significant arterial disease in >90% of limbs. Doppler being used to detect the dorsalis pedis pulse Absence of pulses and an ABPI of <1 confirms significant ischaemia. An exception is in medial artery calcification, in which the ABPI can be falsely elevated due to the simultaneously lower blood pressure (BP) in the upper limb. Page 22 of 67

23 Common abnormalities / deformities include:
Assessment Structural Abnormalities and Deformities Structural abnormalities and deformities lead to bony prominences which are associated with high mechanical pressure on the overlying skin. This results in ulceration, particularly in the absence of a protective pain sensation and when shoes are unsuitable. Ideally, the deformity should be recognised early and accommodated in properly fitting shoes before ulceration occurs. Common abnormalities / deformities include: Callus Bunion Hammer toes Claw toes Charcot foot Nail deformities Note: It is vital to inspect the patients shoes as part of the assessment! Callus on plantar surface Page 23 of 67 Bunion on the medial border of the foot

24 Charcot foot deformity
Assessment Some Common Foot Deformities Claw toes Page 24 of 67 Charcot foot deformity Nail deformity

25 A neuropathic ulcer on the sole of the foot
Assessment Ulcers “Pre-ulcer assessment all done! What about after an ulcer has developed?” Several foot ulcer classifications have been proposed although none is universally accepted. The simplest classification is based on the underlying pathogenesis: neuropathic, ischaemic or neuroischaemic. It is vital to carefully monitor the progress of an ulcer once one has developed. The University of Texas system shown on the next slide can be used to predict outcome by grading wound depth and presence of infection and/or ischaemia. However there is no measure of neuropathy. A neuropathic ulcer on the sole of the foot Page 25 of 67

26 Assessment University of Texas system for classification of ulcers
Ulcer Grade ( depth ) Ulcer stage A Pre / postulcerative lesion completely epethelialised Superficial lesion, not involving tendon, capsule or bone Wound penetrating to tendon or capsule Wound penetrating to bone or joint B Pre / postulcerative lesion with Infection Superficial lesion, not involving tendon, capsule or bone with Infection Wound penetrating to tendon or capsule with Infection Wound penetrating to bone or joint with Infection C Pre / postulcerative lesion with ishaemia Superficial lesion, not involving tendon, capsule or bone with ischaemia Wound penetrating to tendon or capsule with ishaemia Wound penetrating to bone or joint with ishaemia D Pre /postulcerative lesion with infection and ishaemia Superficial lesion, not involving tendon, capsule or bone with infection and ischaemia Wound penetrating to tendon or capsule with infection and ishaemia Wound penetrating to bone or joint with infection and ishaemia Page 26 of 67

27 Signs suggesting infection include; purulent secretions
Assessment Infected Ulcers “How do you know if the ulcer is infected then?” Assessing foot ulcers for the presence of infection is vital. All open wounds are likely to get colonised with microorganisms, such as Staphylococcus aureus, and not necessarily infected. Therefore, the presence of infection needs to be defined clinically rather than microbiologically. Signs suggesting infection include; purulent secretions presence of friable tissue undermined edges foul odour Page 27 of 67 An infected ulcer

28 Simple investigations include:
Assessment Infected Ulcers: Investigations Simple investigations include: Tissue specimens or material obtained from the bottom of a wound for gram staining and culture for microbial sensitivity. Aspiration of material for culture is better than taking a swab which is prone to contamination. Full blood count, urea and electrolytes, inflammatory markers (WCC, ESR and CRP) for assessing severity of infection Plain X-ray of the leg for signs of bone damage, presence of foreign body, or gas in soft tissue (gas gangrene) More advanced radiology involves: Technetium bone scan and MRIs may be necessary in some patients to define underlying bony involvement Invasive investigations include: Bone biopsy, as the gold test for diagnosing osteomyelitis. Arteriography using contrast dye can be used to visualise leg ischaemia Page 28 of 67

29 You have come to the end of the second section
End of Section 2 Well done! You have come to the end of the second section We suggest that you answer Questions 5 to 9 to assess your learning so far. Please remember to write your answers on the mark sheet before looking at the correct answers! Page 29 of 67

30 Click here for the answers
Section 2 Quiz Question 5: List the 3 components of diabetic foot assessment. Write your answer in your mark sheet ……………………….. Click here for the answers Page 30 of 67

31 Section 2 Quiz Question 6: Write ‘T’ or ‘F’ on the answer sheet. After completing all 5 questions, click on the boxes and mark your answers. A high medial longitudinal arch and prominent metatarsal heads are signs of ischaemia The tuning fork and biothesiometer are used for assessing pressure sensation Ankle brachial pressure index is the ratio of ankle systolic pressure to brachial diastolic pressure A doppler can be used to confirm the presence of pulses but cannot quantify the vascular supply Bone biopsy is the gold standard for diagnosing osteomyelitis a b c d Page 31 of 67 e

32 Click here for the answers
Section 2 Quiz Question 7: Identify these clinical images. Write your answer in your mark sheet 1 2 Click here for the answers 4 Page 32 of 67 3

33 Click here for the answers
Section 2 Quiz Question 8: List 5 common foot deformities found in association with diabetic feet. Write your answers on the mark sheet. ……………………………… Page 33 of 67 Click here for the answers

34 Section 2 Quiz Question 9: Fill in the blanks in the University of Texas grading and staging table. Write your answer in your mark sheet Ulcer Grade ( depth ) Ulcer stage A Pre / postulcerative lesion completely epethelialised Superficial lesion, not involving tendon, capsule or bone Wound penetrating to tendon or capsule Wound penetrating to bone or joint B Superficial lesion, not involving tendon, capsule or bone with Infection Wound penetrating to bone or joint with Infection C Pre / postulcerative lesion with Ishaemia Wound penetrating to tendon or capsule with Ishaemia D Pre /postulcerative lesion with Infection and Ishaemia Superficial lesion, not involving tendon, capsule or bone with Infection and Ischaemia Wound penetrating to tendon or capsule with Infection and Ishaemia Wound penetrating to bone or joint with Infection and ishaemia Page 34 of 67

35 Management General measures
“Ok, so now we know the extent of the problem, how it occurs and how to assess for it. Now what do we do about it?” General measures Managing diabetes and it’s complications requires a multidisciplinary approach because optimum glycaemic control is key in reducing all complications cardiovascular risk factors such as smoking, dyslipidaemia and hypertension should be addressed to reduce risks of PVD, acute coronary syndrome and chronic renal failure education of patients on proper foot care and on the importance of seeking medical advice early is very important Page 35 of 67

36 Management The Normal Foot
“If a patient with diabetes has normal feet do we need to worry?...YES!” Your aim is to keep the foot normal. Key elements are: wearing the correct footwear the diagnosis and prompt treatment of foot problems that are common in the general population including people without diabetes. Good shoe guide: Toe box should be sufficiently long, broad and deep to accommodate the toes without pressing on them, with a clear space between the apices of the toe the toe box Shoes should be fasten with adjustable lace, strap or Velcro high on the foot in order to hold foot firmly inside the shoe and thus reduce frictional forces when the patient walks The heel of the shoe should be less than 5 cm to avoid weight being thrown forward into metatarsal heads The inner lining of shoe should be smooth Stocking or socks should always be worn to avoid blisters Page 36 of 67 Good pairs of shoes for men and women An example of a bad shoe type

37 Management Diagnosing and treating common foot problems
Most people in this stage will be able to cut their own toe nails. However specific nails and other minor foot problems will need treatment from the podiatrist. These are the most common conditions: Onychogryphosis (ram’s horn nail); regular debulking by a podiatrist Onychocryptosis (ingrowing toe nail); removal of the offending nail splinter and filing of the ragged edge by a podiatrist Involuted toe nail; clearance of the sulcus with a Black’s file (specially design for it) Onychomycosis; reduce bulk of the nail at regular intervals, treat with antifungals Tinea pedis (athletes foot); treat with topical antifungals (e.g canesten). Verrucae (warts); treat by cryotherapy. Most resolve within 2 years. Corns; removal by a podiatrist. Nail cutting Page 37 of 67 Athletes foot

38 Management The At-Risk Foot
“And if neuropathic or ischaemic and/ or deformities are present?” - This foot is susceptible to ulcers, so... Deformities should be accommodated in properly fitting footwear. Special footwear will be needed if the deformity is severe. Some specific deformities need special management; Clawed toes need a shoe with a wide, deep, soft toe box to reduce pressure on the dorsum of the toes. Extra depth shoes to protect the apices of the toes Prominent metatarsal heads: an extra depth stock shoe with a cushioning insole may suffice Callus: Is the most important pre-ulcerative lesion in this stage. It should be regularly and sufficiently remove by a podiatrician with a scalpel. Dry skin and fissure: treat with an emolient (E45 or calmurid cream), reduce fissure margins with scalpel Callus removal Page 38 of 67

39 Palpation of the dorsalis pedis pulse
Management Peripheral Arterial Disease (PAD) If PAD is evident: address cardiovascular risk factors smoking dyslipidaemia hypertension treat with oral aspirin 75mg OD seek advice from a vascular surgeon if available Palpation of the dorsalis pedis pulse Page 39 of 67 Note: Vascular assessment is also needed before cutting nails/calluses to ensure that wound healing is adequate.

40 “How should we advise patients that get deformities?”
Management Foot Deformities “How should we advise patients that get deformities?” Provide patients with the following information: Never walk bare footed Visit a podiatrist regularly if you have callus Never try to remove corns or callus by yourself Prevent dryness in your feet by using creams Be careful not to burn your feet Shake out loose pebbles or grit before you put on your shoes Run a hand around the sides of the shoes to detect rough, worn places Repair or replace worn out shoes Claw toes Page 40 of 67

41 Ischaemic necrosis of a toe and an extensive plantar ulcer
Management Ulcers due to Ischaemia “It’s an ulcer..what now!?”-Don’t panic, be methodical. Treatment of diabetic foot ulcers largely depends on the underlying causes: ischaemia, neuropathy or a combination of both. Treatment approaches for ischaemia include: Medical: reduce cardiovascular risk factors (see above) Surgical: revascularisation to achieve timely and durable wound healing is sometimes necessary. Patients with supra-inguinal (aorta-iliac) disease may be amenable to angioplasty (+/- stenting), with good long-term results being achieved at a low risk. Open bypass surgery may be considered for those patients who do not have an endovascular option. Page 41 of 67 Ischaemic necrosis of a toe and an extensive plantar ulcer

42 The key to treatment here is to redistribute plantar pressure.
Management Ulcers due to Neuropathy The key to treatment here is to redistribute plantar pressure. The best method is some form of cast (see later) . If not available, temporary ready-made shoes with a plastozote insole such as Drushoe can off-load the site of ulceration. Alternatively, weight-relief shoes and felt pads may also be used. Other weight-relieving measures such as the use of crutches, wheelchairs and zimmer frames should be encouraged. Heeled ulcers also need off-loading by foam wedges, heel protector splints or rings. The common site for a neuropathic ulcer Page 42 of 67 When the neuropathic ulcer has healed, it is vital that the patient is fitted with a cradled insole and bespoke shoes to prevent recurrence.

43 “These cast things sound useful...what are they?”
Management Offloading Pressure: Casts “These cast things sound useful...what are they?” Various casts are available and all aim to relieve plantar pressure. Their use is governed by local experience and expertise Air cast (walking brace) A bivalved cast with the halves joined together with Velcro strapping. The cast is lined with 4 air cells which can be inflated with a hand pump to ensure a close fit. The cast can be removed easily by patients to check their ulcers and before going to bed. Scotch cast boot A simple, removable boot made of stockinette, soffban bandage, felt and fibreglass tape. Total contact cast It is a close-fitting plaster of paris and fibreglass cast applied over minimum padding. It is very efficient method of redistributing plantar pressure, and should be reserved for plantar ulcers that have not responded to other casting treatments. An air cast Page 43 of 67 A scotch cast boot

44 Cast problems to be aware of:
Management Casts: Some Precautions Casts should be removed every week for wound inspection and then renewed. Once the ulcer is healed, the patient should be assessed for cradled insoles and bespoke shoes. Cast problems to be aware of: Iatrogenic lesions (rubs, pressure sores, infections) which often go undetected Cast are often heavy and uncomfortable and reduce the patient’s mobilty Patients may not drive a car in a cast The leg may develop immobilisation osteoporosis Danger of fracture and the development of a Charcot foot when coming out of a cast if patient walks too far too soon A few patients develop a cast phobia and will not wear them Page 44 of 67

45 Debridement is undertaken to:
Management Wound Debridement “What can we do to treat the ulcer?” In both isacheamic and neuropathic ulcers, treatment is based on debridement of the wound and dressing application. Debridement is the removal of necrotic and dead tissue in order to enhance healing. Debridement is undertaken to: Remove callus in neuropathic foot to lower plantar pressure Assess the true dimension of the ulcer Drain exudate and remove dead tissue to render infection less likely Take a deep swab for culture Encourage healing and restore a chronic wound to an acute wound Forcep and a scalpel is the usual technique by cutting away of all slough and non-viable tissue. Page 45 of 67

46 Contra-indications to maggot therapy:
Management Wound Debridement using maggots (larvaetherapy) The larvae of the green bottle fly (which feed on dead flesh) are sometimes used to debride ulcers, especially in the ischaemic foot. Only sterile maggots obtained from a medical maggot farm should be used! Maggots produce a mixture of proteolytic enzymes that breakdown slough and necrotic tissue which they ingest as a source of nutrients. During this process, they also ingest and kill bacteria including antibiotic resistant strains. As a result of their wound cleansing activity, the application of maggots has been found to reduce wound odour, and it has also been reported that their presence within a wound stimulates the formation of granulation tissue. Contra-indications to maggot therapy: Free range maggots should not be introduced into wounds that communicate with the body cavity or any internal organ They should not be applied to wounds that have a tendency to bleed easily or contain exposed large blood vessels They should not be applied to patients with clotting disorders, or individuals receiving anticoagulant therapy unless under constant medical supervision in a health facility. Page 46 of 67

47 BioFOAM dressing with maggots inside
Management Larvaetherapy Preparations Maggots are available in 2 forms. ‘Free Range’ maggots applied directly to the wound roam freely over the surface seeking out areas of slough or necrotic tissue generally left on wound for a maximum of 3 days. BioFOAM Dressing Maggots enclosed in net pouches containing pieces of hydrophilic polyurethane foam dressing is placed directly upon the wound surface BioFOAM Dressing can be left for up to 5 days then the wound is reassessed. BioFOAM dressing with maggots inside Page 47 of 67

48 Additional approaches include Skin graft:
Management Wound Dressings A sterile, non-adherent dressing should cover all open diabetic foot lesions to protect them from trauma, absorb exudate, reduce infection and promote healing. Dressings should be lifted every day to ensure that problems or complications are detected quickly, especially in patients who lack nociception. Additional approaches include Skin graft: A split-skin graft may be harvested and applied to the ulcer to speeds healing of the ulcer which if has a clean granulating wound bed Vacuum-Assisted closure (VAC) pump: This is an innovative measure to close diabetic foot wounds. It applies gentle negative pressure to the ulcer via a tube and foam sponge which are applied to the ulcer over a dressing and sealed in place with a plastic film to create a vacuum. Exudate from the wound is sucked along the tube to a disposable collecting chamber. The negative pressure improves the vascularity and stimulates granulation of the wound. Page 48 of 67

49 Management New Developments
“Are there any new interesting aids for wound healing?” –Yes, three here; Hyperbaric oxygen therapy: Poor tissue oxygenation with diabetic microangiopathy reduces wound healing. Therefore hyperbaric oxygen therapy (HBOT) would theoretically aid in faster wound healing, there is however little evidence for this at present. Growth factor therapy: Recombinant platelet derived growth factor (PDGF) was the first growth factor approved by the Food and Drug Administration (FDA) for the treatment of lower extremity diabetic neuropathic ulcers that extend into the subcutaneous tissue and have adequate blood supply. PDGF, applied as a gel , theoretically acts to enhance granulation tissue formation and facilitate epithelialisation . It may be useful in small, low-grade so may have a role in chronic neuropathic ulcers that are refractory to conventional therapy but there is no evidence to support this theory. Bioengineered human dermis transplantation: Dermagraft is a cultured human dermis produced by seeding dermal fibroblasts on a biodegradable scaffold. After culture, a living dermal tissue is created which can later support the formation of an epidermis. Furthermore, dermatograft can generate growth factors, cytokines, matrix proteins and glycosaminoglycan, thus aiding the healing process. There have been a limited number of trials have confirmed the efficacy of dermagraft in healing chronic ulcers in a significantly shorter time. Page 49 of 67

50 Perenteral antibiotics
Management Infected Ulcers - Antibiotics “It appears infected...which antibiotics to use?” Treating infected ulcers: Ensure the previously described physical wound management techniques are used. The initial antibiotic regime is usually selected empirically based upon clinical experience and local preferences; cover of +cocci is essential as they are the usual culprits of infection as they thrive cutaneously. Antibiotics are modified on the basis of clinical response and and wound culture / sensitivity results. Good examples include; Oral antibiotics Perenteral antibiotics Penicillin V OR co-amoxiclav +/- Benzylpenicillin +/- Flucloxacillin Ciprofloxacillin Cephalexin clindamycin Imipenem-cilastin Ampicillin-sulbactam Cefuroxime Metronidazole ( for anaerobes ) Page 50 of 67 For mild infections, 7-10 day course is usually sufficient. Severe infections may need up to 2-3 weeks of treatment.

51 Treating Charcot’s neuro-osteoarthropathy
Management The Charcot Foot “And when the bone gets infected?” Lastly, treating underlying osteomyelitis is an important therapeutic challenge. Presence of osteomyelitis warrants long-term treatment of at least 4 – 6 weeks duration with antibiotics that penetrate well into bone such as fluoroquinolones, clindamycin or fusidic acid. Surgical ressection still remains the most definitive treatment for osteomyelitis especially for patients not responding to antibiotics. An infected ulcer draining pus Treating Charcot’s neuro-osteoarthropathy “Charcot foot” refers to bone and joint destruction that occurs in the neuropathic foot or rarely just the toe. It can be divided into three phases: Acute onset; Bony destruction / deformity; Stabilistion; 1. Acute onset Characterised by unilateral erythema and oedema and the foot is at least 2˚C hotter than the contralateral foot. About 30% of patients may complain of pain or discomfort which is rarely severe. X-ray may be normal, but a technnetium methylene diphosphonate bone scan will detect early evidence of bony destruction. Page 51 of 67

52 Management The Charcot Foot - 2
Patients awaiting bone scan should be treated as if the diagnosis has been confirmed; Initially the foot is off-loaded and immobilised in a non-weight-bearing cast to prevent deformity. After 1 month, a total-contact cast is applied and the patient may mobilise for brief period. However, the patient is given crutches and encouraged to keep walking to a minimum. If given early, these measures can prevent bony destruction. Bisphosphonates are potent inhibitors of osteoclast activation and may also be used in this phase. 2. Bony destruction Clinical signs are swelling, warmth, a temperature 2˚C greater than the contralateral foot and deformities including the rocker-bottom deformity and medial convexity. X-ray reveals fragmentation, fracture, new bone formation, subluxation & dislocation. The aim of treatment is immobilisation until there is no X-ray evidence of continuing bone destruction and the foot temperature is within 2˚C of contra lateral foot. A photo showing a charcot foot with an ulcer on the sole Page 52 of 67

53 Management The Charcot Foot - 3
3. Stabilisation The foot is no longer warm and red. There may still be oedema but the difference in skin temperature between the feet is less than 2˚C. the X-ray shows fracture healing, sclerosis and bone remodelling. The patient can now progress from a total-contact cast to an orthotic walker, fitted with cradled moulded insoles if necessary to accommodate a rocker-bottom or medial convexity deformity. Cautious rehabilitation should be the rule, beginning with a few short steps in a new footwear. Finally, the patient may progress to bespoke footwear with moulded insoles as the rocker-bottom charcot foot with plantar bony prominence is a site of very high pressure. Regular reduction of callus can prevent ulceration. During the acute stage, charcot foot’s foot may be misdiagnosed as; Cellulitis Osteomyelitis Deep vein thrombosis Inflammatory arthropathy Therefore a high index of suspicion is very important at this stage! Page 53 of 67

54 Management Amputation
“...if the foot does not stabilise or ulcer is worsening?”- Definitive management Amputation Referral to vascular surgeons for possible amputation is made on clinical findings that the ulceration is not healing/ infection worsening in spite of intensive antibiotic therapy Signs include: Extensive tissue loss Unreconstructable ischaemia Failed revascularisation Charcot’s of ankle with instability Page 54 of 67

55 Treating painful diabetic neuropathy:
Management Pain “What about giving them some analgesia?” Treating painful diabetic neuropathy: General approach; Reassure the patient that intense pain improves within 2 years. Regular appointments to monitor their pain and try new strategies if refractory to previous attempts. It is essential to optimise diabetic control. Drugs; Simple analgesics; e.g. aspirin, paracetamol, and mild opiates such as codeine phosphate singly or in combination. Prescribe hypnotics for disturbed sleep. Trycyclic antidepressants; e.g imipramine, amitriptyline. Commence with low dose and gradually increase according to symptomatic response Anticonvulsants; e.g carbamazepine, valproate, phenytoin, gabapentin, lamotrigine may be very useful. The latter two may improve sleep in addition to pain relief. Capsaicin is a very useful topical analgesic Page 55 of 67

56 Prophylactic foot surgery:
Management New Surgical Techniques “So that’s where we are at the moment. How about future developments?” Prophylactic foot surgery: The last decade has a dramatic interest in reconstructive foot surgery for the diabetic foot. The aim of this surgery is to reduce risk of ulceration. A short Achilles tendon may be associated with elevated forefoot plantar pressure and hence may benefit from Achilles tendon lengthening surgery. Tenotomy of toe extensors may reduce toe deformities, thus preventing recurrent ulcerations in this group of patients. Metatarsal osteotomy may reduce the risk of ulcer recurrences in subjects with prominent metatarsal heads. However, currently there is no randomise control trial evidence comparing these surgical techniques with medical therapy. Page 56 of 67

57 You have come to the end of the last section
End of Section 3 Well done! You have come to the end of the last section We suggest that you answer Question 10 to 18 to assess what you have learnt. Please remember to write your answers on the mark sheet before looking at the correct answers! Page 57 of 67

58 Section 3 Quiz Question 10: Write ‘T’ or ‘F’ on the answer sheet. First complete all 5 questions, then click on the boxes and mark your answers. Good shoe guide: Toe box should be sufficiently long, broad and deep to accommodate the toes without pressing on them, with a clear space between the apices of the toe box Shoes should be fasten with adjustable lace, strap or velcro high on the foot in order to hold foot firmly inside the shoe and thus reduce frictional forces when the patient walks The heel of the shoe should be over 5 cm high to avoid weight being thrown forward into metatarsal heads The inner lining of shoe should be smooth Stocking or socks should not be worn with shoes a b c Page 58 of 67 d e

59 Section 3 Quiz Question 11: List five common foot problems that occur in the population at large.Write your answer in your mark sheet ………. Click here for the answers Page 59 of 67

60 Section 3 Quiz Question 12: Identify the following photos below. Write your answer in your mark sheet. Click here for the answers 2 1 Page 60 of 67 3 4

61 Section 3 Quiz Question 13: name three cast techniques used for off-loading pressure in neuropathic diabetic foot. Write your answer in your mark sheet ………. Click here for the answers Page 61 of 67

62 Section 3 Quiz Question 14: List five reasons why debridement is important in the treatment of diabetic foot ulcers. Write your answer in your mark sheet ……………….. Click here for the answers Page 62 of 67

63 Oral antibiotics; ………….. Parenteral antibiotics; ……………
Section 3 Quiz Question 15: List 4 oral and 4 parenteral antibiotics used in treating infected diabetic foot ulcers.Write your answer in your mark sheet Oral antibiotics; ………….. Parenteral antibiotics; …………… Click here for the answers Page 63 of 67

64 …………………………………………………… ………….
Section 3 Quiz Question 16: Describe the term charcot foot and mention its three phases of evolution .Write your answer in your mark sheet …………………………………………………… …………. Click here for the answers Page 64 of 67

65 Section 3 Quiz Question 17: identify the following photos below Write your answer in your mark sheet Click here for the answers 2 1 Page 65 of 67 3 4

66 Section 3 Quiz Question 18: List 5 categories of drugs used in the treatment of painful diabetic neuropathy. Write your answer in your mark sheet. ……………… Click here for the answers Page 66 of 67

67 Sources of Information/Images and References
A Clarke (2005). Pathology of the non-ulcerative foot. Diabetes voice; volume 50. Time to Act (2005). International Diabetes Federation and the International Working Group on Diabetic Foot. Edmonds ME, Foster AVM (2005). Managing the diabetic foot (2nd edition). Blackwell Science, Oxford. Khanolkar MP, Stephens JW, Bain SC. (2007) The Diabetic Foot. (in press). Morriston Hospital, Swansea, UK. LarvE® data card version 2.9 and dressing application version 2.0 (2007). Levin and O’Neal. Eds. John H. Bowker and Michael A. Pfeifer. (2007) The Diabetic Foot. Mosby, Elsevier. 7th edition The 5th International Symposium on the Diabetic Foot. (May 9-12, 2007). International Diabetes Federation. Noordwijkerhout, the Netherlands,. Page 67 of 67

68 ü Epidemiology Quiz - 1 Europe
In 2007 there were 55 million adults with diabetes in Europe compared with 10 million adults in Africa. ü Back

69 ü Epidemiology Quiz - 2 Europe
By 2025 the prevalence of diabetes in Europe is estimated at 7.8 % (1.4 % increment) compared with Africa’s estimated prevalence of 3.8 % (0.5 % increment). ü Back

70 Epidemiology Quiz - 3 Africa: The prevalence of diabetic foot ulcer is 20 % in developing countries (including Africa) compared with 15 % in developed countries (including Europe). The IDF/ IWDF* showed that foot amputation in people with diabetes was 50 times more frequent in Tanzania (Africa) than Croatia (Europe) in a hospital- oriented studies. ü * International Diabetes Federation and The international Working Group on Diabetes joint publication 2005. Back

71 Artherosclerosis is the narrowing or sometimes blockage of arteries
Artherosclerosis is the narrowing or sometimes blockage of arteries. It is due to abnormal deposition of fat (cholesterol) on their inner lining which subsequently mixes with fibrin and platelets to form hard plaques. Plaques reduce or completely blocks the artery lumen. Artherosclerosis is known to be common in diabetes although the reason for this is not known. E.g retinal blood vessels are affected (diabetic retinopathy) which may cause blindness. Ischaemic toes due to artherosclerosis Artheroma plaque narrowing the arterial lumen Back

72 Larvaetherapy - 1 Materials Next Preparation of the wound site:
Photo showing a BioFOAM dressing with maggots inside A dressing tray Preparation of the wound site: Remove existing dressing and irrigate the wound to remove any dressing residues Protect intact skin around the margin of the wound by application of a layer of sudocrem or zinc paste bandages An ulcer with necrosis for lavaetherapy Next

73 Larvaetherapy - 2 Back Application of the dressing:
Remove the Dressing ( BioFOAM Dressing ) containing maggots from the transit container and place directly on the surface of the wound Repeat using as many Dressing ( BioFOAM Dressing ) as necessary to cover the area to be cleansed Cover the Dressing (BioFOAM Dressing ) with a low adherent pad and complete the dressing with an absorbent pad held in place with tape or bandage as appropriate NB: Occlusive dressing or film dressings SHOULD NOT be used as these will cause the maggots to suffocate. A BioFOAM dressing on the ulcer A diabetic foot already dressed with BioFOAM Back

74 Authors and Reviewers Authors:
Dr. Lamin ES Jaiteh, Senior House Officer, Royal Victoria Teaching Hospital, Banjul, The Gambia. Dr. Alexander B Werhun, Senior House Officer, Morriston Hospital, Swansea, UK. Sr. Rosalyn Thomas, Podiatrist, Diabetic Unit, Morriston Hospital, Swansea, UK. Reviewers: Dr. Jeff Stephens, Senior Lecturer in Medicine; Miss Jess Griffiths, Learning Technologist; Dr. Steve Allen, Reader in Paediatrics, Swansea Medical School, Swansea, UK. Back

75 ü Answer to Question 1a The statement is true. About
2 million people worldwide are diabetic, a global prevalence of 5.1% making it an epidemic four years ago. ü Back

76 Answer to Question 1b The statement is false.more than 300 million people will be diabetic in 2025 making the prevalence to be higher by more than a fold. û Back

77 Answer to Question 1c The statement is false.the incidence of foot ulceration is 20% in developing countries compare to the 2% incidence in developed countries. û Back

78 Answer to Question 1d The statement is true.Diabetic foot amputation is common in developing countries because in these coutries patients seek medical care late and also the foot care is sub-optimal. ü Back

79 Answer to Question 1e The statement is false. Studies have shown that mortality after amputation of a diabetic foot is higher in developing countries compared to the developed countries. û Back

80 Answer to Question 2a The statement is true.Studies have shown that people’s life are grossly affected after diabetic foot amputation, they can’t pursue active social life. It has also been found out that diabetic foot cost 12-15% of health care resource in developed countries and up to 40% in developing countries. ü Back

81 Answer to Question 2b The statement is true.Studies done by the International Diabetic Federation and the International Working Group on diabetic foot showed that depression is common in diabetic patients after amputation. ü Back

82 Answer to Question 2c The statement is true. Due to high blood sugars a) damaging white cells to reduce leucocyte function. b) disrupting blood vessel endothelium giving diabetic microangiopathy thereby reducing tissue perfusion c) giving microorganisms an ideal environment to proliferate and infect ulcers ü Back

83 Answer to Question 2d The statement is true. Artherosclerosis is common in diabetes even though it is not still explained with evidence why people with diabetes suffers from artherosclerosis. ü Back

84 Answer to Question 3 The other two main causes of diabetic foot ulcer are deformities and trauma. Back

85 Answer to Question 4 The following are the predisposing factors to diabetic foot ulcer according to the flow chart; Foot deformities Stress and shear pressures on the foot Reduced perception of pain sensation Callus formation Fissures and cracks Bulging veins NB: Trauma can cause foot ulceration in the presence of any of these factors above. Diabetic foot ulcer is susceptible to infection irrespective of its cause. Back

86 Answer to Question 5 The three components of diabetic foot assessment are; Neuropathic assessment Vascular assessment and Structural assessment Back

87 Answer to Question 6a The statement is false. A high medial longitudinal arch and prominent metatarsal heads is classical of neuropathy û Back

88 Answer to Question 6b The statement is false. Tuning fork and biothesiometer are used for assessing vibration sensation. û Back

89 Answer to Question 6c The statement is false. Ankle brachial pressure index is the ratio of ankle systolic pressure to brachial systolic pressure. û Back

90 Answer to Question 6d The statement is false. A doppler can be used to confirm the presence of pulses and quantify the vascular supply. û Back

91 Answer to Question 6e The statement is true. Bone biopsy remains the gold standard for diagnosing osteomyelitis ü Back

92 Charcot foot deformity
Answer to Question 7 1 2 Claw toes Charcot foot deformity 4 Monofilament test Callus on the sole 3 Back

93 Answer to Question 8 Common foot abnormalities / deformities found in association with diabetic foot include; Callus Bunion Hammer toes Charcot foot Claw toes Nail deformities Back

94 Answer to Question 9 Back
Tables showing the University of Texas gading and staging of diabetic foot ulcer. Ulcer Grade ( depth ) Ulcer stage A Pre / postulcerative lesion completely epethelialised Superficial lesion, not involving tendon, capsule or bone Wound penetrating to tendon or capsule Wound penetrating to bone or joint B Pre / postulcerative lesion with Infection Superficial lesion, not involving tendon, capsule or bone with Infection Wound penetrating to tendon or capsule with Infection Wound penetrating to bone or joint with Infection C Pre / postulcerative lesion with Ishaemia Superficial lesion, not involving tendon, capsule or bone with Ischaemia Wound penetrating to tendon or capsule with Ishaemia Wound penetrating to bone or joint with Ishaemia D Pre /postulcerative lesion with Infection and Ishaemia Superficial lesion, not involving tendon, capsule or bone with Infection and Ischaemia Wound penetrating to tendon or capsule with Infection and Ishaemia Wound penetrating to bone or joint with Infection and ishaemia Back

95 Answer to Question 10a The statement is true. Toe box should be sufficiently long, broad and deep to accommodate the toes without pressing on them, with a clear space between the apices of the toe box ü Back

96 Answer to Question 10b The statement is true. Shoes should be fasten with adjustable lace,strap or velcro high on the foot in order to hold foot firmly inside the shoe and thus reduce frictional forces when the patient walks ü Back

97 Answer to Question 10c The statement is false. The heel of the shoe should be under 5 cm high to avoid weight being thrown foreward into metatarsal heads û Back

98 The statement is true. The inner lining of the shoe should be smooth.
Answer to Question 10d The statement is true. The inner lining of the shoe should be smooth. ü Back

99 Answer to Question 10e The statement is false. Stocking or socks should be worn with shoes to avoid blisters û Back

100 Answer to Question 11 Foot problems common in the population at large include; Tinea pedis ( athletes foot ) Corns Verrucae ( warts ) Onychomycosis Involuted toe nail Onychocryptosis ( ingrowing toe nail ) Onychogryphosis ( ram’s horn nail ) Back

101 Answer to Question 12 3 1 4 2 Back
Foot of a diabetic patient showing athletes foot 1 Foot of a diabetic patient showing ischaemic necrosis of a toe and an extensive plantar ulcer 4 2 A scotch cast boot on a patient An air cast on patient Back

102 Answer to Question 13 Cast techniques used for off-loading pressure in neuropathic diabetic foot include; Aircast ( walking brace ) Total-contact cast Scotchcast boot Back

103 Answer to Question 14 The rationale for debridement include;
Removal of callus in neuropathic foot, thus lowering plantar pressure It enables the true dimension of the ulcer to be perceived Drainage of exudate and removal of dead tissue renders infection less likely It enables a deep swab to be taken for culture It encourages healing, restoring a chronic wound to an acute wound Back

104 Answer to Question 15 Comonly used oral antibiotic regime include ;
Amoxicillin-clavulanic acid Ciprofloxacin Cephalexin Clindamycin Intravenous regimes commonly used include; Imipenem-cilastin Ampicillin-sulbactam Peperacillin-tazobactam Broad spectrum cephalosporins e.g cefuroxime Metronidazole for anaerobic infection. Back

105 Answer to Question 16 The term charcot foot refers to bone and joint destruction that occurs in the neuropathic foot or rarely just the toe. It can be divided into three phases: Acute onset; Bony destruction / deformity; Stabilisation; Back

106 Answer to Question 17 3 1 2 4 Back
A BioFOAM dressing with maggots inside Process of callus removal in a diabetic patient 2 4 Process of nail cutting in a diabetic patient An example of a bad shoe type Back

107 Answer to Question 18 Back
Drugs used in the treatment of painful diabetic neuropathic foot include; Simple analgesics; e.g aspirin, paracetamol, and mild opiates such as codeine phosphate singly or in combination. Prescribe hypnotics for disturbed sleep. Trycyclic antidepressants; e.g imipramine, amitriptyline. Comence with low dose and gradually increase according to symptomatic response Anticonvulsants; e.g carbamazepine, valproate, phenytoin, gabapentin, lamotrigine may be very useful. The latter two may improve sleep in addition to pain relief. Antiarrhythmics; e.g lidocaine, mexiletine may provide relief for several days Antioxidants; e.g benfotiamine, alpha-lipoic acid are also used. Aldose reductase inhibitors such epalrestat, fidarestat, ranirestat Newer therapies include; C-peptide Immunoglobulins Nerve growth factor Gene therapy Back


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