2. In the beginning……..
Diabetic patients were losing limbs, long stays in hospital, no hope of healing chronic ulcers inevitable amputation.
No light at the end of the tunnel, only destruction, dismay and death.
…But a new era was emerging….

3. Historical Events Launch of Sky TV
Unleaded Petrol was at 38p per litre
Inauguration of the 1st President Bush
Order of the garter opened to women
Terry Waite was kidnapped in Beirut
First ever Rugby World Cup kicks off

4. Reduce Amputations by 50%
‘ Where are we – where do we want to be, and how can we get there’?

5. Scotchcast Boot

7. The Greater Team Podiatrist Specialist Care Patients Wards
District Nurses
Practice Nurses
G.P’s

8. 100 boots in Blackburn – 1988
Showed average healing rates of 8 weeks in neuropathic ulceration
BUT
How do we prevent the first ulcer?
How do we keep them healed?

9. Precipitating Factors of Ulcers
Historical Data 1988/1989
Precipitating Factors of Ulcers
Kings
(n=210)
Blackburn
(n=100)
Shoes
85%
74%
Accident 9%
14%
Thermal 2% 3%
Pressure 4%

12. LOW RISK Optimise diabetes and blood pressure control (<139/80)
Protective sensation intact
(10g pressure)
Optimise diabetes and blood pressure control (<139/80)
Foot education/Low risk leaflet
Podiatry only for problems

13. MODERATE RISK Loss of protective sensation No deformity No callus
No previous ulcer
Foot education/Moderate risk leaflet
Consider Consultant opinion
Optimise diabetes and blood pressure control (<139/80)
Footwear advice and assessment
Regular Podiatry (12 weekly)

14. Regular Podiatry (4 – 12 weekly)
HIGH RISK
Loss of protective sensation
Deformity and/or callus present
No previous ulcer
Optimise diabetes and blood pressure control (<139/80)
Foot education/High risk leaflet
Consultant opinion
Specialist prescribed Footwear/Shoe review
Regular Podiatry (4 – 12 weekly)

15. Regular podiatry and review
Very High Risk
Ulcer present or
Previous ulcer
Loss of protective sensation (10 g pressure)
Foot education leaflets/ very high risk leaflet
Consultant opinion
Specialist prescribed footwear / shoe review
Optimise diabetes & blood pressure control (<130/80)
Regular podiatry and review
(1-4 weekly)

16. Regular Podiatry especially nail care (1-12 weekly)
Arterial Disease
Abnormal flow
+/- History of claudication
telephone:
If you suspect acute vascular insufficiency
Optimise diabetes & blood pressure control (>139/80)
Prescribe aspirin/statin
‘Stop smoking and keep walking’
Foot education/leaflet
Consider consultant opinion
Specialist prescribed footwear / shoe review
Regular Podiatry especially nail care (1-12 weekly)

17. Referral Pathways For The Diabetic Foot
Referral for Urgent Problems
Referral for Non-urgent Problems
Referral for Diabetic Footwear
Urgent Patient
Non Urgent Patient
New patient
Existing patient
Referral letter, or fax ( )
Dr G.R. Jones, Diabetes unit, RBH
Prescribed footwear
Same Day Referral
Letter of Referral to
Dr G.R. Jones, Diabetes unit, RBH
Continue treatment until Outpatient Appointment
Ring :-
Diabetes Hot Foot line
Blackburn
Burnley
Orthotics
RBH
BGH
Orthotics
RBH
BGH
Condition becomes urgent refer via RED Pathway

18. N.I.C.E Guidelines recommend:-
Annual inspection and examination
Aggressive intervention to reduce morbidity
Primary and secondary care should work together to identify a package of care for at risk feet

19. N.I.C.E.
‘foot ulceration and lower limb amputation can be reduced if people who have sensory neuropathy affecting their feet are identified and offered regular podiatry and protective footwear if required’

20. Do Shoes and Orthoses work?
To look at the precipitating factors responsible for new DFU compared to previous studies.
Are shoes still a major factor or have things changed?
“Change is inevitable – except from a vending machine!”
Robert C. Gallagher

21. Precipitating Factors of Referred Ulcers
Kings
1988
(n=210)
Blackburn 1988
(n=100)
Blackburn
2004
(n=72)
Shoes
85%
74%
47.2%
Accident 9%
14%
12.5%
Thermal 2% 3%
4.2%
Pressure 4%
15.3%

22. Diabetic population and Ulcer Frequency
Outcomes
Diabetic population and Ulcer Frequency

23. Aetiology of Foot Ulcers in Diabetic Foot Clinic

26. 100 boots in Blackburn – 1988
Showed average healing rates of 8 weeks in neuropathic ulceration
BUT
How do we prevent the first ulcer?
How do we keep them healed? 26

27. Stock footwear
Bespoke footwear
Diabetic specification
Custom made insoles
Modular footwear

28. (Orthotic & Podiatric)
Continuous follow-up
(Orthotic & Podiatric)
2-3 servicable pairs of shoes
Long term care (>2yrs)
Weaning process
Long term healing
“A neuropathic patient is a footwear patient for life” (Ulbrect J 15/05/08)

29. Footwear Follow-up Study
100 consecutive patients recalled after 2 years
Then followed up for a further 7 years

30. Results 2 Years 5years 10Years Intact 70% 24% Cracked skin/callus 30%
23%
14%
Ulceration 3%
22%
Amputation
1 Major
3 Minor
7 Major
5 Minor

31. Conclusion from footwear follow-up study
Prescribed footwear is effective when worn, inspection is a vital part of follow up although this is written into guide lines it is not usually adhered to.
The importance of footwear review needs more emphasis at all levels of care

32. That’s ok but is it cost effective?

33. G H Nuttall P/O BSc(hons) MBAPO
I am asked (told) to provide footwear for diabetic patients.
20% of my working week is dedicated to working within the East Lancashire Diabetic Foot Team.
I am expected to provide orthosis that will prevent high risk feet from ulcerating & healed ulcerated feet from re-ulcerating.
Ensure patients have TWO serviceable pairs of footwear.

34. Am I of value in treating feet ? (or am I just an expensive accessory?)
Effective?
Efficient?
Contribution?
Cost effective?

35. Cost Savings by Orthotics
of £102,000
Cost saving
of £147,000
Cost saving
of £282,000
Cost saving
of £392,000 30 39 66 88

36. Allied Health Professions input to the Diabetes pathway
The cost on the NHS to heal one ulcer is £3k to £7.5k. Should this progress to amputation the cost is estimated to escalate to £65k. This is much more than the cost of preventative orthoses.
For every £1 spent in orthotics the NHS saves £4.
Hutton and Hurry 2009, Orthotic Service in the NHS: Improving Service Provision. York Health Economics

40. Ulceration/Hot Foot
REFER patients to a multidisciplinary foot care team within
24 hours if any of the following occur:
new ulceration (wound)
new swelling
new discolouration (redder, bluer, paler, blacker, over part or all of foot).
(NICE Guideline – Type 2 diabetes: prevention and management of foot problems)
REFER non-healing wounds from 0 – 4 weeks duration

41. Treatment of Ulceration
Pressure relief (preferably non removable)
Medical management (CVS, oedema, diabetes, infection)
Debridement and dressings
And…….. a team

42. Pressure Relieving Devices
Aircast Walker
DH shoe
DARCO walker
Padding & strapping
Podo-med
Half shoe

43. Nothing works like casting

44. Cast Variations Modified TCC Bi-valved cast Focused Rigidity Cast
Heel ulceration

45. Innovations from Diabetic foot Service
Scotchcast Boot
Bespoke casting
Screening Programme
Effective and efficient orthotic service
Hot foot line
House shoe
Charcot data and register

46. HOME? NOT SO SWEET HOME Lomax G McLaughlin C Jones G R Kenwright C
Blackburn Royal Infirmary

47. HOME? NOT SO SWEET HOME “THE GREATEST NUMBER OF STEPS PER DAY
ARE TAKEN IN
THE PATIENTS
OWN HOME.”
David Armstrong et al.
(American Podiatric Medicine 2001)

48. HOME? NOT SO SWEET HOME
PRESCRIBED INSOLES AND FOOTWEAR CAN PREVENT FOOT PATHOLOGY
(TOVEY F.I. 1987)

49. HOME? NOT SO SWEET HOME
Footwear is most effective when worn for a minimum of 60% of the day. (Chanteleau, E. Haage, P.)
Most effective when worn for 100% of the ambulatory time.

50. HOME? NOT SO SWEET HOME AIM OF STUDY
To assess what proportion of patients who had been prescribed Diabetic footwear were wearing at home.

51. How could we do this study?
HOME? NOT SO SWEET HOME
How could we do this study?
Ask patients at clinics?
A telephone survey?
Send patient questionnaires?
Knock on patient doors and ask and look?
Data collection by Community Podiatrists visiting patients homes on Domiciliary visits.
“The sneak approach”

52. HOME? NOT SO SWEET HOME RESULTS
Question
No shoes
Own shoes
Own slippers
Prescribed
shoes
1. What is patient wearing on entry to house?
19% 8%
52%
21%
2. What does patient apply after treatment?
15%
56%

53. HOME? NOT SO SWEET HOME CONCLUSION
75% of patients visited do not wear prescribed shoes at home.
All health care professionals need to be aware of this.

54. “ HOME SAFE HOME”

55. Charcot Foot

56. Care of People with Charcot Osteoarthropathy (NICE 01/04)
“People with suspected or diagnosed Charcot osteoarthropathy should be referred immediately to a specialist multidisciplinary foot care team for immobilisation of the affected joint(s) and for long-term management of offloading to prevent ulceration.”

57. Definition ? No definitive “test”
Xrays & scans – open to interpretation
Diagnosis is primarily clinical & subjective

58. Identification of Charcot Arthropathy
Unified district wide diabetic foot service
Centralised referral point
Validated district diabetes register

59. Charcot Data (1996-2006) Incidence and Prevalence
Patient Characteristics
Diagnostic Presentation
Treatment and Outcomes
(including the effect of an audit and community education event in 2001)

60. Presenting Site Of Charcot Arthropathy
1st.
2nd.
3rd.
Midfoot 32(71%)
Ankle 9(20%)
Forefoot 4(9%)

61. Presentation Charcot 10 (35%) delayed diagnosis on presentation
7 (24%) developed C.N.A on ipsilateral limb
3 (10%) developed C.N.A on contralateral limb.
9 (31%) diagnosed correctly

62. Local Charcot “Programme” (2001)
Why Delays in diagnosis/
Late Presentations
How Education event in community for all HCPs
What Road show – staff meetings,
lunch hours, training events

63. Presentation

64. Treatment of Charcot Arthropathy
Mean time in casts
2001, weeks (8 - 56) , weeks (range )
(p<0.001)
Mean time from active to quiescence
2001, weeks (8 -70) , weeks (range 8 – 40)
39 (87%)
4 (9%)
2 (4%)

65. exostectomies and minor amputations
Outcomes n=45
No. of
C.N.A
Surgery -
exostectomies and minor amputations
Below Knee
Amputation
Deaths
Healed/
Stable
Feet 31 7
Feet with Ulcers 14
5+4 4 2

66. Mortality/Morbidity Charcot v Matched Controls
(p>0.05)

67. Summary Charcot Arthropathy IS uncommon (1:500 people with diabetes)
Diagnosis is often initially delayed, but community education and awareness significantly reduces this
Poor diabetic control appears to be a prerequisite for CNA

68. Outcome for both limb and life is NOT adversely affected.
Conclusion
Earlier recognition and treatment of C.N.A. translates into significantly faster healing & 3/12`s less time in casts!
(Charcot “Road shows” work!)
Our local surgical practice is conservative & reserved for feet with recurrent or non healing ulcers only
Outcome for both limb and life is NOT adversely affected.
Larger patient numbers are needed to be studied to ratify these findings and this will demand collaborative working e.g. CDUK

69. Grant from DUK The Charcot register
National data base
Lead and managed from ELHT

70. The Charcot Register Scotland 6 North East 4 North West 10
Yorkshire & Humberside
West Midlands 3
East Midlands
Northern Ireland 1
Republic of Ireland 2
Wales
East Anglia 5
South West
South East 16
We’ve had centres registering patients from as far north as Aberdeen and as far south as Plymouth. The majority of centres have been in the south and north west.
We’ve also had interest in the project from America, Argentina, Malta and Australia.

73. Finally Latest Benchmarking Data from the SHA
Lowest non-elective admission rates
Shortest length of stay
Effective and efficient service

74. Then & now Diabetic Foot Service 1988
People working in isolated pockets
Foot clinic inaugurated
MDT formed
Inadequate referral pathways
High amputation rates
Long in patient stays
Huge NHS costs
NOW
Foot clinic 23 years old
Effective implemented pathways
Well established clinics
Good interagency and interprofessional relationships
Low amputation rates
Reduced in patient stay
Cost efficient

76. Thank you