1. Prevention of Amputation
Rebecca Gardner
Podiatry Diabetes Specialist Practitioner
Hi my name is Rebecca Gardner and I am one of the Podiatry Diabetes Specialist Practitioners working for Hertfordshire Community NHS trust. I work mostly at the QEII and Lister hospitals with Dr Alsabbagh but I do also cover Hemel hospital as well. I am going to be giving a short presentation on the prevention of amputation.

2. 1-4% of people with diabetes will develop an ulcer per year (Leese at al, 2011; TRIEPodD-UK, 2012).
Approximately 58% of DFU patients will become clinically infected. (Eurodiale study group 3)
The number of diabetes-related amputations in England has now reached an all-time high of 20 a day (Diabetes UK 2016)
1-4% of people with diabetes will develop an ulcer per year Leese et al
According to a study published by the Eurodiale study group 3, approximately 58% of DFU patients will become clinically infected.
Amputation rate is on the rise: Public Health England data suggests there are about 7,370 amputations a year, compared to the previous figure of 7,042, according to Diabetes UK.
So to begin these are some of the latest statistics which do not give a very optimistic outlook for our patients with Diabetes.

3. Individuals with diabetic foot ulcers have a 50% chance of mortality in 5 years (Young 2012)
Early diagnosis and early intervention by an MDT approach can achieve good outcomes (Edmonds2009)
Studies have shown that individuals with diabetic foot ulcers have a 50% chance of mortality in 5 years ( Young 2012)
However research has shown that with early diagnosis and intervention within a multidisciplinary team can achieve good outcomes but it’s a huge challenge for us as health professionals.
I am now going to present 2 case studies which demonstrate successful MDT working

4. Case Study One Red Hot swollen Foot
This is a male who was 66 years of age at the time of presentation.
He has type 2 Diabetes and severe neuropathy.
Unfortunately he presented late to Podiatry with a red hot swollen foot and as you can see already established deformity. These photos and x ray were taken on day of presentation.
Anyone have a guess at the diagnosis?
Yes it is a Charcot of the left midfoot.
Charcot is a chronic and progressive condition affecting the bones and joints of the feet, it is seen in patients with Diabetes and severe neuropathy.
The pathogenesis is still not fully understood but the main predisposing factor is neuropathy which can be subdivided into sensory, motor and autonomic neuropathy which all have a part to play in the development of Charcot neuroarthropathy.
Autonomic neuropathy results in increase blood flow to the foot with increased bone resorption, osteopenia and increases the likelihood of fracture.
Sensory neuropathy results in loss of feeling in the foot so the person will be unaware of any trauma to the foot, such as a fracture and will continue to walk on the affected foot resulting in repeated micro trauma and further damage to the foot.
Motor neuropathy leads to deformity resulting in the typical neuropathic foot. High medial longitudinal arch, clawed toes with prominent metatarsal heads. This results in altered pressures on certain parts of the foot again increasing the risk of damage.
Reported in an article in the Diabetic foot and ankle in 2013 the prevalence of Charcot may be as much as 13% of patients with diabetes.
As you can from this x ray there is a Lisfrancs fracture of the midfoot with disorganisation of the tarsometatarsal joints.
This can be a devastating condition and unless diagnosed early enough can lead to defomrity, ulceration, infection and ultimately amputation.
This is why it is important that with any red hot swollen foot to consider Charcot until proven otherwise.
Charcot is often misdiagnosed for other conditions such as infection, peripheral vascular disease and gout.
There are several stages to the process of CAN.
The acute stage when the foot may be red hot and swollen but no radiological evidence to suggest a CHARCOT. It is at this stage that we want to see the patient.
If we consider it’s a charcot and x ray does not confimr this then we would refer the pt for an MRI.
The following stage include localised osteopenia, bony fragmentation, and destruction, followed by subluxation and dislocation and joint collapse. And the foot can become deformed very quickly.
The final stage us when the destructive stage slows down and the bones and joints start to heal with bony fusion and new bone formation. The result is a stable but often deformed foot. this can take any time form a year to 18 months to
Treatment is to offload the affected foot either in an Aircast or a total contact cast until the foot stabilises, This patient was treated in a TCC with limted weight bearing for ??? And then an aircast. The foot was stable in ????
Unfortunately with patients A. he had established deformity which resulted in reccuring ulceration on the plantar aspect of the foot.
Mr A was treated as part of the mDT and was seen by Podiatry, Diabetes Consultant, Orthotic department and Orthoapedics. This was treated successfully for a number of years until the decision was made to shave off the prominent bone which was causing the ulceration. .

5. Case Study One
Learning Points
Any red hot swollen foot to consider Charcot until proven otherwise.
Urgent referral to MDT.
Early diagnosis helps prevent deformity.
A diagnosis of Charcot is a life changing event for the patient. R
This was carried out on 26th July 2016.
This photo was taken a week ago. The wound is healing well with healthy granulation tissue.
Once this has healed Mr A can go back into surgical footwear and hopefully the foot will not ulcerate again.

6. Case Study 2 Complex Foot Ulceration
47 year old male
Type 1 Diabetes
Peripheral Vascular disease
Neuropathy
Nephropathy – Dialysis
MI and TIA
HbA1c 68 mmol/mol

7. Case Study 2

8. Learning Points Early referral to podiatry and the MDT is essential.
Good MDT working prevents major amputation.
Patients with a history of a foot ulcer have a 50% risk of re-ulceration.
People with diabetes have a 50% risk of reulceration within 1 year ( Maciejewski et al 2004)

9. Diabetic Foot Community clinics Clinics
MDT Foot clinics
Diabetic Foot Community clinics
Clinics
All of our 25 clinics across Hertfordshire see patients with Diabetes at both increased and high risk Many of these patients will have an ulcer. In the year 2013/2014 there were approximately 2500 patients with Diabetic foot ulcers seen by Podiatry.
Our guidelines suggest that if the ulcer is not improving in 6 weeks or is deteriorating the patient can be referred into the Diabetic foot care clinics. These clinics are led by Podiatrists who work within the MDT with a specialist interest in Diabetes.
These patients may alternate/rotate have their care jointly between the MDT and DFCC.
5 MDT clinics
WGH- 6 appt slots
HHGH - 10 appt slots
Lister - 16 appt slots
QE appt slots
HCH - 2 appt slots
MDT capacity is currently limited
West Hertfordshire 16 appointments per week
East Hertfordshire 28 appointments per week
When people with a foot attack get rapid access for treatment by a specialist multi-disciplinary team this has been shown to promote faster healing and fewer amputations, saving money and lives.

10. The Multidisciplinary Diabetes Team
Diabetologist
Paediatric Consultant
Practice Nurse
Diabetes Specialist Nurse
District Nurse
The Patient
G.P.
Dieticians
Tissue Viability Nurses
Orthotist
We are all part of that multidisciplinary team and each have a role for the care of these complex patients
Podiatrists
Orthopaedic Surgeon
Pharmacist
Radiologist
Microbiologist
Vascular Surgeon

11. Increased Diabetic Feet
Your feet have been assessed as being at increased risk of developing diabetic foot complications.
Podiatry Head Office: (Mon – Fri – 16.30)
Diabetic Foot Emergencies:
New pain or throbbing
Foot hotter than usual
New redness or swelling
New / increased discharge or smell
Unexplained increase in blood glucose
Flu like symptoms (hot / shivery)
If you notice any of the above, contact your GP straight away. Explain that you have a diabetic emergency. Outside of normal hours, call the Out of Hours GP or go to A&E.

12. Urgent referrals to NHS Podiatry
Ulceration +/- infection
Red Hot Foot
Fax to HCT Podiatry
Have we answered your burning questions
Evaluation
Tel
Fax

13. Non urgent referrals to NHS Podiatry
On going specialist foot care
Callus and corns in people at risk
Nail care for those at risk
Tel
Fax
The NHS provides a comprehensive service for those who’s feet are at risk.
Don’t attempt to treat corns and callus with blades or medicated corn plaster
If people require on going podiatry care – nails hard skin corns or if
Complete application form from HCT website and send to podiatry