1. The Diabetic Foot A Medical View Associate Professor Jonathan Shaw

3. Prevalence of neuropathy by diabetes status Tapp Diabet Med 2003 2 or more of: symptoms signs monofil insens post hypotension 2 or more of: symptoms signs monofil insens post hypotension

4. Prevalence of PVD by diabetes status Tapp Diabet Med 2003

5. Page 5: Baker IDI The percentage of people who had a foot examination in the previous year % (Duration of diabetes ≥1 year) Overall = 51% Tapp Diabetes Care 2004

6. Page 6: Baker IDI The percentage of people who had an eye examination in the previous year % (Duration of diabetes ≥1 year) Overall = 85% Tapp Diabetes Care 2004

7. Page 7: Baker IDI Independent predictors of screening Duration of diabetes1.33 DNE in last 12 mths1.89 Insulin treatment4.17 DNE in last 12 months2.14 Foot screening OR Retinal screening Tapp Diabetes Care 2004

8. Page 8: Baker IDI Foot ulcer assessment Neuropathic and/or ischaemic Neuropathic and/or ischaemic Infected or not Infected or not

9. Page 9: Baker IDI Neuropathic ulcer - diagnosis At site of repeated pressure –Dorsum of toes (shoes) –Under metatarsal heads Painless Surrounded by callus

11. Page 11: Baker IDI Ischaemic ulcer - diagnosis At the end of the circulation –Apex of toes –heel Painful No callus Foot cool with weak/absent pulses

12. Page 12: Baker IDI Grading of a foot lesion predicts outcomes Grade 0 Complete epithelialisation 1Superficial 2Penetrating to tendon or capsule 3Penetrating to bone or joint Stage A No infection or ischaemia B Infection C Ischaemia D Infection and ischaemia Armstrong et al. Diabetes Care. 21:855-9, 1998. Texas Wound Classification System

13. Page 13: Baker IDI Neuropathic ulcer - management Relieve pressure Debride callus and infected tissue Treat infection Appropriate dressings

14. Page 14: Baker IDI Pressure-relieving devices

15. Page 15: Baker IDI Pressure relief from a total contact cast

16. Page 16: Baker IDI Total contact cast leads to more rapid healing of neuropathic ulcers Half shoe Aircast TCC Armstrong et al. Diabetes Care. 2001;24:1019-22

17. Page 17: Baker IDI Removable vs non-removable cast walkers Removable Non-removable P = 0.02

18. Page 18: Baker IDI Ischaemic ulcer - management Debride callus and infected tissue Restore circulation (surgery/angioplasty) Treat infection Appropriate dressings

19. Page 19: Baker IDI Infected ulcers Infections usually polymicrobial Swabs fail to differentiate between infecting and colonising organisms Treat if local clinical signs of infection Use broad spectrum (Augmentin, clindamycin, ciprofloxacin, cephalexin) Usually need minimum of 2 weeks treatment

20. Page 20: Baker IDI Diabetic foot infections 84% polymicrobial 47% included aerobes and anaerobes Mean of 2.7 organism per culture of aerobes Mean of 2.3 organisms per culture of aerobes Citron et al. J Clin Microbiol. 2007; 45:2051-6

21. Page 21: Baker IDI Summary Annual foot examination to screen for risk factors is essential Foot ulcer management depends on type of ulcer and presence of infection Pressure relief is central to the management of neuropathic ulcers