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MIAMI CRITICAL LIMB ISCHEMIA SYMPOSIUM
Prevention of Diabetic Foot Wounds
Ira Baum, DPM, FACFAS 2014
?
Ira Baum, DPM, FACFAS 2014
“An ounce of prevention is worth a pound of cure.”
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PREVENTION REQUIRES UNDERSTANDING OF THE CAUSATIVE FACTORS:
Neuropathy
Peripheral Arterial Disease
Trauma
Ira Baum, DPM, FACFAS 2014
Causative Factors
Flow Pattern Contributing to Diabetic Wound
Ira Baum, DPM, FACFAS 2014
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Contributing FactorsContributing Factors
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Peripheral Neuropathy
� Nutrition
� Vascular
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Sensory Neuropathy
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Loss of Protective SensationIncrease in Amputation 7 X
Autonomic Neuropathy
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� A-V shunting
� Abnormal vascular response
� Combined with Sensory & Motor Neuropathy
Charcot Foot
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Charcot Foot or Cellulitis?
Ira Baum, DPM, FACFAS 2014
Motor Neuropathy
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� Achilles Tendon Contracture
� Increased forefoot pressure
� Small intrinsic muscles atrophy
� Structural foot deformities
� Abnormal pressure area
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~2 X AS COMMON IN PEOPLE WITH DM
THAN WITHOUT DM
Peripheral Arterial Disease
Ira Baum, DPM, FACFAS 2014
Peripheral Arterial Disease
� Local Ischemia
� Abnormal Immunological Response
� thick toenails and skin infection
Ira Baum, DPM, FACFAS 2014
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Local Ischemia
� Slow healing
� risk of infection
� Gangrene
� Amputation
Ira Baum, DPM, FACFAS 2014
Abnormal Immune Response
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� Hyperglycemia affects the cellular response to tissue injury
Delayed immune cells response to injury necessary for wound healing
Impaired functioning of immune cells in diabetes mellitus
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Diabetic Infected Wound
Ira Baum, DPM, FACFAS 2014
Lucky !!!
Indirect Contributing Factors
Ira Baum, DPM, FACFAS 2014
� Smoking
� Hyperlipidemia
� Obesity
� Hypertension
� Inactive lifestyle
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Prevent This
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Identify Patients “At-Risk”
Ira Baum, DPM, FACFAS 2014
� Previous foot ulceration
� Prior lower extremity amputation
� Long duration (>10 years) of having diabetes
� Poor glycemic control (glycosylated hemoglobin >9%;
� Impaired vision
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Previous Foot Ulceration & Amputation
Ira Baum, DPM, FACFAS 2014
� Structural predisposition to areas of previous ulcer
� Change in the underlying subcutaneous tissue
� Changes in gait with abnormal weight distribution
Duration of Diabetes & Age
Ira Baum, DPM, FACFAS 2014
� Increased incidence of Peripheral Arterial Disease� >~60 years old incidence of PAD and LLA increases 8 fold
� Increase incidence of Peripheral Neuropathy� >~60 years old have some form of peripheral neuropathy
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Glucose Control
Ira Baum, DPM, FACFAS 2014
� 1% mean reduction in hemoglobin A1c was associated with a 25% reduction in microvascular complications, including neuropathy.
� A nonsignificant reduction in amputations (by 36%) in the intensive compared with the conventional treatment
� Pinzur MS, Slovenkai MP, et al. Guidelines for diabetic foot care: recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society. Foot Ankle Int.
Increased HgA1C
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� Increase in HgA1C � Advanced Glycation End-Products
� Increase collagen cross fibers stiffness to soft tissue
� Ability to withstand shearing and repetitive stress
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Impaired Vision
Ira Baum, DPM, FACFAS 2014
� Inability to detect minor wounds that progress
� Easily injures themselves
� May be causal relationship with retinopathy and ulcer development?
Foot Examination
Ira Baum, DPM, FACFAS 2014
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History
Ira Baum, DPM, FACFAS 2014
� Past History� Previous Ulcer/Slow healing wound
� Vascular Surgery/Angioplasty
� Charcot Foot/Foot Surgery
� Smoking
� Neuropathic Symptoms� Positive: Burning, Electric Shock, Shooting, Sharp Pain
� Negative: Numbness, “Feet feel dead”
� Vascular Symptoms� Claudication
� Rest Pain
Ira Baum, DPM, FACFAS 2014
� For structural abnormalities (eg, calluses, hammer or claw toes, flat feet, bunions)
� Reduced joint mobility
� Dry or fissured skin, tinea, or onychomycosis
� Inspect footwear to ensure proper fit
Examine Feet
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VascularVascular
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�Pedal Pulses�Skin
Temperature�Skin Color�Hair Growth�Skin Elasticity�Swelling
Examine Feet
Pedal Pulses
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� Dorsalis Pedis Pulse
� Absent ~3% of population
� Posterior Tibial Pulse
� Popliteal Pulse
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Ankle Brachial Index
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� ABI
� <9 Abnormal
� <5 Refer to Vascular Specialist
Inspect and Palpate the Feet
Ira Baum, DPM, FACFAS 2014
� Cold
� Rubor
� Swollen
� Hair growth
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Assess Protective Sensation
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� Semmes Weinstein 5.07 monofilament� 10g force
Loss Of Protective Sensation
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� Patient does not experience SW 5.07 (5 areas?)
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Examine Feet
Neurological
� Vibratory Sensation (128 CPS)
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Mechanoreceptors in the skin - Large Nerve Fibers
NeurologicalNeurological
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� Proprioception
� Achilles Tendon Reflex
� Tinel’s Sign
Examine Feet
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MusculoskeletalMusculoskeletal
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Range of Motion
Limited ROM
Pressure
Deformities
Examine Feet
Tight Achilles Tendon
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� Cause
� Muscle imbalance
� Subtle drop foot
� Congenital
� Increased forefoot pressure
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Foot Deformities
Ira Baum, DPM, FACFAS 2014
� Bunion
� Hammertoe
� Prominent metatarsal
� Charcot foot
DermatologicalDermatological
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� Onychomycosis
� Tinea Pedis
� Fissured Skin
Examine Feet
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DermatologicalDermatological
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� Healed Ulcers� Fibrous Subq Tissue
� Callus - Corn� Repetitive abnormal
pressure
Examine Feet
Risk Category 0Risk Category 0 RecommendationRecommendation
Ira Baum, DPM, FACFAS 2014
� No LOPS, no PAD, no deformity
� Patient education including advice on appropriate footwear.
� Annually (by generalist and/or specialist)
ADA Risk Category
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Risk Category 1Risk Category 1 RecommendationsRecommendations
Ira Baum, DPM, FACFAS 2014
� LOPS ± deformity � Consider prescriptive or accommodative footwear
� Consider prophylactic surgery if deformity is not able to be safely accommodated in shoes
� Continue patient education.
� Every 3–6 months (by generalist or specialist)
ADA Risk Category
Risk Category 2Risk Category 2 RecommendationsRecommendations
Ira Baum, DPM, FACFAS 2014
� PAD ± LOPS � Consider prescriptive or accommodative footwear.
� Consider vascular consultation for combined follow-up.
� Every 2–3 months (by specialist
ADA Risk Category
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Risk Category 3Risk Category 3 RecommendationsRecommendations
Ira Baum, DPM, FACFAS 2014
� History of ulcer or amputation
� Same as category 1.
� Consider vascular consultation for combined follow-up if PAD present
� Every 1–2 months (by specialist)
ADA Risk Category
PATIENT EDUCATION
Ira Baum, DPM, FACFAS 2014
Prevention
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Ira Baum, DPM, FACFAS 2014
� Reduce thick abnormal toenails to avoid ulcer under nail
� Reduce Hyperkeratosis (callus) abnormal pressure
Professional Foot Care
Accommodative Shoes
Ira Baum, DPM, FACFAS 2014
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Accommodation – Healing Shoe
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Accommodative – Pressure Reducing Insoles
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Control Weight Distribution
Ira Baum, DPM, FACFAS 2014
Charcot Restraint Orthotic WalkerControlled Ankle Motion BootWith Molded Insole
The Gold Standard
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TCC allows for Weight Bearing (cane – walker)
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Inspect Barefeet Once or Twice DailyInspect Barefeet Once or Twice Daily
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Patient Focused Education
Use what ever you need to ensure satisfactory
self- assessment
Use what ever you need to ensure satisfactory
self- assessment
Ira Baum, DPM, FACFAS 2014
Patient Focused Education
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Never use sharp instrument or corn/callus remover medicine on feet
Never use sharp instrument or corn/callus remover medicine on feet
Ira Baum, DPM, FACFAS 2014
� Poor vision
� Diminished sensation
� Recipe for disaster
Patient Focused Education
Avoid dryness and cracking to skin of feetAvoid dryness and cracking to skin of feet
Ira Baum, DPM, FACFAS 2014
� Use quality emollient on feet
� Avoid placing lotion between toes
Patient Focused Education
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Ensure proper fitting footwearEnsure proper fitting footwear
Ira Baum, DPM, FACFAS 2014
� Foot measuring system are inaccurate
� Purchase new shoes at end of the day
� Break-in shoes slowly
� Check inside of shoe before putting on
Patient Focused Education
Check feet at every office visitCheck feet at every office visit
Ira Baum, DPM, FACFAS 2014
� Have physician or nurse check feet at every office visit
Patient Focused Education
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Instruct patient to call immediately if they have or even suspect a foot problem
Instruct patient to call immediately if they have or even suspect a foot problem
Ira Baum, DPM, FACFAS 2014
� The most effective time to assess a potential foot problem is before it becomes a real foot problem
Patient Focused Education
In my officeIn my officeWhy is there
noncompliance?Why is there
noncompliance?
Ira Baum, DPM, FACFAS 2014
� Video on DM foot care
� Consultation w/ Dr.
� Educational Handout
� Reinforcement every visit
Failure
� Fear� Incurable Disease
� Inevitable amputation
� Limited capacity
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Why Prevention: reduce costs
Healthcare Cost
&
Intangible Cost
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Facts Associated with Amputation
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� 1 in 5 diabetic infected wounds require amputation
� ~60% non traumatic amputations in USA associated with Diabetes
� Within ~ 2 years of major LLA� 50% increased risk of amputation of the contra lateral limb
� Within ~5 years� ~60% mortality rate
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Healthcare Cost of Treatment
Not Requiring AmputationNot Requiring Amputation
~$33,000.00/Year
Outpatient Visits -14/Year
Hospitalization -1.5/Year
Requiring AmputationRequiring Amputation
~52,000.00/Year
Outpatient Visits -12/Year
Hospitalization -2/Year
Ira Baum, DPM, FACFAS 2014
Time Suffering
Emotional Stress
Intangible Costs To Patient & Family
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Intangible Costs
Disability/ Premature Retirement Increased Cost of Insurance
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Conclusion
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� Following recommendations on diabetic wound prevention will:� reduce suffering
� control healthcare costs
� reduce # of amputations and save lives
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― Benjamin Franklin
Ira Baum, DPM, FACFAS 2014