The Diabetic FootA Medical View

Associate Professor Jonathan Shaw

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

Prevalence of PVD by diabetes status

Tapp Diabet Med 2003

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The percentage of people who had a foot examination in the previous year%

(Duration of diabetes ≥1 year)

Overall = 51%

Tapp Diabetes Care 2004

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The percentage of people who had an eye examination in the previous year%

(Duration of diabetes ≥1 year)

Overall = 85%

Tapp Diabetes Care 2004

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Independent predictors of screening

• Duration of diabetes 1.33

• DNE in last 12 mths 1.89

• Insulin treatment 4.17

• DNE in last 12 months 2.14

Foot screening OR

Retinal screening

Tapp Diabetes Care 2004

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Foot ulcer assessment

Neuropathic and/or ischaemicNeuropathic and/or ischaemic

Infected or notInfected or not

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Neuropathic ulcer - diagnosis

• At site of repeated pressure– Dorsum of toes (shoes)– Under metatarsal heads

• Painless

• Surrounded by callus

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Ischaemic ulcer - diagnosis

• At the end of the circulation– Apex of toes– heel

• Painful

• No callus

• Foot cool with weak/absent pulses

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Grading of a foot lesion predicts outcomes

Grade0 Complete epithelialisation1Superficial2Penetrating to tendon or capsule3Penetrating to bone or joint

StageA No infection or ischaemiaB InfectionC IschaemiaD Infection and ischaemia

Armstrong et al. Diabetes Care. 21:855-9, 1998.

Texas Wound Classification System

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Neuropathic ulcer - management

• Relieve pressure

• Debride callus and infected tissue

• Treat infection

• Appropriate dressings

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Pressure-relieving devices

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Pressure relief from a total contact cast

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Total contact cast leads to more rapid healing of neuropathic ulcers

Half shoe

Aircast

TCC

Armstrong et al. Diabetes Care. 2001;24:1019-22

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Removable vs non-removable cast walkers

Removable

Non-removable

P = 0.02

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Ischaemic ulcer - management

• Debride callus and infected tissue

• Restore circulation (surgery/angioplasty)

• Treat infection

• Appropriate dressings

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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

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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

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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