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The Diabetic Foot A Medical View

The Diabetic Foot A Medical View. Associate Professor Jonathan Shaw. 0. Prevalence of neuropathy by diabetes status. 2 or more of: symptoms signs monofil insens post hypotension. Tapp Diabet Med 2003. 0. Prevalence of PVD by diabetes status. Tapp Diabet Med 2003.

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The Diabetic Foot A Medical View

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  1. The Diabetic FootA Medical View Associate Professor Jonathan Shaw

  2. 0 Prevalence of neuropathy by diabetes status • 2 or more of: • symptoms • signs • monofil insens • post hypotension Tapp Diabet Med 2003

  3. 0 Prevalence of PVD by diabetes status Tapp Diabet Med 2003

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

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

  6. Independent predictors of screening Foot screening OR • Duration of diabetes 1.33 • DNE in last 12 mths 1.89 • Insulin treatment 4.17 • DNE in last 12 months 2.14 Retinal screening Tapp Diabetes Care 2004

  7. Foot ulcer assessment Infected or not Neuropathic and/or ischaemic

  8. Neuropathic ulcer - diagnosis • At site of repeated pressure • Dorsum of toes (shoes) • Under metatarsal heads • Painless • Surrounded by callus

  9. Ischaemic ulcer - diagnosis • At the end of the circulation • Apex of toes • heel • Painful • No callus • Foot cool with weak/absent pulses

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

  11. Neuropathic ulcer - management • Relieve pressure • Debride callus and infected tissue • Treat infection • Appropriate dressings

  12. Pressure-relieving devices

  13. Pressure relief from a total contact cast

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

  15. Removable vs non-removable cast walkers Removable P = 0.02 Non-removable

  16. Ischaemic ulcer - management • Debride callus and infected tissue • Restore circulation (surgery/angioplasty) • Treat infection • Appropriate dressings

  17. 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

  18. 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

  19. 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

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