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PREVENTION OF DIABETIC FOOT ULCERS AND LOWER EXTREMITY AMPUTATION

PREVENTION OF DIABETIC FOOT ULCERS AND LOWER EXTREMITY AMPUTATION. Barry Stults, M.D. Scott Clark, D.P.M Thomas Miller, M.D. University of Utah Medical Center. ©2006. American College of Physicians. All Rights Reserved. CASE: Mr. M.C. 64 yr-old obese white male, not seen x 12 mo

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PREVENTION OF DIABETIC FOOT ULCERS AND LOWER EXTREMITY AMPUTATION

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  1. PREVENTION OF DIABETIC FOOT ULCERS AND LOWER EXTREMITY AMPUTATION Barry Stults, M.D. Scott Clark, D.P.M Thomas Miller, M.D. University of Utah Medical Center ©2006. American College of Physicians. All Rights Reserved.

  2. CASE: Mr. M.C. • 64 yr-old obese white male, not seen x 12 mo • Type 2 DM (15 yrs) BP  (18 yrs) Dyslipidemia (18 yrs) CABG (10 yrs ago) Claudication (today; 25 yds) • Insulin/Metformin/Statin/ARB/Hctz/CCB/ASA • “Sore on my left foot, Doc” ©2006. American College of Physicians. All Rights Reserved.

  3. ©2006. American College of Physicians. All Rights Reserved.

  4. CASE: Mr. M.C. • Clinical evaluation of heel ulcer: • Probe reached bone • Extensive subcutaneous abscess • MRI: extensive osteomyelitis • ABI: 0.2 • Angiography: severe infrapopliteal, suprapopliteal obstruction • Not amenable to revascularization • Uncontrolled infection despite antibiotics/drainage ©2006. American College of Physicians. All Rights Reserved.

  5. ©2006. American College of Physicians. All Rights Reserved.

  6. AMPUTATIONS IN DIABETES Common: • Worldwide – amputation 2 to diabetes q 30 sec. • U.S.A. – 80,000 amputations/y (2002) • Higher rates in men, racial/ethnic minorities Costly: • $60,000/amputation • $2 billion/y total costs Lancet 2005; 366:1719 DiabetesCare 2004; 27:1598 DiabetesCare 2003; 26:495 ©2006. American College of Physicians. All Rights Reserved.

  7. AMPUTATIONS IN DIABETES Tragic: “Rule of 50” • 50% of amputations transfemoral/transtibial level • 50% of patients 2nd amputation in  5y • 50% of patients Die in  5y ClinicalCareoftheDiabeticFoot, 2005 ©2006. American College of Physicians. All Rights Reserved.

  8. FOOT ULCERS IN DIABETES Precipitate 85% of amputations: “Rule of 15” • 15% of diabetes patients Foot ulcer in lifetime • 15% of foot ulcers Osteomyelitis • 15% of foot ulcers Amputation ClinicalCareoftheDiabeticFoot, 2005 ©2006. American College of Physicians. All Rights Reserved.

  9. FOOT ULCERS IN DIABETES Costly: • $30,000/ulcer • $9 billion/y total costs Tragic: • Quality of life: ulcer patient  amputation patient • Burden of non-weight-bearing as ulcer heals • Lifetime behavioral adaptations to prevent recurrence • Fear of recurrent ulcer/amputation • 70% ulcer recurrence in  3y FootAnkleInt 2005; 26:32, 128 ClinInfectDis 2004; 39(Suppl 2):S129 ©2006. American College of Physicians. All Rights Reserved.

  10. TEAM CARE REDUCES ULCERS/AMPUTATIONS Five clinical trials: • Format: integrated, risk-stratified interventions • ID high-risk patients with exam: • Frequent follow-up to detect early problems • Educate/motivate self-care behaviors • Prophylactic nail/skin care by podiatry • Therapeutic footwear, if needed • Prompt, multidisciplinary Rx of ulcers Lancet 2005; 366:1676 ©2006. American College of Physicians. All Rights Reserved.

  11. TEAM CARE REDUCES ULCERS/AMPUTATIONS Efficacy of team care: • 50-80% reductions in ulcers/amputations • Economic modeling studies of team care: • Cost-effective if 25-40% reduction in ulcer rate • Cost-saving if > 40% reduction in ulcer rate Applicable only to high-risk patients Lancet 2005; 366:1719 DiabetesCare 2004; 27:901 ©2006. American College of Physicians. All Rights Reserved.

  12. PATHOGENESIS OF DIABETIC FOOT ULCER AND AMPUTATION Sensory  Joint Motor Autonomic PAD Neuropathy Mobility Neuropathy Neuropathy Protective Muscle atrophy and  Sweating Ischemia sensation 2° foot deformities 2° dry skin Foot pressure  Foot pressure Fissure  Healing Minor trauma esp. over recognition bony prominences Callus Pre-ulcer ULCER Infection AMPUTATION Minor Trauma: Interdigital Maceration Mechanical (Moisture, Fungus) Chemical Thermal ©2006. American College of Physicians. All Rights Reserved.

  13. OTHER RISKS FOR ULCER/AMPUTATION Failure to adequately care for the feet: • Inadequate patient education • Inadequate patient motivation • Depression, anxiety, anger more common in diabetes • Physical disability • Cannot see feet 2 to retinopathy • Cannot reach feet 2 to obesity, age (?50% of patients) • Limited access to podiatry services AgeAgeing 1992; 21:333 DiabetesCare 2003; 29:495 DiabMetabResRev 2004; 20(Suppl 1):S13 ©2006. American College of Physicians. All Rights Reserved.

  14. CAUSAL PATHWAYS FOR FOOT ULCERS % Causal Pathways NEUROPATHY Neuropathy: 78%  Minor trauma: 79% DEFORMITY Deformity: 63%  Behavioral issues ? MINOR TRAUMA - Mechanical (shoes) POOR SELF- - Thermal FOOT CARE - Chemical ULCER DiabetesCare 1999; 22:157 ©2006. American College of Physicians. All Rights Reserved.

  15. DETECTING FEET-AT-RISK • History: • Prior amputation • Prior foot ulcer • PAD: known or claudication at < 1 block • Exam: • Insensate to 5.07/10g monofilament • Major foot deformities • PAD • Absent DP and PT pulses • Prolonged venous filling time • Reduced Ankle-Brachial Index (ABI) • Pre-ulcerative cutaneous pathology ArchInternMed 1998; 158:157 ©2006. American College of Physicians. All Rights Reserved.

  16. RISK STRATIFY FOR FOOT ULCERATION Foot Ulcer, % Office Patients Risk Level%/yr(diabetes clinics) 3: prior amputation 28.1% 7% prior ulcer 18.6% 2: insensate 6.3% 10% and foot deformity or absent pedal pulses 1: insensate 4.8% 17 - 30% 0: all normal 1.7% 66% DiabetesCare 2001; 24:1442 DiabetesMetab 2003; 29:261 ©2006. American College of Physicians. All Rights Reserved.

  17. ANNUAL DIABETIC FOOT EXAMS2000 Behavioral Risk Factor Surveillance System, CDC ©2006. American College of Physicians. All Rights Reserved.

  18. PHYSICAL EXAMINATION OF THE FEET IN PERSONS WITH DIABETES ©2006. American College of Physicians. All Rights Reserved.

  19. SENSORY NEUROPATHY IN DIABETES • Loss of protective sensation in feet • Sensory loss sufficient to allow painless skin injury • Major risk factor for foot ulcer in diabetes • Detect with 5.07/10g Semmes-Weinstein monofilament • Prevalence of insensate feet to 10g monofilament: • Age > 40y: 30% of diabetic patients • Age > 60y: 50% of diabetic patients • Up to 50% have no neuropathic symptoms DiabetesCare 2006; 29(Suppl 1):S24 DiabetesCare 2004; 27:1591 ©2006. American College of Physicians. All Rights Reserved.

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  22. UTILITY OF MONOFILAMENT TESTING Predicts ulcer/amputation in 5 prospective studies: • NPV (normal sensing) = 90-98% PPV (fail to sense) = 18-36% • Prospective 32 mo observational study: • 80% of ulcers/100% of amputations in insensate feet • Superior predictive value to other tests: • Pin prick, cotton wisp, symptoms • ? 128 Hz tuning fork? • ADA recommendation, 2006: also test vibration DiabetesCare 2006; 29(Suppl 1):S25 JFamPract 2000; 49:S30 DiabetesCare 1992; 15:1386 ©2006. American College of Physicians. All Rights Reserved.

  23. USING THE 5.07/10gm MF (Tool-Kit) • Demonstrate sensation on the forearm or hand • Place monofilament perpendicular to test site • Bow into C-shape for one second • Test four sites/foot: Predicts 95% of ulcer formers vs. 8 sites • Heel testing does not discriminate ulcer formers • Avoid calluses, scars, and ulcers ©2006. American College of Physicians. All Rights Reserved.

  24. USING THE 5.07/10g MF (Tool-Kit) • Minimize bias: • Test sites in random sequences • Test each site X3, sham test as 1 of 3 • Do you feel it? Yes or No? • Retest site if patient fails (misses 2/3 responses) • Insensate at 1 site = insensate feet • Falsely insensate with edema, cold feet • Test annually when sensation normal • Use < 100x/d; replace if bent; replace q 3 mo. • Purchase calibrated MF (See Tool-Kit) ©2006. American College of Physicians. All Rights Reserved.

  25. PAD IN DIABETES • Prevalence (ABI < 0.9): 20-30% • 10-20% in type 2 diabetes at Dx • 30% in diabetics  age 50y • 40-60% in diabetics with foot ulcer • Complications: • Claudication and functional disability • Increases risk for concurrent CAD and CVD • Delays ulcer healing • Increases amputation risk • Not increase foot ulcer risk JACC 2006; 47:921 DiabetMed 2005; 22:1310 DiabetesCare 2003; 26:3333 ©2006. American College of Physicians. All Rights Reserved.

  26. HX TO DETECT PAD IN DIABETES • Claudication at < 1 block suggests severe ischemia Vascular LevelSite of Pain Aorto-iliac Buttocks/Thigh Femoral Calf Tibioperoneal Foot/Ankle • Rest pain indicates critical ischemia • Toes and forefoot • Difficult to distinguish from neuropathic pain ©2006. American College of Physicians. All Rights Reserved.

  27. Ischemic Rest Pain Unilateral (usually) Continuous;  hs With dependency Absent DP/PT pulses Neuropathic Pain Bilateral (usually) Wax/wane No change with dependency Variable DP/PT pulses HX TO DETECT PAD IN DIABETES (After Pompogelli and Campbell, 2002) ©2006. American College of Physicians. All Rights Reserved.

  28. HX TO DETECT PAD IN DIABETES • Asymptomatic, severe PAD common in diabetes • Tibio-peroneal disease predominance: • Unrecognized ankle/foot claudication • No claudication • Sensory neuropathy blunts/eliminates pain sensation of claudication and rest pain DiabetesCare 2003; 26:3333 ©2006. American College of Physicians. All Rights Reserved.

  29. EXAM TO DETECT PAD IN DIABETES • Pedal pulse exam: • Absent DP and PT: LR = 3.0-3.8 for severe PAD • Absent DP or PT not predict PAD • Non-palpable DP (8%) or PT (3%) in normals • Present DP and PT not R/O PAD! • 30% with PAD have one palpable pulse (collaterals) • High PAD suspicion  vascular testing • Claudication, foot ulcer JAMA 2006; 295:536 ArchInternMed 1998; 158:1357 DiabetesCare 2003; 26:3333 ©2006. American College of Physicians. All Rights Reserved.

  30. EXAM TO DETECT PAD IN DIABETES • Venous filling time • Technique: • Sitting: ID pedal vein bulging above skin • Supine: Elevate leg to 45° for 1 min • Sitting:  time to pedal vein bulging above skin JClinEpidemiol 1997; 50:659 ArchInternMed 1998; 158:1357 ©2006. American College of Physicians. All Rights Reserved.

  31. EXAM TO DETECT PAD IN DIABETES • Venous filling time • Filling time > 20 sec predicts ABI < 0.5 • Sensitivity = 22%; Specificity = 94%; LR = 3.9 JClinEpidemiol 1997; 50:659 ArchInternMed 1998; 158:1357 ©2006. American College of Physicians. All Rights Reserved.

  32. OTHER EXAM FINDINGS FOR PAD • Helpful: • Femoral bruit (LR = 4.7–5.7) • Unilateral cool extremity • Not predictive of PAD: • Atrophic skin • Hair loss • Capillary refill > 5 sec DiabetesMed 2005; 22:1310 ArchInternMed 1998; 158:1357 ©2006. American College of Physicians. All Rights Reserved.

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  34. VASCULAR LAB TO DETECT PAD • Ankle/Brachial BP Index or ABI Testing • Screening: 2004 ADA recommendation • “Consider” at age 50 and q 5 yr • Screen earlier if multiple CVD risks • Diagnosis: • Claudication, absent DP/PT pulses, foot ulcer • Limitations: • Underestimate severity if medial artery Ca++ • Consider pulse volume recording, systolic toe BP, vascular consultation if uncertain about PAD DiabetesCare 2005; 28:2206 DiabetesCare 2004; 27(Suppl 1): S15-S35 ©2006. American College of Physicians. All Rights Reserved.

  35. INTERPRETATION OF THE ABI ABI Normal 0.91-1.30 Mild obstruction 0.71-0.90 *Moderate obstruction 0.41-0.70 *Severe obstruction  0.40 **Poorly compressible >1.30 2° to medial Ca++ *Poor ulcer healing with ABI  0.50 **Further vascular evaluation needed ©2006. American College of Physicians. All Rights Reserved.

  36. MOTOR NEUROPATHY AND FOOT DEFORMITIES • Hammer toes • Claw toes • Prominent metatarsal heads • Hallux valgus • Collapsed plantar arch ©2006. American College of Physicians. All Rights Reserved.

  37. Hammer Toes • Claw Toes From Levin and Pfeifer, TheUncomplicatedGuidetoDiabetesComplications, 2002 ©2006. American College of Physicians. All Rights Reserved.

  38. Hallux Valgus From Levin and Pfeifer, TheUncomplicatedGuidetoDiabetesComplications, 2002 ©2006. American College of Physicians. All Rights Reserved.

  39. From Boulton, et al DiabeticMedicine 1998, 15:508 ©2006. American College of Physicians. All Rights Reserved.

  40. PRE-ULCER CUTANEOUS PATHOLOGY Neuropathy  inappropriate footwear: • Persistent erythema after shoe removal • Callus • Callus with subcutaneous hemorrhage: “pre-ulcer” Autonomic neuropathy and secondary dry skin: • Fissure  ulceration • Augment callus formation Poor self-care of the feet: • Interdigital maceration with fungal infection • Nail pathology ©2006. American College of Physicians. All Rights Reserved.

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