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The diabetic foot
1. The diabetic foot
Mollie Donohoe and Zoe Boulton
07 Feb 2014
• Current situation - amputations
• Cases
• Assessment of diabetic foot
• The role of the podiatrist
3. Why need to improve diabetic foot care
• Diabetic foot disease accounts for more hospital
bed days than all other diabetes complications.
• 100 people a week lose a lower limb because of
diabetes in the UK.
• 1 in 20 people with diabetes will develop a foot
ulcer in one year.
• 80% of people die within 5 years after amputation.
4. NHS Atlas of Variation
Amputation in Type 2 Diabetes
Percentage of people in the
National Diabetes Audit (NDA)
having major lower limb amputations
five years prior to the end of the
audit period by PCT
1 January 2009 to 31 March 2010
5. NHS Expenditure –
Ulceration and Amputation in Diabetes
Amputation
£119m. £125m.
Inpatient Care Ulceration
£213m.
Primary, Comm
unity, Outpatie
nt Care and A &
E £307m. £324m.
• In 2010-11 the NHS spent an estimated £639 million to
£662 million a year on diabetic foot care
• Equivalent to £1 in in every £150 of total NHS spending
6. Why it is so important?
• 80% of people die within five years of having
foot ulcers or amputations
80%
49%
20%
Amputation /
Foot Ulcer
Colon
Cancer
Prostate
Cancer
• Cost to the NHS
17%
Breast
Cancer
7. But …
... up to 80 per cent of
amputations are potentially
preventable
8. Targets - NICE
Structured education at time of diagnosis and on ongoing basis (A)
(A)
Directly based on evidence from metanalysis of RCTs/at least one RCT
9. Impact of foot ulcers on
quality of life
Health related quality of life (SF-6D) scores for people with diabetic foot ulcers and other long-term
conditions, and for healthy people aged 75+ (Source: Jeffcoate et al. (2009), Brazier et al. (2004), Davison
et al.(2009))
•Diabetic foot ulcer QOL rated lower than osteoarthritis, COPD, dialysis
•SF-6D or EQ-5D are building blocks for QALY estimation
13. New CCG boundaries
(also reflect catchment areas)
NEW Devon CCG
northern locality
NEW Devon CCG
eastern locality
NEW = North East West
NEW Devon CCG
western locality
South Devon and
Torbay CCG
15. Calculating rates per catchment area
CCGs are the “externally visible” unit of healthcare
•YHPHO has calculated amputation rates by CCG
•NEW Devon CCG includes catchment areas of 3 hospitals
Shane Coe obtained the required data
•Information analyst for NHS Devon
•Used YHPHO methodology
•Calculated amputation rates by CCG and locality
16. New CCG boundaries
(also reflect catchment areas)
1.3
1.4
2.0
1.2
Thanks to Shane Coe – NEW Devon
CCG
1.2
England 0.9
20. We are 20 years ahead of the country
(Sidmouth 2075)
21. Confounding factors?
Amputation rates in
diabetic and nondiabetic patients
correlate strongly –
r=0.43, p=0.0005
Holman, Diabetologia 2012; 55: 1919.
22. The South Western Region
White
94.1%
Legacy
effect
50%
older
migrants
Older
population
25% >65
Rural occupation
longer survival
•High rate of
diabetic foot
disease in
South West
23. Interpret all data with caution
Atlas of Variation is not a scientific document
•Some implausible data
•Inadequate adjustment for confounders
•Health service “units” are not helpful
•Successfully achieved headlines
There is lots of room to improve, and we need to
•Pan-Devon problem – perhaps pan-SW
•Improvements need to cross primary and secondary care
24. RCA of Major Amputations in Diabetic Patients
Jan 2012-13
• 16 patients - 22 amputations
• 6 patients had 2 amputations same leg
• 3 patients out of area
– 2 Somerset with ESRF
– 1 Torbay (patient choice)
• 5 patients under renal physicians: 4 on dialysis
• 2 patients diagnosed with diabetes when admitted
25. Problems identified so far
• Only 50% of patients known to Diabetic foot clinic
• 5/16 (31%) solely under vascular as inpatient (no
involvement from diabetes team)
• 4/16 (25%) of amputees had ESRF
• 5/13 (38%) not referred to podiatry post amputation
• 2/16 (12%) frequent DNA
26. Problems identified so far
• 5/8 (62%) documented given education in foot clinic.
• 2/16 (13%) had previous care in another area – no record
of prior podiatric care.
• 1/16 (6%) critical event was ulcer which developed
when patient previous inpatient.
• 16/16 (100%) had no inpatient podiatric care
29. The Touch Test
• Up to 15% of inpatients have diabetes mellitus at any one time (1)
• 33% had feet examined (14% RD&E).
• Robust screening method
–
–
–
–
•
Accurate
Simple
Acceptable
Cost effective
Touch test performs consistently and favourably compared
with Monofilament.
(1)
National Diabetes Inpatient Survey 2009
30. Testing for neuropathy
• The Ipswich Touch Test (IpTT)
A simple and novel method to identify inpatients with diabetes at risk of
foot ulceration Diabetes Care, 34, July 2011
n = 265
3 hospitals
18 examiners 4 physicians, 9 podiatrists, 5 medical students
>2 of 6 insensate areas signifying at risk feet
Sensitivity
Specificity
IpTT MF
76% 81%
90% 91%
Concordance IpTT v MF Very good
(k=0.85, p<0.0001)
Inter observer reproducibility
Good
(k=0.68, p<0.001)
31.
32.
33. Results
• Prevalence of neuropathy = GP:11.4% ,DM:16.6%
• Compared to MF as “gold standard”
• IpTT
: 88.9% sensitivity (PPV 94%)
: 99.28% specificity (NPV 98%)
• Overall accuracy 98.1%
• Concordance: excellent agreement between IpTT +
monofilament (k=0.9, p<0.001)
• Inter operator reproducibility
N= 27
IpTT Good
(K=0.51, p=0.006)
MF Less good
(K=0.44, p=0.01)
34.
35. MANAGEMENT OF
PAINFUL NEUROPATHY
• Is the pain neuropathic?
• What is the dominant unpleasant
symptom?
• When are the symptoms worse?
• Does the patient have important fears or
beliefs about the pain?
• What are patient’s expectations?
36. Painful diabetic peripheral neuropathy
Amitriptyline (unlicensed)
Start at 10mg, titrate to max. tolerated over 8/52
Gabapentin
Day 1 300mg od
Day 2 300mg bd
Day 3 300mg tds
Max 1800mg daily
8/52 trial
Pregabalin
75mg bd
Increase to
150mg bd
over 3-7 days
8/52 trial
Duloxetine
60mg od
Max 60mg bd
8/52 trial
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42. HISTORY
Mrs C:
Age 22
Type 1 DM of 20 years
° Smoker
° Alcohol
PT shop assistant.
C/O severe pain left foot 2/12
History stubbing toe left toe 3/12 ago
HbA1c 78, Chol 5.1, Creatinine 100, CRP 10,
Urate 317
43. Mrs C
Left foot warmer than right
Monofilament 3/6
All peripheral pulses felt
Left foot medial protrusion of inner
long arch
49. Mr A
• Type 1 diabetes (HBA1c 51 , creat 85 chol 4 ,proliferative
retinopathy )
• Developed neuropathic fracture of talus and navicular +
cuboid when playing squash 2010
• Treated with off loading but continued to exercise fluctuating
temp difference
• 2012 : S/B orthopaedics – stop squash
• 2013 : L mid foot fusion with bone grafting . 5*C difference
between feet
• 2014 Recommenced cycling competitively
54. Mr D
• Type 1 DM
• CKD4
• Proliferative retinopathy
• Biphasic pulses
• Foot ulcer healed R 2nd met head.
• Hot foot
55.
56.
57. CHARCOT’S
JOINT/NEUROARTHROPATHY
• Relatively painless progressive arthropathy
of single or multiple joints, caused by an
underlying neurological deficit.
• Simultaneous presence of bone and joint
destruction, fragmentation and remodelling.
58. DEMOGRAPHICS
• 0.1 - 5% in patients with diabetic peripheral
neuropathy.
• Age 20 - 70 + years (50 - 60 > common)
• History of long-standing diabetes.
• Bi-lateral in about 15%.
• Joints: tarso-metatarsal 60% (mid foot)
metatarsophalangeal 20%
ankle
10%
59. Patterns of bone and joint destruction
Sanders LJ, Frykberg RG: Diabetic Neuropathic osteoarthropathy; The Charcot foot: the
high risk foot in diabetes mellitus, New York 1991, Churchill Livingstone
61. Eichenholtz Classification
• Stage I - Developmental (acute)
– Hyperemia due to autonomic neuropathy
weakens bone and ligaments
– Diffuse swelling, joint laxity, subluxation,
frank dislocation, fine periarticular
fragmentation, debris formation
63. Eichenholtz Classification
• Stage II - Coalescence (quiescent)
– Absorption of osseous debris, fusion of
larger fragments
– Dramatic sclerosis
– Joints become less mobile and more stable
– Aka the “hypertrophic”, or “subacute”
phase of Charcot
65. Eichenholtz Classification
• Stage III - Consolidation (resolution)
– Osseous remodelling
– for clinical purposes, stage I is regarded as
the acute phase, while stages II and III are
regarded as the chronic or quiescent phase
67. PATHOPHYSIOLOGY
• Initiating event: trivial injury/unnoticed
repetitive minor trauma minor or periarticular
or major fracture.
• Susceptible feet: peripheral neuropathy loss of
protective sensation.
: >Inflammatory cytokines (TNF-α)
: Autonomic neuropathy >blood flow with
osteopenia.
: Increased osteoclastic activity
bone
resorbtion.
NHS spending on ulceration and amputation in diabetes is substantial. In 2010-11 we estimate that the NHS spent between £639 million and £662 million on diabetic foot care. Almost half of this money was spent in primary, community and outpatient care. Much of this care was not pro-actively commissioned for the diabetic foot, or recognised by commissioners as relating to diabetic foot problems.
A reminder why it is so importantPoint 1: There is an 80% likelihood of people dying within five years of having foot ulcers or amputationsThe risk is more than people who have colon, prostate and breast cancerNUMBERS: In England there are approx 6,000 amputations a year and in Scotland 450 a year.UK wide - 120 amputations a week during 2010Stark contrast: Troops in Afghanistan suffered 76 in the whole of 2010 (Source: Defence Analytical Services & Advice) Point 2: Cost to the NHS In England it is estimated that between £600m - £700m is spent each year on foot ulcers and amputations. £60m – £70m spent annual on foot ulcers and amputations in Scotland. This is an expensive and serious problem.
