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The British Journal of Diabetes & Vascular

http://dvd.sagepub.com/content/9/4/155The online version of this article can be found at:

 DOI: 10.1177/1474651409341420

2009 9: 155British Journal of Diabetes & Vascular DiseaseGraham P Leese

Review: The varied attractions of the diabetic foot  

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Abstract

Various advances have been seen in the manage-ment of the diabetic foot. In some areas the rate of diabetes-related major amputations is declining.

Duloxetine, pregabalin, venlafaxine and oxycodone are all well proven to help alleviate the pain of diabetic neu-ropathy. Negative pressure wound therapy has been shown to accelerate the healing of foot ulcers. New antibiotic policies designed to reduce Clostridium difficile and meth-icillin-resistant Staphylococcus aureus (MRSA) infections focus on narrow spectrum short duration antibiotics, and 80% of osteomyelitis can be successfully treated without surgery. Foot screening identifies patients who will ulcer-ate, with high-risk patients being up to 83 times more likely to ulcerate than low-risk patients. The ‘holiday foot’ and distal peripheral vascular disease remain as major risk factors for foot ulcer development and non-healing. The diabetic foot provides many interesting and varied challenges for the interested clinician.Br J Diabetes Vasc Dis 2009;9:155–159

Key words: amputation, diabetes, foot, neuropathy, screen-ing, ulcer.

IntroductionDiabetic foot problems are the commonest cause of hospital admission with a diabetes-related problem. Despite this, lack of attention to foot-related problems remains an issue in many clinics, and many amputations are potentially avoidable. Management of the diabetic foot requires knowledge and practical skills in a number of different key areas, which are diverse and interesting in their own right. This article highlights a few topics in the management of the diabetic foot that may be of interest to practising clinicians.

Ulcer managementThe ideal outcome of foot ulcer care is to achieve healing without amputation. Avoidance of amputation is not necessarily the best outcome for an individual patient, as an amputation can improve

a patient’s mobility and quality of life when compared with a chronic ulcer. MDFCs can improve healing and reduce amputation rates,1,2 and are the cornerstone of modern diabetic foot manage-ment. Within an MDFC healing rates are generally around 65–75%,3-6 with about 10–15% going for amputation; while 10% die with their ulcer, and the remainder have unhealed ulcers.

For neuropathic ulcers, the total contact cast has been shown to be more effective than RCWs or orthotic half-shoe devices,7 but many centres do not have access to the necessary expertise for contact casts. However, RCWs may be less effec-tive because patients take them off and walk without them. Using an RCW rendered irremovable by applying a strip of plaster of Paris has been shown to be as effective as total con-tact casts,8 and may be more practical in many centres. For bed-bound patients other devices such as a pressure relieving ankle foot orthoses (PRAFOs), which can be very useful for protecting heels, prevent ulcer formation and promote ulcer healing at this site. The value of heel protection for inpatients with diabetic neuropathy is generally underestimated.

The varied attractions of the diabetic footGRAHAM P Leese

© The Author(s), 2009. Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav 10.1177/1474651409341420 155

REVIEW

Correspondence to: Dr Graham LeeseWard 1 and 2, Ninewells Hospital, Dundee, DD1 9sY, UK.Tel: +44 (0)1382 633882; Fax: +44 (0)1382 425509e-mail: graham.leese@nhs.net

Abbreviations and acronyms

IDsA Infectious Diseases society of America

IWGDF International Working Group on the Diabetic Foot

MDFC multidisciplinary diabetes foot clinic

MRsA Methicillin-resistant Staphylococcus aureus

NPWT negative pressure wound therapy

PVD peripheral vascular disease

RCW removable cast walker

sIGN scottish Intercollegiate Guideline Network

Graham P Leese

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Wound healingseveral trials have shown that NPWT can help accelerate wound healing.9 The trials have all been on relatively small numbers of patients, and blinding the treatments is difficult in randomised controlled trials. A recent systematic review indicated that over-all NPWT may be of some benefit,10 and it is likely that very moist wounds are those which benefit most. The increasing availability of such devices in the community certainly makes them more accessible, and although expensive, they may be cost-effective.11

Hydrotherapy is a tool with which pressurised saline is forced through a small nozzle to create a high velocity stream and a vacuum that cuts through tissue. It certainly enables much more aggressive and extensive wound debridement in the outpatient setting than the scalpel. Individual hand-held pieces are required for each individual patient, increasing the cost and meaning that patient selection is important. studies on useful clinical outcomes in the diabetic foot, and cost-effec-tive studies, are required.

Foot ulcer classificationseveral wound classification systems have been introduced. Although mainly useful in the research setting, many of these classifications can help to map progress for individuals with ulcers, or to allow comparisons between patients or between different centres. Ulcer classifications include the Wagner scale and the Texas score from the UsA, and the sinbad system and others from the UK and europe.12,13 These classifications can use a variety of simple clinical criteria such as presence of neuropathy, ischaemia, sepsis, size of wound, depth of wound and others. The IDsA classification can be useful for grading the severity of infection in a foot ulcer.14 The categories of infection include no infection, mild infection or cellulitis < 2 cm, moderate infection or cellulitis > 2 cm or infection with systemic toxicity for which patients should be admitted. The patient management and choice of initial antibiotic should be guided by the severity of infection (see table 1 and below).

Antibiotic use for infected foot ulcerationAntibiotics are recommended for foot ulcers that have clinical signs of infection, such as redness, cellulitis, pus, lymphangitis or abscesses, and also when osteomyelitis is suspected.15-17 As many wounds are usually polymicrobial, prolonged use of broad-spectrum antibiotics have traditionally been used. However, antibiotics such as co-amoxiclav, ciprofloxacin, clin-damycin and others, have been associated with the develop-ment of Clostridium difficle and MRsA, although mainly in the inpatient setting. It is now advised that shorter courses, such as one to two weeks for soft-tissue infections, of narrow-spectrum antibiotics should be used.15-17 The specific antibiot-ics used should depend on known local sensitivities, but regional approaches can be taken where local sensitivities are known to be similar, with adjustments depending on the results of specific cultures. For instance scottish guidelines, pertain-ing to scottish sensitivities, have recently been published

recommending the use of flucloxacillin as first line, with doxycycline or co-trimoxazole as alternatives, as Staphylococcus aureus is the commonest infecting organism (table 1). Recommended antibiotics change with increasing severity of the infection, and longer courses (e.g. 6 weeks or longer) of antibiotics with the addition of agents such as rifampicin are advised in the presence of osteomyelitis.18

‘Probe to bone’The ‘probe to bone’ test has been used for a long time as a clinical marker of osteomyelitis, but is it reliable? Well con-ducted clinical trials show that when bone can be touched at the base of a foot ulcer (probe to bone test) the positive predic-tive value, or likelihood, of osteomyelitis being present is only around 50%,19,20 which is much less than previously thought. However, the negative predictive value of not touching bone

Table 1. New scottish ORAL antibiotic guidelines for use in diabetic foot ulcers. Guidance is divided by IDsA infection categories. Antibiotics are not recommended if there is no sign of clinical infection and patients with severe infection should be admitted for IV antibiotics. Narrow spectrum, short duration use is advised. For full guideline see Leese et al.18

MILD INFECTION

Treat 5–7 days and

review treatment

MODERATE INFECTION

Treat 5–7 days and review

treatment.

If osteomyelitis treat 4–6 weeks

and consider adding rifampicin

600 mg bd

Flucloxacillin 1 g qds

Alternatives

Doxycycline 100 mg bd

(Clindamycin if allergic)

Antibiotic naïve:

Flucloxacillin 1g qds

Alternatives

Co-trimoxazole 960 mg bd

Co-amoxiclav 625 mg tds

(Clindamycin if allergic)

Antibiotic given in last 90 days,

i.e. not antibiotic naÏve

Co-amoxiclav 625 mg tds

Co-trimoxazole 960 mg bd

Alternatives may need to be

intravenous, but oral options

include:

Ciprofloxacin 500–750 mg bd and

metrondidazole

Ciprofloxacin 500–750 mg bd and

clindamycin 300–450 mg qds

Key: bd = twice daily; qds = four times a day; tds = three times a day.

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was 85–98%.19,20 In practical terms this means that a positive probe to bone test is not very helpful in deciding if osteomyeli-tis is present, but a negative test is useful as it makes osteomy-elitis very unlikely. For patients who do have osteomyelitis, around 80% can be treated successfully with medical therapy and debridement alone, without the need for surgery.21 Thus surgery can be important for a select group of patients, but is not required in the majority.

Charcot footThe Charcot foot continues to be a challenge to diagnose and manage, especially when associated with foot ulceration. Virtually all cases occur in patients with neuropathy and a good blood supply to the foot. A recent UK audit22 indicated that Charcot foot is frequently precipitated by mild trauma or a foot ulcer. Osteoporosis of the bones in the foot appears to be a risk factor for patients with type 1 but not type 2 diabe-tes,23 while weight was a major risk factor for patients with type 2 diabetes.23,24

Risks of foot ulcerationIn a recent study examining the causal pathway to foot ulcer-ation, of 24 potential pathways to developing foot ulceration, the commonest seven accounted for 64% of all ulcers.25 The four main factors were neuropathy in the presence of callus or deformity, PVD, penetrating injuries and ill-fitting footwear.25

NeuropathyPeripheral diabetic neuropathy is present in 22–24% of patients who have diabetes.26,27 For the majority of patients this results in numb feet, but about 10% of these patients develop pain. simple analgesics, tricyclic antidepressants such as amitrip-tyline, and gabapentin remain the main treatments for painful diabetic neuropathy (table 2). Pregabalin is being used increas-ingly in doses of 150–600 mg per day in two to three divided doses. Although it is more expensive than gabapentin, it is effective28 has fewer side effects and is easier to titrate. Duloxetine 60 mg once daily is another useful alternative29,30 that acts by inhibiting the reuptake of serotonin and nora-drenaline. Venlafaxine, a pure serotonin reuptake inhibitor, may also be effective especially in higher total daily doses of 150–225 mg.31 Opioids such as oxycodone can be useful,32 and other therapies such as capsaicin, acupuncture and dorsal col-umn stimulators can have occasional use.

Peripheral vascular diseasePVD is a major obstacle to achieving better outcomes for patients with diabetic foot problems. The disease commonly affects the small distal vessels, and not the larger peripheral vessels as seen in more standard PVD. This means that bypass surgery is more difficult, with increased risk of thrombo-embo-lic complications with a resulting high risk of amputation. Distal angioplasty carries the same risks, while more proximal angio-plasty only occasionally has major beneficial impact, due to poor distal run-off. Although observational studies have shown better outcomes for patients with diabetes undergoing vascu-lar intervention,33 there were major confounders of patient selection in this report. One randomised control trial showed no difference between angioplasty and infra-inguinal bypass for limb salvage,34 but this trial was designed to look at patients with diabetic foot ulcers. In general, for surgical interventions in diabetic foot disease there is a paucity of evidence from randomised control trials.

Footwear and injuriesTwo thirds of patients wear poor-fitting shoes,35 but therapeutic shoes designed by orthotists can reduce re-ulceration rates by a half,36 at least in the short term. Therapeutic shoes, or simple advice to those with neuropathy to avoid loose fitting footwear like slippers and rubber boots, and avoid open shoes such as sandals and flip-flops, can help towards the avoidance of pene-trating and abrasive injuries to the foot. Holidays in warm cli-mates are a common time for ulcers to develop, when sand enters open shoes and then acts as an abrasive, or patients with neuropathy walk with bare feet on hot flagstones. This is well recognised and has been labelled the ‘holiday foot syndrome’,37 and patients need to be warned and prepared for such risks.

ScreeningThe purpose of screening is to identify the patients who are at high risk of foot ulceration. Various screening programmes have been trialled. The North West Diabetes Care Foot study26 dem-onstrated the value of risk factors for new diabetic foot ulcer-ation in a community-based cohort of 6,613 patients. The seattle Diabetic Foot study38 published data from follow-up of 1,285 patients showing the utility of clinical information, such as neuropathy, previous foot ulceration, poor vision and other information to predict future foot ulceration. These data sup-port previous work from their unit.39 The International Working Group on the Diabetic Foot40 and the sIGN guideline41 have independently developed screening criteria which use similar simple clinical criteria of lack of sensation, absent pulses, previ-ous ulceration, foot deformities, and inability to self-care. The IWGDF evaluated their screening criteria in a cohort of 225 patients, and showed that their criteria did predict foot ulcer-ation.42 The sIGN criteria were used in a community-based project of 3,526 patients categorising patients as being at low, moderate or high risk of ulceration. Patients identified at high risk were at least 83 times more likely to develop a foot ulcer than low-risk patients during subsequent follow-up.43 This system is

Table 2. Treatment of painful diabetic neuropathy

simple analgesics, e.g. paracetamolMembrane stabilisers, e.g. gabapentin, amitriptyline, pregabalinssRI drugs, e.g. duloxetine, venlafaxineOpioids e.g. oxycodoneOther e.g. capasacin, acupuncture, dorsal column stimulators

Key: ssRI = selective serotonin reuptake inhibitor.

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now being used across scotland, and nearly 50% of all 230,000 patients with diabetes have already undergone foot risk assess-ment. Low-risk patients are recommended to self-care and seek help at appropriate times, moderate risk patients are recom-mended to receive podiatry or foot-care assistance, while high-risk patients are directed towards more intensive podiatry support, by the few podiatrists with extensive knowledge and experience of diabetes-related foot problems (table 3).

Epidemiology/amputationsRates of major amputation in patients with diabetes is a useful measure of outcome for the diabetic foot, although not the only measure of success. Various studies have shown that the rates of major amputation are now decreasing at the regional level with rates declining from around 550 to 160–360 per 100,000 patients with diabetes.44-49 In areas where diabetes ascertainment can be uncertain, it is recommended that rates per total population should be quoted, and these have also been shown to decline.45,46 In the Netherlands there is evidence of a national decrease in amputation rates47 with similar data reported from scotland.50 In most of these studies the rates of minor amputation (toe/forefoot) have not changed, or even increased, but this minor amputation can be an important inter-vention to avoid major amputations and accelerate healing.

Although MDFCs have been shown to reduce amputation rates there are other contributing factors towards the decreasing rates of amputation.1,2 The aggressive treatment of cardiovascu-lar risk factors with increased use of statins, angiotensin convert-ing enzyme inhibitors and aspirin,48 and lower glycated haemoglobin A1C, blood pressure and cholesterol across the population49 have been associated with lower amputations, and may be at least as important. Aggressive treatment with cardio-protective drugs has also been shown to improve survival in patients with foot ulceration,51 and is likely to have a benefit for

patients undergoing amputation who currently have about a 30% survival rate at 5 years post-amputation.52-54 Compared with amputees without diabetes, those with diabetes have increased risk of death, further amputation and cardiac failure.52

This article highlights the variety of issues facing a clinician who cares for patients with diabetic foot problems. The risks of neglecting feet are huge, and there is an increasing amount that can be done to help patients to avoid foot ulceration and leg amputation that requires enthusiastic physicians dedicated to working within a multidisciplinary team.

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Key messages

● Negative pressure wound therapy can help healdiabetic foot ulcers

● New guidance recommends short duration use ofnarrow-spectrum antibiotics

● An absent ‘probe to bone test’ makes osteomyelitisvery unlikely, but only 50% of patients with a positive test have osteomyelitis

● Pregabalin, duloxetine, venlafaxine and oxycodoneare newer drugs proven to help painful diabetic neuropathy

● Foot risk stratification identifies patients at high riskof developing foot ulceration

● Amputation rates are declining in some areas

Table 3. screening for foot disease. Risk stratification and identified care pathways

HIGH RISK: 13%

Previous amputation or ulcer orAbsent pulses and neuropathy orNeuropathy with callus or deformity

Care from a podiatrist with skillsin diabetes

MODERATE RISK: 20%

Absent pulses orneuropathy orFoot deformity or inabilityto self-care

Care from a general podiatristor a foot-care assistant (e.g. forthose unable to self-care)

LOW RISK: 67%

At least one foot pulse palpable andNormal sensation andNo deformity andNo previous ulcer

Educate to self care, withknowledge of when and how toseek help

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