prevention of diabetic foot wounds - baum...previous foot ulceration & amputation ira baum, dpm,...

6/5/2014

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MIAMI CRITICAL LIMB ISCHEMIA SYMPOSIUM

Prevention of Diabetic Foot Wounds

Ira Baum, DPM, FACFAS 2014

?


“An ounce of prevention is worth a pound of cure.”

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PREVENTION REQUIRES UNDERSTANDING OF THE CAUSATIVE FACTORS:

Neuropathy

Peripheral Arterial Disease

Trauma


Causative Factors

Flow Pattern Contributing to Diabetic Wound


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Contributing FactorsContributing Factors


Peripheral Neuropathy

� Nutrition

� Vascular


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Sensory Neuropathy


Loss of Protective SensationIncrease in Amputation 7 X

Autonomic Neuropathy


� A-V shunting

� Abnormal vascular response

� Combined with Sensory & Motor Neuropathy

Charcot Foot

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Charcot Foot or Cellulitis?


Motor Neuropathy


� Achilles Tendon Contracture

� Increased forefoot pressure

� Small intrinsic muscles atrophy

� Structural foot deformities

� Abnormal pressure area

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~2 X AS COMMON IN PEOPLE WITH DM

THAN WITHOUT DM




� Local Ischemia

� Abnormal Immunological Response

� thick toenails and skin infection


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Local Ischemia

� Slow healing

� risk of infection

� Gangrene

� Amputation


Abnormal Immune Response


� Hyperglycemia affects the cellular response to tissue injury

Delayed immune cells response to injury necessary for wound healing

Impaired functioning of immune cells in diabetes mellitus

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Diabetic Infected Wound


Lucky !!!

Indirect Contributing Factors


� Smoking

� Hyperlipidemia

� Obesity

� Hypertension

� Inactive lifestyle

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Prevent This


Identify Patients “At-Risk”


� Previous foot ulceration

� Prior lower extremity amputation

� Long duration (>10 years) of having diabetes

� Poor glycemic control (glycosylated hemoglobin >9%;

� Impaired vision

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Previous Foot Ulceration & Amputation


� Structural predisposition to areas of previous ulcer

� Change in the underlying subcutaneous tissue

� Changes in gait with abnormal weight distribution

Duration of Diabetes & Age


� Increased incidence of Peripheral Arterial Disease� >~60 years old incidence of PAD and LLA increases 8 fold

� Increase incidence of Peripheral Neuropathy� >~60 years old have some form of peripheral neuropathy

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Glucose Control


� 1% mean reduction in hemoglobin A1c was associated with a 25% reduction in microvascular complications, including neuropathy.

� A nonsignificant reduction in amputations (by 36%) in the intensive compared with the conventional treatment

� Pinzur MS, Slovenkai MP, et al. Guidelines for diabetic foot care: recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society. Foot Ankle Int.

Increased HgA1C


� Increase in HgA1C � Advanced Glycation End-Products

� Increase collagen cross fibers stiffness to soft tissue

� Ability to withstand shearing and repetitive stress

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Impaired Vision


� Inability to detect minor wounds that progress

� Easily injures themselves

� May be causal relationship with retinopathy and ulcer development?

Foot Examination


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History


� Past History� Previous Ulcer/Slow healing wound

� Vascular Surgery/Angioplasty

� Charcot Foot/Foot Surgery

� Smoking

� Neuropathic Symptoms� Positive: Burning, Electric Shock, Shooting, Sharp Pain

� Negative: Numbness, “Feet feel dead”

� Vascular Symptoms� Claudication

� Rest Pain


� For structural abnormalities (eg, calluses, hammer or claw toes, flat feet, bunions)

� Reduced joint mobility

� Dry or fissured skin, tinea, or onychomycosis

� Inspect footwear to ensure proper fit

Examine Feet

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VascularVascular


�Pedal Pulses�Skin

Temperature�Skin Color�Hair Growth�Skin Elasticity�Swelling

Examine Feet

Pedal Pulses


� Dorsalis Pedis Pulse

� Absent ~3% of population

� Posterior Tibial Pulse

� Popliteal Pulse

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Ankle Brachial Index


� ABI

� <9 Abnormal

� <5 Refer to Vascular Specialist

Inspect and Palpate the Feet


� Cold

� Rubor

� Swollen

� Hair growth

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Assess Protective Sensation


� Semmes Weinstein 5.07 monofilament� 10g force

Loss Of Protective Sensation


� Patient does not experience SW 5.07 (5 areas?)

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Examine Feet

Neurological

� Vibratory Sensation (128 CPS)


Mechanoreceptors in the skin - Large Nerve Fibers

NeurologicalNeurological


� Proprioception

� Achilles Tendon Reflex

� Tinel’s Sign

Examine Feet

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MusculoskeletalMusculoskeletal


Range of Motion

Limited ROM

Pressure

Deformities

Examine Feet

Tight Achilles Tendon


� Cause

� Muscle imbalance

� Subtle drop foot

� Congenital

� Increased forefoot pressure

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Foot Deformities


� Bunion

� Hammertoe

� Prominent metatarsal

� Charcot foot

DermatologicalDermatological


� Onychomycosis

� Tinea Pedis

� Fissured Skin

Examine Feet

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DermatologicalDermatological


� Healed Ulcers� Fibrous Subq Tissue

� Callus - Corn� Repetitive abnormal

pressure

Examine Feet

Risk Category 0Risk Category 0 RecommendationRecommendation


� No LOPS, no PAD, no deformity

� Patient education including advice on appropriate footwear.

� Annually (by generalist and/or specialist)

ADA Risk Category

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Risk Category 1Risk Category 1 RecommendationsRecommendations


� LOPS ± deformity � Consider prescriptive or accommodative footwear

� Consider prophylactic surgery if deformity is not able to be safely accommodated in shoes

� Continue patient education.

� Every 3–6 months (by generalist or specialist)

ADA Risk Category



� PAD ± LOPS � Consider prescriptive or accommodative footwear.

� Consider vascular consultation for combined follow-up.

� Every 2–3 months (by specialist

ADA Risk Category

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� History of ulcer or amputation

� Same as category 1.

� Consider vascular consultation for combined follow-up if PAD present

� Every 1–2 months (by specialist)

ADA Risk Category

PATIENT EDUCATION


Prevention

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� Reduce thick abnormal toenails to avoid ulcer under nail

� Reduce Hyperkeratosis (callus) abnormal pressure

Professional Foot Care

Accommodative Shoes


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Accommodation – Healing Shoe


Accommodative – Pressure Reducing Insoles


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Control Weight Distribution


Charcot Restraint Orthotic WalkerControlled Ankle Motion BootWith Molded Insole

The Gold Standard


TCC allows for Weight Bearing (cane – walker)

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Inspect Barefeet Once or Twice DailyInspect Barefeet Once or Twice Daily


Patient Focused Education

Use what ever you need to ensure satisfactory

self- assessment

Use what ever you need to ensure satisfactory

self- assessment



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Never use sharp instrument or corn/callus remover medicine on feet

Never use sharp instrument or corn/callus remover medicine on feet


� Poor vision

� Diminished sensation

� Recipe for disaster


Avoid dryness and cracking to skin of feetAvoid dryness and cracking to skin of feet


� Use quality emollient on feet

� Avoid placing lotion between toes


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Ensure proper fitting footwearEnsure proper fitting footwear


� Foot measuring system are inaccurate

� Purchase new shoes at end of the day

� Break-in shoes slowly

� Check inside of shoe before putting on


Check feet at every office visitCheck feet at every office visit


� Have physician or nurse check feet at every office visit


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Instruct patient to call immediately if they have or even suspect a foot problem

Instruct patient to call immediately if they have or even suspect a foot problem


� The most effective time to assess a potential foot problem is before it becomes a real foot problem


In my officeIn my officeWhy is there

noncompliance?Why is there

noncompliance?


� Video on DM foot care

� Consultation w/ Dr.

� Educational Handout

� Reinforcement every visit

Failure

� Fear� Incurable Disease

� Inevitable amputation

� Limited capacity

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Why Prevention: reduce costs

Healthcare Cost

&

Intangible Cost


Facts Associated with Amputation


� 1 in 5 diabetic infected wounds require amputation

� ~60% non traumatic amputations in USA associated with Diabetes

� Within ~ 2 years of major LLA� 50% increased risk of amputation of the contra lateral limb

� Within ~5 years� ~60% mortality rate

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Healthcare Cost of Treatment

Not Requiring AmputationNot Requiring Amputation

~$33,000.00/Year

Outpatient Visits -14/Year

Hospitalization -1.5/Year

Requiring AmputationRequiring Amputation

~52,000.00/Year

Outpatient Visits -12/Year

Hospitalization -2/Year


Time Suffering

Emotional Stress

Intangible Costs To Patient & Family


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Intangible Costs

Disability/ Premature Retirement Increased Cost of Insurance


Conclusion


� Following recommendations on diabetic wound prevention will:� reduce suffering

� control healthcare costs

� reduce # of amputations and save lives

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― Benjamin Franklin


prevention of diabetic foot wounds - baum...previous foot ulceration & amputation ira baum, dpm,...

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