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

2. Evolution and the diabetic foot Increasing numbers Fashion victims

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 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 Cost to the NHS 80% 49% 20% 17% Amputation / Foot Ulcer Colon Cancer Prostate Cancer 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

10. Old PCT boundaries Devon PCT Torbay PCT Plymouth PCT

11. PCT major amputation rates – YHPHO 2012 1.6 1.0 1.8 England 1.0 1.3

12. NEW Devon CCG northern locality NEW Devon CCG eastern locality NEW Devon CCG western locality South Devon and Torbay CCG New CCG boundaries (also reflect catchment areas) NEW = North East West

13. NEW CCG amputation rates YHPHO 2012 1.6 England 0.9

14. 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

15. New CCG boundaries (also reflect catchment areas) 1.4 1.3 2.0 1.2 Thanks to Shane Coe – NEW Devon CCG 1.2 England 0.9

16. Devon is an outlier…

17. …because it ’ s the biggest

18. Ethnicity White – risk = 1.0 S Asian – risk = 0.25 Black – risk = 0.62 Age 2% increase per year Confounding factors?

19. We are 20 years ahead of the country (Sidmouth 2075)

20. Confounding factors? Holman, Diabetologia 2012; 55: 1919. Amputation rates in diabetic and non-diabetic patients correlate strongly – r=0.43, p=0.0005

21. The South Western Region High rate of diabetic foot disease in South West Legacy effect 50% older migrants Older population 25% >65 longer survival Rural occupation White 94.1%

22. 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

23. 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

24. 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

25. 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

26. Inpatient foot care

27. The Touch Test

28. 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

29. 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 IpTT MF Sensitivity 76% 81% Specificity 90% 91% Concordance IpTT v MF Very good (k=0.85, p<0.0001) Inter observer reproducibility Good (k=0.68, p<0.001)

30. 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)

31. 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?

32. 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 Discuss/refer – options capsaicin, GTN, lignocaine patches Start tramadol meantime

33. CASES

34. Sausage toe - Osteomyelitis

35. 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

36. Mrs C Left foot warmer than right Monofilament 3/6 All peripheral pulses felt Left foot medial protrusion of inner long arch

37. Differential diagnosis ? Charcot /Sprain Infection: osteomyelitis: Cellulitis Gout DVT

38. One month later

39. Bones in foot

40. Mr P

41. 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

42. Mr A

43. Mr D Type 1 DM CKD4 Proliferative retinopathy Biphasic pulses Foot ulcer healed R 2 nd met head. Hot foot

44. 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.

45. 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%

46. 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

47. Radiographic Staging ( Eichenholtz , 1966 ) I Developmental (acute) stage II Coalescence (quiescent) stage III Consolidation (resolution) stage

48. 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

49. Radiographs Stage I

50. 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

51. Radiographs Stage II

52. 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

53. Radiographs Stage III

54. 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.

55. An algorithm depicting a basic approach to the Charcot foot

56. Cycle of pathophysiology of Charcot osteoarthropathy

57. RANKL pathway in the pathophysiology of Charcot arthropathy

58. The Role of RANKL in Charcot neuroarthropathy

59. TREATMENT Non-weight bearing: rest aircast shoes Bisphosphonates - PAMIDRONATE Watch other foot Surgery - trimming of bony exostos - arthrodesis

60. Maggot Therapy

61. FEET FIRST