prevention of diabetic foot ulcers and lower extremity amputation barry stults, md scott a. clark,...
TRANSCRIPT
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Prevention ofDiabetic Foot Ulcers and
Lower Extremity Amputation
Barry Stults, MD
Scott A. Clark, DPM
Thomas Miller, MD
© 2007. American College of Physicians. All rights reserved.
This content has been excerpted from the ACP Clinical Skills Module, "Diabetic Foot Ulcers."
For more information visit: http://www.acponline.org/clinicalskills/
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“…the enormity of the global burden of diabetic foot disease…this much neglected, but potentially devastating, complication of a disease that is reaching epidemic proportions…Someone, somewhere, loses a leg because of diabetes every 30 seconds of everyday…”
Lancet. 2005;366:1674
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Case Study
64-year-old obese man
Type 2 DM (15 yrs) BP (18 yrs) Dyslipidemia (18 yrs) CABG (10 yrs ago) Claudication (today; 25 yds)
Insulin/Metformin/Statin/ACEI/HCTZ/ASA
“Sore on my left foot, Doc”
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Case Study (continued)
Clinical evaluation of heel ulcer: Probe reached bone Extensive subcutaneous abscess
MRI: extensive osteomyelitis
ABI: 0.2
Angiography: Inoperable severe vascular disease
Uncontrolled infection
Amputation necessary
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Amputations in Diabetes
Common:
U.S.A. – 80,000 amputations/year (2002)
Costly:
$60,000/amputation
$2 billion total costs annually
Lancet. 2005;366:1719
Diabetes Care. 2004;27:1598
Diabetes Care. 2003;26:495
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50% ofamputations
50% of patients
50% of patients
Tragic “Rule of 50”
Transfemoral/transtibial level
2nd amputation in 5 years
Die in 5 years
Clinical Care of the Diabetic Foot, 2005
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Tragic “Rule of 15”
15% of diabetes Foot ulcer in lifetimepatients
15% of foot ulcers Osteomyelitis
15% of foot ulcers Amputation
Clinical Care of the Diabetic Foot, 2005
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Team Care
Identification of high-risk patients
Detection of early problems
Educate/motivate self-care behaviors
Prophylactic nail/skin care
Therapeutic footwear
Prompt, multidisciplinary treatment of ulcers
Lancet. 2005;366:1676
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Team Care Reduces Ulcers/Amputations
50%-80% reductions in ulcers/amputations
Economic modeling studies
Cost-effective if 25%-40% reduction in ulcer rate Cost-saving if > 40% reduction in ulcer rate
Lancet. 2005;366:1719
Diabetes Care. 2004;27:901
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Causal Pathways for Foot Ulcers
Neuropathy
Deformity
ULCER
% Causal Pathways
Neuropathy: 78%
Minor trauma: 79%
Deformity: 63%
Behavioral ?
Diabetes Care. 1999; 22:157
Poor self-foot care
Minor Trauma
- Mechanical (shoes)
- Thermal
- Chemical
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Detecting Feet-at-risk
History: Prior amputation or foot ulcer Peripheral artery disease (PAD)
Exam: Insensate Foot deformities Absent pulses Prolonged venous filling time Reduced ABI Pre-ulcerative cutaneous pathology
Arch Intern Med. 1998;158:157
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Risk Stratify for Ulcer Risk
Diabetes Care. 2001;24:1442
Diabetes Metab. 2003;29:261
Risk LevelFoot Ulcer
%/yr% Office Patients(diabetes clinics)
3: Prior amputationPrior ulcer
28.1%18.6%
7%
2: Insensate andfoot deformity orabsent pedalpulses
6.3% 10%
1: Insensate 4.8% 17%-30%
0: All normal 1.7% 66%
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Annual Diabetic Foot Exams
TotalPrivate
InsuranceMedicaid-Medicare VA Uninsured
% with footexam in past year
63 64 65 84* 48*
Health Services Research. 2005;40:361
*p < 0.01
2000 Behavioral Risk Factor Surveillance System, CDC
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Physical Examination of the Feet
in Persons with Diabetes
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Sensory Neuropathy in Diabetes
Loss of protective sensation in feet
Detect with 5.07/10-g Semmes-Weinstein monofilament
50% of insensate patients have no symptoms
Diabetes Care. 2006;29(Suppl 1):S24
Diabetes Care. 2004;27:1591
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Monofilament Testing
Test characteristics:
Negative predictive value = 90%-98% Positive predictive value = 18%-36%
Prospective observational study:
80% of ulcers and 100% of amputations occur in insensate feet
Superior predictive value vs. other test modalities
J Fam Pract. 2000;49:S30
Diabetes Care. 1992;15:1386
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Using the Monofilament
Demonstrate on forearm or hand
Place monofilament perpendicular to test site
Bow into C-shape for 1 second
Test 4 sites/foot
Heel testing does not predict ulcer
Avoid calluses, scars, and ulcers
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Monofilament Testing Tips
Insensate at 1 site = insensate feet
Falsely insensate with edema, cold feet
Test annually when sensation normal
Use monofilament < 100 times day Replace if bent Replace every 3 months
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Vibration Testing
Biothesiometer
Best predictor of foot ulcer risk
128-Hz tuning fork at halluces
Equivalent to 10-g monofilament Newly recommended by ADA
Diabetes Care. 2006;29(Suppl 1):S25
Diabetes Res Clin Pract. 2005;70:8
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Motor Neuropathy and Foot Deformities
Hammer toes
Claw toes
Prominent metatarsal heads
Hallux valgus
Collapsed plantar arch
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Hammer Toes
Claw Toes
© 2002 American Diabetes AssociationFrom The Uncomplicated Guide to Diabetes ComplicationsReprinted with permission from The American Diabetes Association
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© 2002 American Diabetes AssociationFrom The Uncomplicated Guide to Diabetes ComplicationsReprinted with permission from The American Diabetes Association
Hallux Valgus
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Boulton, et al. Guidelines for Diagnosis of Outpatient Management of Diabetic Peripheral Neuropathy. Diabetic Medicine 1998, 15:508-512
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Pre-ulcer Cutaneous Pathology
Persistent erythema after shoe removal
Callus
Callus with subcutaneous hemorrhage
Fissure
Interdigital maceration, fungal infection
Nail pathology
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AJM Boulton, H Connor, PR Cavanagh, The Foot in Diabetes, 2002
Pre-ulcer
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Peripheral Artery Disease
Prevalence (ABI < 0.9): 10%-20% in type 2 diabetes at diagnosis 30% in diabetics age 50 years 40%-60% in diabetics with foot ulcer
Complications: Claudication Associated coronary and cerebral vascular
disease Delayed ulcer healing
Diabet Med. 2005;22:1310
Diabetes Care. 2003;26:3333
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Pedal Pulse Examination
Absent pedal pulses predicts severe PAD
Absence of a single pedal pulse does not predict PAD
Presence of pedal pulses does not rule out PAD!
Arch Intern Med. 1998;158:1357
Diabetes Care. 2003;26:3333
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Venous Filling Time
Sitting: Locate pedal vein bulging above skin
Supine: Elevate leg to 45° for 1 minute
Sitting: Check time to pedal vein bulging
J Clin Epidemiol. 1997;50:659
Arch Intern Med. 1998;158:1357
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Venous Filling Time Interpretation
Filling Time
Normal <20 sec
Abnormal/collaterals 20-40 sec
Severe PAD >40 sec
Filling time > 20 sec predicts ABI < 0.5 Sensitivity, 22%; Specificity, 94%; LR, 3.9
J Clin Epidemiol. 1997;50:659
Arch Intern Med. 1998;158:1357
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Adapted from: Norman PE, Eikelboom JW, Hankey GJ. Peripheral arterial disease: prognostic significance and prevention of atherothrombotic complications. Medical Journal of Australia 2004; 181:150-154. Figure 1, p.151
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Ankle-Brachial Index
Screening: 2004 ADA recommendation
“Consider” at age 50 years and every 5 years
Diagnosis:
Claudication, absent DP/PT pulses, foot ulcer
Limitations:
Underestimates severity in calcified arteries
Diabetes Care. 2005;28:2206
Diabetes Care. 2004;27(Suppl 1):S15-S35
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Interpretation of the ABI
Interpretation ABI
Normal 0.90-1.30
Mild obstruction 0.70-0.89
Moderate obstruction* 0.40-0.69
Severe obstruction* <0.40
Poorly compressible** >1.30
2° to medial calcification
*Poor ulcer healing with ABI < 0.50**Further vascular evaluation needed
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Risk-stratified Management of the Diabetic Foot
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Low Risk
Annual comprehensive foot examination
Questionnaire completed by patient Examination
Self-management and footwear education
Brief counseling Written handout
JAMA. 2005;293:217
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High Risk
Annual comprehensive foot exam
Inspect feet every office visit
Podiatry care as needed
Intensive patient education
Detect/manage barriers to foot care
Therapeutic footwear, as needed
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High Risk: Nursing Tasks
Place “High-Risk Feet” stickers on each chart
Remove patient’s shoes/socks
Determine if patient can reach/see soles of feet
Stock 10-g monofilament in each room
Consider training to perform monofilament exam
Provide patient education forms
J Gen Intern Med. 2003;18:258
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High Risk: Podiatry Care
Provide nail and skin care
Assess footwear needs
Visit frequency not evidence-based
Diabetes Care. 2003;26:1691
J Fam Practice. 2000;49(Suppl):S30
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High Risk: Patient Education
Reinforce frequently – low retention
Patient demonstrates self-care knowledge
Evidence: May reduce foot ulcer/amputation rates
Cochrane Database Syst Rev. 2005 Jan 25;(1)CD001488
Foot Ankle Int. 2005;26:38
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Basic Foot Care Concepts
Daily foot inspection
May require mirror, magnification, or caregiver
Patient able to recognize/report:
Persistent erythema Enlarging callus Pre-ulcer (callus with hemorrhage)
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Basic Foot Care Concepts
Commitment to self-care
Wash/dry daily
Lubricate daily (not between toes)
Debride callus/corn (low-risk patients)
No self-cutting of nails if:
Neuropathy PAD Poor vision
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Basic Foot Protective Behaviors
Avoid temperature extremes
No walking barefoot/stocking-footed
Appropriate exercise for insensate feet
Inspect shoes for foreign objects
Optimal footwear at all times
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Basic Footwear Education
Avoid:
Pointed toes
Slip-ons
Open toes
High heels
Plastic
Black color
Too small
Favor:
Broad-round toes
Adjustable (laces, buckles, Velcro)
Athletic shoes, walking shoes
Leather, canvas
White/light colors
½” between longest toe and end of shoe
Diabetes Self-Management. 2005;22:33
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Barriers to Foot Care
Depression
Alcoholism
Social isolation if unable to inspect feet
Financial barriers
Diab Metab Res Rev. 2004;20(Suppl 1):S13
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Therapeutic Footwear Goals
Protect feet
Reduce plantar pressure, shock, and shear
Accommodate, stabilize, support deformities
Suitable for occupation, home, leisure
Diabetes Care. 2004;27:1832
Diab Metab Res Rev. 2004;20(Suppl1):S51
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Therapeutic Footwear Components
Padded socks (e.g., CoolMax, Duraspun, others)
Shoe inserts/insoles (closed-cell foam, viscoelastic)
Therapeutic shoes
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Therapeutic Footwear Efficacy
Decreases plantar pressure 50%-70%
Uncertain reduction in ulcer rate
Diabetes Care. 2004;27:1774
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Medicare Requirements
Certify diabetic patient with foot at risk
Prescribe therapeutic footwear
Prepare/fit therapeutic footwear
Pedorthist, orthotist, prosthetist, D.P.M. www.cpeds.org
Foot Ankle Int. 2005;26:42
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Medicare Coverage
Total Amount Allowed
Amount Covered by Medicare
Extra-depth shoes $132.00 $105.60
Custom-made shoes $396.00 $316.00
Diabetic pre-fab insoles $67.00 $53.60
Diabetic custom insoles $67.00 $53.60
Medicare pays 80% of payment amount allowed:
1 pair extra-depth shoes 3 pair insoles/y, or 1 pair extra-depth shoes with modification 2 pair insoles/y, or 1 pair custom-molded shoes 2 pair insoles/y
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Conclusion
Diabetic foot ulcer is common
Foot ulcers have devastating consequences
Screening is simple
Screening and team care reduce diabetic foot ulcers and amputations