Lesions in the feet caused by diabetes mellitus

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1 Lesions in the feet caused by diabetes mellitus N. Tentolouris 1 st Dept. of Internal Medicine Athens University Medical School Laiko General Hospital Athens, Greece

2 Prevalence of the diabetic foot Diabetic foot. In: Vascular Surgery, Liapis Ch (Eds), Sringer-Verlag, Berlin, 2005

3 Prevalence and incidence of the diabetic foot worldwide Prevalence 4-10% Age < 45 yrs % Age > 60 yrs 5-10% Incidence % per year

4 Which is the most common cause of diabetic foot problems?

5 EURODIALE Study (2006) A total of 1229 patients with a new ulcer between September and October Ιschaemia: 49% Ischaemia and infection: 31%

6 Κάπνιζμα δςζλιπιδαιμία Σακσαπώδηρ Διαβήηηρ Πεπιθεπική Απηηπιοπάθεια Αιζθηηικοκινηηική νεςποπάθεια Νεςποϊζσαιμικό Πόδι ζε κίνδςνο. Απώλεια μεζοζηέων μςών Παπαμοπθώζειρ Ελαηη αίζθηζη πόνος & ιδιοδεκηική αίζθηζη Πεπιοπιζμένη κινηηικόηηηα απθπώζεων Αςξημένερ Πιέζειρ ζηο πόδι Τπαύμα Νεςποπάθεια Αςηονόμος ΝΣ Ελαηηωμένη εθίδπωζη Ξηπό δέπμα Κάλορ Νεςποπαθηηικό Πόδι ζε κίνδςνο Μεηαβολέρ αιμαη. ποήρ Διάηαζη θλεβών Θεπμό πόδι Ιζσαιμικό Έλκορ Νεςποϊζσαιμικό Έλκορ Ψςσοκοινωνικά πποβλήμαηα Πποβλήμαηα ζςμπεπιθοπάρ Νεςποπαθηηικό Έλκορ

7 Why diabetic foot matters? 50-70% of the amputations are performed in patients with diabetes The RR of amputation is times higher in persons with diabetes USA: ~ amputations per year in patients with diabetes In 85% of the amputations the cause is a foot ulcer Ischaemia and non-healing ulcers: Cause of amputation in 50-70% in patients with diabetes Infections complicated ulcers: Cause of amputation in 20-50% in patients with diabetes Reiber et al. National Institute of Health, 1995

8 Diabetes Care, 2004, 271:

9 Prevalnce (%) High prevalence rates of co-morbidity in diabetic patients with foot ulcers * * * *P< * No ulcer Ulcer CAD LEAD Retinopathy Nephropathy Blue columns: Diabetic patients without ulcer (n=508) Red columns: Diabetic patients with ulcer (n=234) Tentolouris N et al., Wounds (2008)

10 Prevalence (%) Even higher prevalence rates of co-morbidity in diabetic patients with neuroischaemic foot ulcers * * *P< * 30 Neuropathic Neuroischaemic CAD Retinopathy Nephropathy Blue columns: Diabetic patients without ulcer (n=152) Red columns: Diabetic patients with ulcer (n=82) Tentolouris N et al., Wounds (2008)

11 Cost of foot ulcers Atlas of the Diabetic Foot, 2 nd Edn, 2010, Wiley-Blackwell

12 Dry gangrene

13 Wet gangrene

14 Colour change of NEUROPAD

15 The performance of Neuropad for the diagnosis of neuropathy FULL PUBLICATIONS ZICK et al, 2003 Sensitivity: 90%, Specificity: 74% PAPANAS et al, 2005 Sensitivity: 94.4%, Specificity: 69.7% PAPANAS et al, 2007 SHEN et al, 2007 Sensitivity: 95%, Specificity: 69.8% Sensitivity: 92.8%, Specificity: 78.5% PAPANAS et al, 2007, in press Sensitivity: 97.8%, Specificity: 67.2% ABSTRACTS MANES et al, 2004 Sensitivity: 90%, Specificity: 66% MARINOU et al, 2005 Sensitivity: 86%, Specificity: 68.2% MALIK et al, 2006 DIDANGELOS et al, 2006 Sensitivity: 86%, Specificity: 60% Sensitivity: 95%, Specificity: 69%

16 Excellent (κ= 0.88) agreement between the health care professional and the patients

17 What will you suggest to a patient with neuropathy? Education in foot care Proper shoes and insoles

20 Orthotics

21 Therapeutic shoes

22 Callosities 1) Off-loading 2) Callus removal 3) Reduction of skin dryness using creams containg urea 10-20% 4) Regular podiatry follow up

23 A patient with long-standing diabetes attends the foot clinic with a foot which is red, swollen and warm: what is your diagnosis?

24 Neuro-osteoarthropathy Definition Charcot neuropathic osteoarthropathy (CN), commonly referred to as the Charcot foot, is a condition affecting the bones, joints, and soft tissues of the foot and ankle, characterized by inflammation in the earliest phase. Prevalence: 0.8-8%

25 Risk factors of CN 1) Long duration of diabetes 2) Dense peripheral somatic neuropathy 3) Autonomic neuropathy 4) Adequate blood supply to the feet 5) Osteoporosis 6) Other microangiopathic complications 7) Kidney tranplantation 8) Anorexia nervosa

26 Typical chronic CN deformity

27 Typical chronic CN deformity

28 Chronic CN deformity

29 Chronic CN deformity with relapsing pedal ulcers

30 Chronic CN deformity with a relapsing pedal ulcer

32 Dry skin, callosities and claw toe deformity

33 Neuropathic ulcers

34 Neuroischaemic ulcers

35 Τσαπόγας Dry gangrene

36 Septic arteritis

38 How will you manage these patients?

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