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
Prevalence of the diabetic foot Diabetic foot. In: Vascular Surgery, Liapis Ch (Eds), Sringer-Verlag, Berlin, 2005
Prevalence and incidence of the diabetic foot worldwide Prevalence 4-10% Age < 45 yrs 1.7-3.3% Age > 60 yrs 5-10% Incidence 2.2-5.9% per year
Which is the most common cause of diabetic foot problems?
EURODIALE Study (2006) A total of 1229 patients with a new ulcer between September 1 2003 and October 1 2004 Ιschaemia: 49% Ischaemia and infection: 31%
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
Why diabetic foot matters? 50-70% of the amputations are performed in patients with diabetes The RR of amputation is 10-15 times higher in persons with diabetes USA: ~80.000 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
Diabetes Care, 2004, 271: 1598-1604
Prevalnce (%) High prevalence rates of co-morbidity in diabetic patients with foot ulcers 40 35 30 * * * *P<0.05 25 20 * No ulcer Ulcer 15 10 5 0 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)
Prevalence (%) Even higher prevalence rates of co-morbidity in diabetic patients with neuroischaemic foot ulcers 60 50 * * *P<0.001 40 * 30 Neuropathic Neuroischaemic 20 10 0 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)
Cost of foot ulcers Atlas of the Diabetic Foot, 2 nd Edn, 2010, Wiley-Blackwell
Dry gangrene
Wet gangrene
Colour change of NEUROPAD
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%
Excellent (κ= 0.88) agreement between the health care professional and the patients
What will you suggest to a patient with neuropathy? Education in foot care Proper shoes and insoles
Orthotics
Therapeutic shoes
Callosities 1) Off-loading 2) Callus removal 3) Reduction of skin dryness using creams containg urea 10-20% 4) Regular podiatry follow up
A patient with long-standing diabetes attends the foot clinic with a foot which is red, swollen and warm: what is your diagnosis?
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%
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
Typical chronic CN deformity
Typical chronic CN deformity
Chronic CN deformity
Chronic CN deformity with relapsing pedal ulcers
Chronic CN deformity with a relapsing pedal ulcer
Dry skin, callosities and claw toe deformity
Neuropathic ulcers
Neuroischaemic ulcers
Τσαπόγας Dry gangrene
Septic arteritis
How will you manage these patients?