In the beginning…….. Diabetic patients were losing

limbs, long stays in hospital, no hope of healing chronic ulcers inevitable amputation.

No light at the end of the tunnel, only destruction, dismay and death.

…But a new era was emerging….

Historical Events• Launch of Sky TV

• Unleaded Petrol was at 38p per litre

• Inauguration of the 1st President Bush

• Order of the garter opened to women

• Terry Waite was kidnapped in Beirut

• First ever Rugby World Cup kicks off

Reduce Amputations by 50%

‘ Where are we – where do we want to be, and how can

we get there’?

Scotchcast Boot

Patients

Podiatrist

District Nurses

G.P’s

Specialist Care

Wards

Practice Nurses

The Greater Team

100 boots in Blackburn – 1988

Showed average healing rates of 8 weeks in neuropathic ulceration

BUT How do we prevent the first ulcer? How do we keep them healed?

Historical Data 1988/1989Precipitating Factors of Ulcers

Kings

(n=210)

Blackburn

(n=100)

Shoes 85% 74%

Accident 9% 14%

Thermal 2% 3%

Pressure 4% 9%

LOW RISK Protective sensation intact

(10g pressure)

Optimise diabetes and blood pressure control (<139/80)

Foot education/Low risk leaflet

Podiatry only for problems

MODERATE RISK • Loss of protective sensation

• No deformity

• No callus

• No previous ulcer

• Foot education/Moderate risk leaflet

• Consider Consultant opinion

• Optimise diabetes and blood pressure control (<139/80)

• Footwear advice and assessment

Regular Podiatry (12 weekly)

HIGH RISK• Loss of protective sensation• Deformity and/or callus present• No previous ulcer

• Optimise diabetes and blood pressure control (<139/80)• Foot education/High risk leaflet• Consultant opinion• Specialist prescribed Footwear/Shoe review

Regular Podiatry (4 – 12 weekly)

Very High Risk• Ulcer present or

• Previous ulcer

• Loss of protective sensation (10 g pressure)

• Foot education leaflets/ very high risk leaflet

• Consultant opinion

• Specialist prescribed footwear / shoe review

• Optimise diabetes & blood pressure control (<130/80)

Regular podiatry and review (1-4 weekly)

Arterial Disease• Abnormal flow• +/- History of claudication

telephone: 07793 119344• If you suspect acute vascular insufficiency

• Optimise diabetes & blood pressure control (>139/80)• Prescribe aspirin/statin• ‘Stop smoking and keep walking’• Foot education/leaflet • Consider consultant opinion• Specialist prescribed footwear / shoe review

Regular Podiatry especially nail care (1-12 weekly)

Referral Pathways For The Diabetic Foot

Referral for Diabetic Footwear

Referral for Non-urgent Problems

Referral for Urgent Problems

Urgent Patient

Same Day Referral

Ring :-Diabetes Hot Foot lineBlackburn 07866684362Burnley 07875011972

Condition becomes urgent refer via RED Pathway

Continue treatment until Outpatient Appointment

Non Urgent Patient

Referral letter, or fax (01254 736311)Dr G.R. Jones, Diabetes unit, RBH

New patient

Existing patient

Letter of Referral to Dr G.R. Jones, Diabetes unit, RBH

Prescribed footwear

OrthoticsRBH01254 294040BGH01282 804602

OrthoticsRBH 01254 294040BGH 01282 804602

N.I.C.E Guidelines recommend:-

Annual inspection and examination

Aggressive intervention to reduce morbidity

Primary and secondary care should work together to identify a package of care for at risk feet

N.I.C.E.

‘foot ulceration and lower limb amputation can be reduced if people who have sensory neuropathy affecting their feet are identified and offered regular podiatry and protective footwear if required’

Do Shoes and Orthoses work?

To look at the precipitating factors responsible for new DFU compared to previous studies.

Are shoes still a major factor or have things changed?

“Change is inevitable – except from a vending machine!”Robert C. Gallagher

Precipitating Factors of Referred Ulcers

Kings

1988

(n=210)

Blackburn 1988

(n=100)

Blackburn

2004

(n=72)

Shoes 85% 74% 47.2%

Accident 9% 14% 12.5%

Thermal 2% 3% 4.2%

Pressure 4% 9% 15.3%

OutcomesDiabetic population and Ulcer Frequency

0

2000

4000

6000

8000

10000

12000

14000

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

0

100

200

300

400

500

600

700

800

900

1000

DiabeticPopulation

Ulcer Frequency

1988

Aetiology of Foot Ulcers in Diabetic Foot Clinic

55

33.3

12

36.1

0102030405060708090

Perc

enta

ge o

f Pat

ients

1988/89 1994/95 1996/97 2003/04

neuropathic

100 boots in Blackburn – 1988

Showed average healing rates of 8 weeks in neuropathic ulceration

BUT How do we prevent the first ulcer? How do we keep them healed?

Custom made insoles

Stock footwear

Modular footwear

Diabetic specification

Bespoke footwear

Continuous follow-up

2-3 servicable pairs of shoes Long term care (>2yrs) Weaning process Long term healing

“A neuropathic patient is a footwear patient for life” (Ulbrect J 15/05/08)

(Orthotic & Podiatric)(Orthotic & Podiatric)

Footwear Follow-up Footwear Follow-up StudyStudy

100 consecutive patients 100 consecutive patients recalled after 2 yearsrecalled after 2 years

Then followed up for a further 7 Then followed up for a further 7 yearsyears

IntactIntact 70%70% 70%70% 24%24%

Cracked Cracked skin/callusskin/callus

30%30% 23%23% 14%14%

UlcerationUlceration 00 3%3% 22%22%

AmputationAmputation 00 1 Major1 Major

3 Minor3 Minor

7 Major7 Major

5 Minor5 Minor

2 Years 5years 10Years

ResultsResults

Conclusion from footwear Conclusion from footwear follow-up studyfollow-up study

Prescribed footwear is effective when worn, inspection is a vital part of follow up although this is written into guide lines it is not usually adhered to.

The importance of footwear review The importance of footwear review needs more emphasis at all levels of needs more emphasis at all levels of carecare

That’s ok but is it cost effective?

£

• I am asked (told) to provide footwear for I am asked (told) to provide footwear for diabetic patients.diabetic patients.

• 20% of my working week is dedicated to 20% of my working week is dedicated to working within the East Lancashire Diabetic working within the East Lancashire Diabetic Foot Team.Foot Team.

• I am expected to provide orthosis that I am expected to provide orthosis that will will preventprevent high risk feet from ulcerating & high risk feet from ulcerating & healed ulcerated feet from re-ulcerating.healed ulcerated feet from re-ulcerating.

• Ensure patients have TWO serviceable Ensure patients have TWO serviceable pairs of footwear.pairs of footwear.

G H Nuttall P/O G H Nuttall P/O BSc(hons) MBAPOBSc(hons) MBAPO

Am I of value in treating feet ?Am I of value in treating feet ?(or am I just an expensive (or am I just an expensive

accessory?)accessory?)

• Effective?Effective?• Efficient?Efficient?• Contribution? Contribution? • Cost effective?Cost effective?

0

100

200

300

400

500

600

0 10 20 30 40 50 60 70 80 90 100Number of ulcers prevented

Mo

ney

sav

ed (

£000

's)

Healed ulcer £5,000

Total orthotic cost £48,142

30 39 66 88

Cost saving of £392,000

Cost saving of £282,000

Cost saving of £147,000

Cost saving of £102,000

Cost Savings by OrthoticsCost Savings by Orthotics

Allied Health Professions input to the Diabetes pathway

• The cost on the NHS to heal one ulcer is £3k to £7.5k. Should this progress to amputation the cost is estimated to escalate to £65k. This is much more than the cost of preventative orthoses.

• For every £1 spent in orthotics the NHS saves £4.

Hutton and Hurry 2009, Orthotic Service in the NHS:

Improving Service Provision. York Health Economics

Ulceration/Hot FootREFER patients to a multidisciplinary foot

care team within24 hours if any of the following occur:

• new ulceration (wound)• new swelling• new discolouration (redder, bluer,

paler, blacker, over part or all of foot). (NICE Guideline – Type 2 diabetes: prevention

and management of foot problems)

REFER non-healing wounds from 0 – 4 weeks duration

Treatment of Ulceration

Pressure relief (preferably non removable)

Medical management (CVS, oedema, diabetes, infection)

Debridement and dressings

And…….. a team

Pressure Relieving Devices

DARCO walker DH shoe

Half shoe

Aircast Walker

Padding & strapping

Podo-med

Nothing works like casting

Modified TCC

Bi-valved cast

Cast Variations

Focused Rigidity Cast

Heel ulceration

Innovations from Diabetic foot Service

• Scotchcast Boot

• Bespoke casting

• Screening Programme

• Effective and efficient orthotic service

• Hot foot line

• House shoe

• Charcot data and register

HOME? NOT SO SWEET HOME

Lomax G McLaughlin C Jones G R Kenwright C Blackburn Royal Infirmary

HOME? NOT SO SWEET HOME“THE GREATESTNUMBER OF STEPS PER DAYARE TAKEN INTHE PATIENTS OWN HOME.”

David Armstrong et al. (American Podiatric Medicine 2001)

HOME? NOT SO SWEET HOMEPRESCRIBED INSOLES AND FOOTWEAR CAN PREVENT FOOT PATHOLOGY

(TOVEY F.I. 1987)

HOME? NOT SO SWEET HOME

Footwear is most effective when worn for a minimum of 60% of the day. (Chanteleau, E. Haage, P.)

Most effective when worn for 100% of the ambulatory time.

HOME? NOT SO SWEET HOME

AIM OF STUDY

To assess what proportion of patients who had been prescribed Diabetic footwear were wearing at home.

HOME? NOT SO SWEET HOME

How could we do this study?

• Ask patients at clinics?• A telephone survey?• Send patient questionnaires?• Knock on patient doors and ask and look?• Data collection by Community Podiatrists visiting

patients homes on Domiciliary visits. “The sneak approach”

HOME? NOT SO SWEET HOMERESULTS

Question No shoes Own shoes Own slippers

Prescribed

shoes

1. What is patient wearing on entry to house?

19% 8% 52% 21%

2. What does patient apply after treatment?

15% 8% 56% 21%

HOME? NOT SO SWEET HOME

CONCLUSION

• 75% of patients visited do not wear prescribed shoes at home.

• All health care professionals need to be aware of this.

“ HOME SAFE HOME”

Charcot Foot

Care of People with Charcot Osteoarthropathy (NICE 01/04)

“People with suspected or diagnosed Charcot osteoarthropathy should be referred immediately to a specialist multidisciplinary foot care team for immobilisation of the affected joint(s) and for long-term management of offloading to prevent ulceration.”

Definition ?

No definitive “test”

Xrays & scans – open to interpretation

Diagnosis is primarily clinical & subjective

Identification of Charcot Arthropathy

Unified district wide diabetic foot service

Centralised referral point

Validated district diabetes register

Charcot Data (1996-2006)

Incidence and Prevalence

Patient Characteristics

Diagnostic Presentation

Treatment and Outcomes (including the effect of an audit

and community education event in 2001)

Presenting Site Of Charcot Arthropathy

Forefoot 4(9%)

Ankle 9(20%)

Midfoot 32(71%)

1st.

2nd.

3rd.

Presentation Charcot

10 (35%) delayed diagnosis on presentation

7 (24%) developed C.N.A on ipsilateral limb

3 (10%) developed C.N.A on contralateral limb.

9 (31%) diagnosed correctly

Local Charcot “Programme”(2001)

Why Delays in diagnosis/ Late Presentations

How Education event in community for all HCPs

What Road show – staff meetings, lunch hours, training events

Presentation25,

56%

12,41%

16,35%13,

45%

4,9%

4,14%

0

5

10

15

20

25

30

2001 2006

No.

of C

.N.A

.s

Acute (<2 weeks) (p<0.05)Sub-acute(<3 months (p>0.05)Chronic(>3 months)

Treatment of Charcot Arthropathy

Mean time in casts

2001, 33.6 weeks (8 - 56) 2006, 20.5 weeks (range 8 - 30) (p<0.001)

Mean time from active to quiescence 2001, 42 weeks (8 -70) 2006, 26.3 weeks (range 8 – 40)

(p<0.001)

39 (87%) 4 (9%) 2 (4%)

Outcomesn=45

No. of

C.N.A

Surgery -

exostectomies and minor

amputations

Below Knee

AmputationDeaths

Healed/

Stable

Feet31 0 0 7

Feet with

Ulcers 14 5+4 4 2

Mortality/Morbidity Charcot v Matched Controls

7,20%4,

11%

12,34%9,

26%

0

5

10

15

20

25

30

35

40

Patients with C.N.A Control Group

No

. o

f P

atie

nts

Total (n=35)

Amputations

Deaths

(p>0.05)

Summary

Charcot Arthropathy IS uncommon (1:500 people with diabetes)

Diagnosis is often initially delayed, but community education and awareness significantly reduces this

Poor diabetic control appears to be a prerequisite for CNA

Conclusion

Earlier recognition and treatment of C.N.A. translates into significantly faster healing & 3/12`s less time in casts!

(Charcot “Road shows” work!)

Our local surgical practice is conservative & reserved for feet with recurrent or non healing ulcers only

Outcome for both limb and life is NOT adversely affected.

Larger patient numbers are needed to be studied to ratify these findings and this will demand collaborative working e.g. CDUK

Grant from DUKThe Charcot register

• National data base

• Lead and managed from ELHT

The Charcot Register

Scotland 6

North East 4

North West 10

Yorkshire & Humberside 4

West Midlands 3

East Midlands 6

Northern Ireland 1

Republic of Ireland 2

Wales 4

East Anglia 5

South West 10

South East 16

Major lower limb Amputations

0

0.5

1

1.5

2

2.5

PCT

Rat

es p

er 1

000

Series1

Minor Lower Limb Amputation

0

0.5

1

1.5

2

2.5

3

3.5

4

PCT

Rat

es p

er 1

000

Series1

Finally

Latest Benchmarking Data from the SHA

• Lowest non-elective admission rates• Shortest length of stay• Effective and efficient service

Diabetic Foot Service

Then & now

1988

• People working in isolated pockets

• Foot clinic inaugurated

• MDT formed

• Inadequate referral pathways

• High amputation rates

• Long in patient stays

• Huge NHS costs

NOW

• Foot clinic 23 years old

• Effective implemented pathways

• Well established clinics

• Good interagency and interprofessional relationships

• Low amputation rates

• Reduced in patient stay

• Cost efficient

Thank you