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Toe‐Morrow Never Dies!An Approach to the Diabetic Foot

2018 Banff ASADr. Michael Yan, MD, CCFPAssistant Clinical ProfessorDepartment of Family MedicineUniversity of Alberta

Faculty/Presenter Disclosure

• Faculty/Presenter: Dr. Michael Yan

• Relationships with commercial interests:

Grants/Research Support:   Not Applicable 

Speakers Bureau/Honoraria: Not Applicable

Consulting Fees:    Not applicable

Other:  This presentation has received support from the Alberta College of Family Physicians in the form of a speaker fee and/or expenses.

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ACFP 63rd ASADisclosure of Commercial Support

This program has received financial support in the form of sponsorship from:

• Potential for conflict(s) of interest: Those speakers/faculty who have made COI disclosure are noted in the   63rd ASA Program and on the Salon A/B slide scroll.

Mitigating Potential Bias

• ACFP: → The ACFP’s Sponsorship Guidelines apply to ASA Sponsorship. The ACFP abides by the College of 

Family Physicians of Canada’s Understanding Mainpro+ Certification Guidelines, the Canadian Medical Association’s Policy Guidelines for Physicians in Interactions With Industry and the Innovative Medicines Canada Code of Ethical Practices (2016). As a non‐profit organization, the ACFP complies with Canada Revenue Agency regulations. When deliberating acceptance of sponsorship, the ACFP considers and accepts sponsorship only from those whose products, services, policies, and values align with the ACFP vision, values, goals, and strategies priorities.

• ASA Planning Committee: → Consideration was given by the 63rd ASA Planning Committee to identify when Planning 

Committee members’ and speakers’ personal or professional interests may compete with or have actual, potential, or apparent influence over program content.

→ Material/Learning Objectives and/or session description were developed and reviewed by a Planning Committee composed of experts/family physicians responsible for overseeing the program’s needs assessment and subsequent content development to ensure accuracy and fair balance.

→ The 63rd ASA Planning Committee reviewed  Sponsorship Agreements to identify any actual, potential or apparent influence over the program.

→ Information/recommendations in the program are evidence‐ and/or guidelines‐based, and opinions of the independent speakers will be identified as such.

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Objectives

• 1. demonstrate an approach to screening and classification for the high‐risk diabetic foot

• 2. assess a foot ulcer in a diabetic patient and select appropriate initial management

• 3. select appropriate footwear and community resources for ulcer prevention

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Diabetic foot: the numbers

• By 2020, 3.7 million people in Canada will have a known diagnosis of diabetes.1

• People with diabetes have about a 15‐25% lifetime risk of a foot ulcer.2,3

• People with diabetes have a 23‐fold higher risk of lower extremity amputation.2

• 85% of lower leg amputations were preceded by an ulcer 4

1. Canadian Diabetes Association, 20092. Alavi A. et al (2013) Diabetic Foot Canda 1:13‐173. Singh N. et al (2005) JAMA 293:217‐284. Orsted HL, et al. Best Practice Recommendations for the Prevention, Diagnosis and Treatment 

of Diabetic Foot Ulcers: Update 2006. Wound Care Canada. 2006;4(1) 57‐71.

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CDA Guidelines: foot protection

• Regular foot examinations and risk evaluation

• Callus debridement• Patient education• Professionally fitted 

therapeutic footwear to – reduce plantar pressure– accommodate foot 

deformities

K. Bowering, J.M. Embil. CDA Clinical Practice Guidelines. Can J Diabetes 37 (2013) S145‐S149

Gaps in Screening

• “fewer than 50% of diabetic patients receive appropriate foot evaluation as part of their annual medical checkups.”1

• Only 51% of Canadian adults with diabetes reported having feet screened in past year.2

1. Bowering, K. (2001). Diabetic foot ulcers: pathophysiology, assessment and therapy. Canadian Family Physician, 47, 1007‐1016. 

2. Canadian Institute for Health Information (2009) Diabetes Care Gaps and Disparities in Canada.

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Diabetic Foot Risk Factors

Peripheral neuropathy (loss of protective sensation) Structural deformity

Previous ulcerations or amputations Limited joint mobility Peripheral arterial disease Microvascular complications High A1C levels Onychomycosis

K. Bowering, J.M. Embil. CDA Clinical Practice Guidelines. Can J Diabetes 37 (2013) S145‐S149

Elements of the Foot Screen:

History Diabetes complications, lifestyle factors, occupation, previous foot ulcers, medications.

Inspection Skin, nails, deformity, calluses, ulcers, footwear.

Palpation Temperature, pulses, range of motion at toes and ankle.

Special Tests

Neuropathy screening, vascular assessments (ABI, PPG).

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CAWC Wound Care Slide Series

Semmes‐Weinstein 10 g filament

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60 Second Foot Screen

https://www.woundscanada.ca/health‐care‐professional/resources‐health‐care‐pros/foot‐screen

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Diabetes Foot Care Clinical Pathway Diabetes Foot Screening Tool

20710(Rev2017-03)

EXAM FINDINGS R L RISK

SKIN

Normal intact skin – healthy or dry *check in between toes LOW Callus/Corn/Fissure/Crack not bleeding or draining

MODERATE Prior history of Diabetic Foot Ulcer(s) ulcer in remission Blister = B or Hemorrhagic callus = HC

HIGH Fissure or Crack Bleeding or draining = F Diabetic Foot Ulcer – Not infected and/or with intact dry black eschar = U Infected Diabetic Foot Ulcer or wet gangrene URGENT

NAILS Normal well-kept with minimal discoloration LOW Missing, sharp, unkept, thickened, long or deformed

MODERATE Infected ingrown nail

STRUCTURE ANATOMY

Normal no noted visual abnormalities LOW Decreased range of motion at ankle or toe joint

MODERATE Deformities Bunion/Hammer or claw toes/overlapping toes Structure Fallen Arch/ Rocker bottom foot/stable Charcot foot Previous amputation X over location or draw/describe on diagram Redness over any structural deformities pressure related HIGH Red, hot painful joint or acute Charcot foot URGENT

SENSATION Testing for LOPS

Normal sensation using 10 g monofilament at the 5 predetermined sites LOW

Sensation of numbness/tingling/throbbing/burning MODERATE

Absent or altered sensation at one or more of the five sites Acute onset of pain in a previously insensate foot URGENT

VASCULAR Testing for Arterial Compromise

Normal pulses normal capillary refill LOW Signs of Ischemia (PAD) Cool skin with pallor, cyanosis or mottling, and/or dependent rubor

HIGH

One or more pulses not palpable or audible (Doppler) Absent pedal pulses with cold white painful foot or toes URGENT

FOOTWEAR Appropriate accommodates foot shape LOW Inadequate Footwear MODERATE

Inappropriate Footwear causing pressure/skin breakdown HIGH

Instructions: Refer to Health Provider’s Guide to Diabetes Foot Screening Mark ulceration location (U). Mark other areas of specific concern: blister (B), draining fissure/crack (F), hemorrhagic callus (HC), and previous amputation (X).

Sensation Testing (monofilament) RIGHT LEFT Identify any wounds and location on the foot or toe(s)

Date Signature Primary Care Site

Comments

Fill in if no sensation

Leave blank if sensation present

/5 /5

https://www.albertahealthservices.ca/scns/Page10321.aspx

Case # 1

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Temperature

X‐ray Findings

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Charcot Neuroarthropathy

Case 245 year old man with 

diabetic foot ulcers

Wound “not healing for 2 months”

What do you see?

How would you debride?

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The “DIME” Approach

Person with Diabetic Foot Ulcer

Treat the Cause

Local Wound Care

Debridement Infection/Inflammation Moisture Balance Edge Effect

Patient‐centered Concerns

Adapted from Sibbald RG et al. Preparing the wound bed 2003. Ostomy/Wound Management. 2003:49(11):24‐51

Debridement

• Autolytic

• Sharp instrument maintenance debridement

• Pulsed lavage, whirlpool, hydrojet

• Ultrasound

• Enzymatic

• Biotherapy: Maggots!

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Beware

It is not always safe to fix all causes of wounds!– Debriding an arterial ulcer can lead to major

infection and a larger non-healable wound

– Malignant wounds can sometimes be non-healable

DEAAD mnemonic

– Drugs: examples include immunosuppressant agents and systemic steroids

– Edema– Albumin: below 30 g/L suggests delayed healing, below 20 g/L suggests non‐healing

– Anemia: below 100 g/L suggests delayed healing, below 70‐80 g/L suggests non‐healing

– Diseases: examples include diabetes, RA, collagen vascular diseases, renal failure

Sibbald RG et al. Best Practice Recommendations for Preparing the Wound Bed: Update 2006. Wound Care Canada. 2006;4(1):15‐29.

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Debridement

• Not a sterile procedure

• Can score (tic tac toe board)

• Can fully debride – may need freezing!!

• Remove debris, necrotic tissue deroof an ulcer

• Need a scalpel, forceps, scissors

• Debride the peel without cutting the pulp

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Debridement

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Infection and Inflammation

Person with Diabetic Foot Ulcer

Treat the Cause Local Wound Care

Debridement

Infection/Inflammation

Moisture Balance Edge Effect

Patient‐centered Concerns

Adapted from Sibbald RG et al. Preparing the wound bed 2003. Ostomy/Wound Management. 2003:49(11):24‐51

• Is this wound infected?

• What dressings can be used to fight infections?

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Infection

Contaminated/ColonisedCritically colonised

Infected

Bacterial count rising = signs of infection increase

Adapted from Flanagan 2003

Bac

teria

l cou

nt

Classical Signs of Overt Wound Infection

Wound Breakdown

Warmth

Erythema Pain

Edema

Discharge

Lymphangitis/Cellulitis

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Infection and Inflammation: NERDS and STONEES

• NERDS

– Non‐healing

– Exudate

– Red, friable granulation

– Debris on surface

– Smell

• STONEES

– Size increased

– Temperature increased >3 F deg

– Os: probes to bone

– New/satellite ulcers

– Erythema

– Exudate

– Smell (even worse)Sibbald RG, Woo K, Ayello EA.  Increased Bacterial Burden and Infection: The Story of NERDS and STONES. ADV SKIN WOUND CARE 2006;19:447‐61

What bugs are we treating?

• < 30 days: skin bacteria

• > 30 days: polymicrobial

• Staphylococcus aureus, MRSA

• Streptococcus spp

• Pseudomonas spp

• Anaerobes

• Why do we swab?

• How do we swab: Levine method

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Topical Antimicrobials

• Ionized Silver (look for high release of silver)

• Cadexamer iodine

• Mupirocin ointment or cream

• Fucidic acid cream (not ointment)

• Silver sulfadiazine cream

• Medical grade honey

• Polyhexamethyl biguanide (PHMB)

Topicals to Avoid

• Neomycin, bacitracin

• Fucidic acid Ointment (lanolin)

• Lanolin, Bacitracin, Neomycin can be sensitizers: contact dermatitis.

• Topical aminoglycosides (gentamicin, tobramycin): increased Pseudomonas resistance

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Systemic Agents

• Ciprofloxacin: gram negatives and Pseudomonas spp

• Clindamycin: gram positives and anaerobes• Metronidazole: anaerobes• Amoxicillin/Clavulanate: broad spectrum• Cephalexin: skin gram positives• Trimethoprim sulfamethoxisole: broad spectrum, anti‐inflammatory, MRSA activity

• Doxycycline: broad spectrum and antiinflammatory

Moisture Balance

Person with Diabetic Foot Ulcer

Treat the Cause Local Wound Care

Debridement Infection/Inflammation

Moisture Balance

Edge Effect

Patient‐centered Concerns

Adapted from Sibbald RG et al. Preparing the wound bed 2003. Ostomy/Wound Management. 2003:49(11):24‐51

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Moisture BalanceTake away moisture Add moisture

Absorbent padsFoamsHydrocolloids (for mildly exudative)HydrofibresAlginatesCadexamer iodine

Hydrogel plus semi‐occlusive foam dressingHydrocolloidsFilms

For more details:

Okan D et al. The Role of Moisture Balance in Wound Healing. Adv Skin Wound Care. 2007;20:39‐53.

Fonder MA et al. Treating the chronic wound: A practical approach to the care of nonhealingwounds and wound care dressings. J Am Acad Dermatology 2008;58:185‐206.

Person with Diabetic Foot 

Ulcer

Treat the Cause

‐Chronic Venous 

Insufficiency

‐Pressure

‐Ischemia

Local Wound Care

DebridementInfection/Inflam

mationMoisture Balance

Edge Effect

Patient‐centered Concerns

Treat the Cause

Adapted from Sibbald RG et al. Preparing the wound bed 2003. Ostomy/Wound Management. 2003:49(11):24‐51

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Lower Limb Assessment

• Ankle/Brachial Pressure Index (ABI)

• Toe Pressures or Photoplethysmography (PPG)

• Arterial doppler study (ultrasound)

• Angiography (CT or MRI)

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CAWC Wound Care Slide Series

Arterial assessment• Doppler/ABPI

ABI and Toe Pressures

ABI PPG

Normal 0.8 to 1.2 > 80 mmHg

Moderate ischemia 0.5 to 0.8 50‐80 mmHg

Severe ischemia < 0.5 < 50 mmHg

Healable: ABI greater than 0.5, toe pressure greater than 50 mmHg

Adapted from:‐Burrows C, et al. Best Practice Recommendations for the Prevention and Treatment of Venous Leg Ulcers Update 2006. Wound Care Canada. 2006;4(1):45‐55.‐Sibbald, RG et al.  Best Practice Recommendations for Preparing the Wound Bed. Wound Care Canada. 2006;4(1): 15‐29.

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Edema: Compression Therapy

• Elastic compression wraps

• Inelastic compression wraps

– Short stretch bandages

– Unna or Duke boot

• Stockings?

• 30‐40 mmHg

• Revascularization in case of ischemia

• Offloading in case of pressure

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Trauma

Remodeling

Inflammation

Proliferation

Maturation

Hemostasis

Defense against bacteria Debridement

PlateletsCoagulation factors

Growth factors

Neutrophils Enzymes Macrophages Proteases

Formation of tissue

Migration of epithelial cells

Angiogenesis

Growth factors

• Consider novel treatments when despite optimal wound care, the wound still does not heal

• A 20% to 40% reduction of wound area in 2 and 4 weeks is likely to be a reliable predictive indicator of healing  weeks. (Flanagan 2003)

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Other treatments

• Matrix metalloprotease inhibitors

• Skin grafts

• UV light therapy

• Maggots

• Hyperbaric oxygen therapy

• Electrical stimulation

Patient Concerns

Person with Venous Leg Ulcer

Treat the Cause Local Wound Care

Debridement Infection/Inflammation Moisture Balance Edge Effect Patient‐centered Concerns

Adapted from Sibbald RG et al. Preparing the wound bed 2003. Ostomy/Wound Management. 2003:49(11):24‐51

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Pain Control

• Nociceptive pain

– OTC and prescription analgesics including opioids

• Neuropathic pain

– Anti‐epileptic agents

– Tricyclic antidepressants

• Local analgesia

• Venous ulcers hurt!

• Edema hurts!

Shoes and footwear !!!!

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Footwear Advice for Patients

• Shake out your shoes before you put them on.

• Wear shoes at all times, indoors and out.

• Buy shoes with closed toes as they protect your feet from injury.

• Change your socks everyday.

• Buy shoes late in the day as feet tend to swell.

• If you do not have feeling in your feet, have your shoes professionally fitted by a footwear specialist.

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https://www.woundscanada.ca/docman/public/diabetes‐healthy‐feet‐and‐you/dhf‐clinician‐s‐brochure/835‐poster‐clinician‐tips‐en/file

Footwear

• Wear proper fitting footwear– Length

– Width 

– Depth

• Removable insole with good arch support

• Closed toe & heel

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Footwear

• Low heel

• No seams

• Velcro or Lace up

• NO slip‐ons!

• Leather or other “breathable” material 

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Rocker bottom shoes

Newton, Veronica. Diabetic Foot Canada, 2014, Vol 2, No 1, pages 22–25

Socks

• Always wear socks with shoes!

• Loose to allow good blood flow

• Fitted to avoid bunching• Soft, absorbent material• Seamless to prevent rubbing

• “Diabetic Socks”

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What should I look for in an orthotic?

• Made onsite, serviced on site

• Customized using casting or foam box

• Moderate/Conservative management

• Consider off the shelf or “semi” custom in some cases

• Slowly break them in (think 3 weeks)

Who Needs Orthotics?

• Functional AND/OR accommodative orthotics

• Functional orthotics: correction of abnormal function

• Accommodative: cushion, relieve pressure

• Made by orthotists/pedorthists

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Summary

• Look at feet!

• Debride wounds if appropriate and provide initial care while awaiting home care/wound clinic

• Make sure the shoe fits!

Resources

• Wounds Canada https://www.woundscanada.ca/

• Diabetes Foot Care Clinical Pathway https://www.albertahealthservices.ca/scns/Page10321.aspx