Screening and

Treatment of the

diabetic foot in

The Netherlands Bela Pagrach

Diabetic Nurse

Hospital Amstelland

Diabetic Foot team

Vascular Surgeon

Rehabilitation Specialist

Plaster Master

Wound Care Nurse

Orthopedic Shoemaker

Diabetic Nurse

Guidelines Diabetic Foot 2017

The old guidlines where from 2006

What has changed in 11 years?

There is a difference between primary care and hospital

care

Changes in Diabetic Foot care 2017

Primary care: examination of the foot ones a year

When there is a wound in primary care and there is no wound healing

within 3 days, than reference to a Hospital.

There has to be a diabetic foot team in the Hospital care.

Casemanager

Additional chapter about the Charcot foot

Choice for Wound care products

Control after Wound healing

How to perform a risk qualification

You have to have:

1. Knowledge of the Diabetic Foot and its risk factors

2. Skills to perform a screening

3. Know how to make a right interpretation of the screening results and make up the risk classificationof the foot

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The screening of the Diabetic Foot

1. Take the history

2. Inspection and test:

- for signs of mechanical stress and/or

foot deformities

- wounds

- shoes

3. Test protective sensibility

4. Test for signs of peripheral arterial disease

Important abbreviations

PAD = Peripheral Arterial Disease

PS = Protective Sensibility

Risk Qualification

In Dutch: Simms QualificationNo. Risk Examination Control

1 No No signs of PS of PAD 1 x per year

2 Mild Signs of PS or PAD 2x per year

3 High Signs of PS and/or PAD

and/or footdeformities

and/or callus

4x per year

4 Very

high

Healed ulcer or healed after

amputation

Every month

Risk classification 1-4

Risk Category 1 = NO risk for ulceration

Your patients risk is as big as yours for

developing an ulcer…..practically zero

NO loss of protective sensibility (PS)

NO PAD

Review of risk classification: Once per year

Risk classification 1-4

Risk Category 2 = MILD risk for ulceration

OR Loss of protective sensibility (PS)

OR Signs of PAD

NO signs of mechanical stress (too much callus or

impaired foot deformation)

Review the status of the foot: 2x per year

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Risk classification 1-4Risk Category 3 = HIGH risk for ulceration:

Loss of PS in combination with PAD

Loss of PS in combination with mechanical stress and/or foot deformation

Signs of PAD in combination with mechanicalstress and/or foot deformation

Both loss of PS, signs of PAD and mechanicalstress and/or foot deformation

Review: 4 x per year12

Risk classification 1-4

Risk Category 4 = VERY HIGH risk forulceration:

Every diabetic foot after healing of an ulcer OR after (healed) amputation

These patients have a risk for re-ulceration: 50-70%

Review: every 1-3 months

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Skin temperature measurement

Palpation from proximal (just below the knee) to distal

(toes):

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Infra red skin temperature

measurement device

More accurate than

just palpation

Evidence based:

More than 2° Celsius

difference between

both feet = alarm!

Possible problems:

- ‘warm’ foot = infection – acute Charcot?

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Skintemperature

Depends always from the temperature of the

surrounding

You have to look

for a temperature

difference more

than 2° Celsius!

If so send your

patient to the doctor

Test for (loss of) Protective Sensibility (PS)

This is your most important instrument!!

10 gram Semmes Weinstein Monofilament

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NOT a test for a risk of an ulcer

Vibration Perception Test = test the risk of losing

balance risk of falling

loss of perception or ‘deep’ sensibility

use a Tuning Fork 128 Hz

Test for LJM

Prayer’s sign

..but also: look for the place of callus formation!

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Shoe inspection!!

Shoe inspection

Care Profile

Reimbursement Foot Care

Risk 1 /care profile 1 = No reimbursement

Risk 1 /care profile 2 = reinbursement

Risk 2,3 and 4/ care profole 2 till 4 = reimbursement

Reimbursement foot care by Podiatrist

and Pedicure

With an high risk care profile the patient have to visit the podiatrist.

The podiatrist is doing the foot test again and make profile for foot

care executed by the pedicure.

The pedicure care will be reimbursed between the 6 and 12 times a

year, depending on risk profile and foot care profile.

Inspection

Why do you see callus on this

spot of the foot?

Look and look good: also between the toes!

Inspection of the color of the

foot Pink = normal

White = cold, lack of circulation

Red = Inflammation?

Early stage Charcotfoot?

Shoes should fit…..

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Very important

This test does NOT tell us about the risk of foot

ulceration

Important to discover lack of propriocepsis

imbalance, increased risk for falling

Therapy: Education!!

Interpretation of the examination

1. Which Risk Classification?

2. What Treatmentplan?

3. Always: Education of the patient!

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Extra vision test

Visual-check card

Telescope mirror

Daily inspection

If the patient can read 4-5 lines: OK

If not hetero-inspection of the foot by??

Interpretation

Your patient can read:

All 5 lines no loss of vision

self inspection is OK

2-4 lines deminished vision

no self-inspection

1 of no lines very bad vision

no self-inspection

Test for signs of PAD

Protocol International Consensus (May 2011):

1. Palpate pulsations:- a. dorsalis pedis- a. tibialis posterior

2. Listen to the vascular tones (pulsations) with a hand Doppler

3. Measure the Ankle-Arm-Index

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Interpretation

According the Int. Consensus 2011:

On each foot 1 of the 2 arteries

pulsations have to be present

If no pulsations can be detected listen to the

vascular tones:

Tri- or Bifasic = normal

Monofasic = not normal

No sounds at all = acute alarm!

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ALL (!) callus has to be removed

Treatment

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Off-loading

Off-loading:

Felt padding in case of superficial

ulcers

BUT:

Total Contact Cast (TCC)

is the ‘Golden Standard’

Patient education!!!!

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Content of education Daily inspection

Good foot care

NEVER walk on bare feet

NO footbath (no soaking)

More issues to discuss

Good shoe advice ( Width,right shoe size, heel hight))

Ware of seamless socks.

How and where to gaininformation: internet??

Important: Can your patient

inspect his/her own feet? We advise every patiënt to look good ad

his/her feet twice a day

But…how do we know that this patient has a

good enough vision?