Toe Morrow Never Dies! An Approach to the Diabetic Foot. Faculty/Presenter Disclosure

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1 Toe Morrow Never Dies! An Approach to the Diabetic Foot 2018 Banff ASA Dr. Michael Yan, MD, CCFP Assistant Clinical Professor Department of Family Medicine University 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. 1

2 ACFP 63 rd ASA Disclosure 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 63 rd 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 63 rd 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. 2

3 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 3

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6 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, Alavi A. et al (2013) Diabetic Foot Canda 1: Singh N. et al (2005) JAMA 293: Orsted HL, et al. Best Practice Recommendations for the Prevention, Diagnosis and Treatment of Diabetic Foot Ulcers: Update Wound Care Canada. 2006;4(1)

7 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 Bowering, K. (2001). Diabetic foot ulcers: pathophysiology, assessment and therapy. Canadian Family Physician, 47, Canadian Institute for Health Information (2009) Diabetes Care Gaps and Disparities in Canada. 7

8 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 Inspection Palpation Special Tests Diabetes complications, lifestyle factors, occupation, previous foot ulcers, medications. Skin, nails, deformity, calluses, ulcers, footwear. Temperature, pulses, range of motion at toes and ankle. Neuropathy screening, vascular assessments (ABI, PPG). 8

9 Semmes Weinstein 10 g filament CAWC Wound Care Slide Series 9

10 60 Second Foot Screen th care professional/resourceshealth care pros/foot screen 10

11 Diabetes Foot Care Clinical Pathway Diabetes Foot Screening Tool EXAM FINDINGS R L RISK Normal intact LOW skin healthy or dry *check in between toes Callus/Corn/Fissure/Crack not bleeding or draining MODERATE Prior history of Diabetic Foot Ulcer(s) ulcer in remission SKIN Blister = B or Hemorrhagic callus = HC Fissure or Crack Bleeding or draining = F HIGH Diabetic Foot Ulcer Not infected and/or with intact dry black eschar = U Infected Diabetic Foot Ulcer or wet gangrene URGENT Normal well-kept with minimal discoloration LOW NAILS Missing, sharp, unkept, thickened, long or deformed MODERATE Infected ingrown nail Normal no noted visual abnormalities LOW Decreased range of motion at ankle or toe joint Deformities Bunion/Hammer or claw toes/overlapping toes STRUCTURE MODERATE Structure Fallen Arch/ Rocker bottom foot/stable Charcot foot ANATOMY Previous amputation X over location or draw/describe on diagram deformities pressure related Redness over any structural HIGH Red, hot painful joint or acute Charcot foot URGENT Normal sensation using 10 g monofilament at the 5 predetermined sites LOW SENSATION Testing for Sensation of numbness/tingling/throbbing/burning MODERATE LOPS Absent or altered sensation at one or more of the five sites Acute onset of pain in a previously insensate foot URGENT Normal pulses normal capillary refill LOW VASCULAR Signs of Ischemia (PAD) Testing for Cool skin with pallor, cyanosis or mottling, and/or dependent rubor HIGH Arterial One or more pulses not palpable or audible (Doppler) Compromise Absent pedal pulses with cold white painful foot or toes URGENT Appropriate accommodates foot shape LOW Inadequate Footwear MODERATE FOOTWEAR 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). ca/scns/page10321.aspx Sensation Testing (monofilament) Fill in if no sensation Leave blank if sensation present /5 /5 RIGHT LEFT Identify any wounds and location on the foot or toe(s) Date Signature Primary Care Site Comments 20710(Rev ) Case # 1 11

12 Temperature X ray Findings 12

13 Charcot Neuroarthropathy Case 2 45 year old man with diabetic foot ulcers Wound not healing for 2 months What do you see? How would you debride? 13

14 The DIME Approach Person with Diabetic Foot Ulcer Treat the Cause Local Wound Care Patient centered Concerns Debridement Infection/Inflammation Moisture Balance Edge Effect Adapted from Sibbald RG et al. Preparing the wound bed Ostomy/Wound Management. 2003:49(11):24 51 Debridement Autolytic Sharp instrument maintenance debridement Pulsed lavage, whirlpool, hydrojet Ultrasound Enzymatic Biotherapy: Maggots! 14

15 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 nonhealable 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 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 Wound Care Canada. 2006;4(1):

16 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 Debridement Debride the peel without cutting the pulp 16

17 Debridement 17

18 Infection and Inflammation Person with Diabetic Foot Ulcer Treat the Cause Local Wound Care Patient centered Concerns Debridement Moisture Balance Edge Effect Infection/Inflammation Adapted from Sibbald RG et al. Preparing the wound bed Ostomy/Wound Management. 2003:49(11):24 51 Is this wound infected? What dressings can be used to fight infections? 18

19 Infection Contaminated/Colonised Critically colonised Infected Bacterial count Bacterial count rising = signs of infection increase Adapted from Flanagan 2003 Classical Signs of Overt Wound Infection Lymphangitis/Cellulitis Erythema Pain Edema Warmth Wound Breakdown Discharge 19

20 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: 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 20

21 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 21

22 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 Patient centered Concerns Debridement Infection/Inflammation Edge Effect Moisture Balance Adapted from Sibbald RG et al. Preparing the wound bed Ostomy/Wound Management. 2003:49(11):

23 Moisture Balance Take away moisture Absorbent pads Foams Hydrocolloids (for mildly exudative) Hydrofibres Alginates Cadexamer iodine Add moisture Hydrogel plus semi occlusive foam dressing Hydrocolloids Films For more details: Okan D et al. The Role of Moisture Balance in Wound Healing. Adv Skin Wound Care. 2007;20: Fonder MA et al. Treating the chronic wound: A practical approach to the care of nonhealing wounds and wound care dressings. J Am Acad Dermatology 2008;58: Treat the Cause Person with Diabetic Foot Ulcer Treat the Cause Chronic Venous Insufficiency Pressure Ischemia Debridement Infection/Inflam mation Local Wound Care Moisture Balance Patient centered Concerns Edge Effect Adapted from Sibbald RG et al. Preparing the wound bed Ostomy/Wound Management. 2003:49(11):

24 Lower Limb Assessment Ankle/Brachial Pressure Index (ABI) Toe Pressures or Photoplethysmography (PPG) Arterial doppler study (ultrasound) Angiography (CT or MRI) 24

25 Doppler/ABPI Arterial assessment CAWC Wound Care Slide Series ABI and Toe Pressures ABI PPG Normal 0.8 to 1.2 > 80 mmhg Moderate ischemia 0.5 to 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 Wound Care Canada. 2006;4(1): Sibbald, RG et al. Best Practice Recommendations for Preparing the Wound Bed. Wound Care Canada. 2006;4(1):

26 Edema: Compression Therapy Elastic compression wraps Inelastic compression wraps Short stretch bandages Unna or Duke boot Stockings? mmhg Revascularization in case of ischemia Offloading in case of pressure 26

27 Neutrophils Enzymes Macrophages Proteases Defense against bacteria Debridement Angiogenesis Trauma Inflammation Proliferation Formation of tissue Growth factors Maturation Remodeling Hemostasis Migration of epithelial cells Coagulation factors Platelets 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) 27

28 Matrix metalloprotease inhibitors Skin grafts UV light therapy Maggots Hyperbaric oxygen therapy Electrical stimulation Other treatments 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 Ostomy/Wound Management. 2003:49(11):

29 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!!!! 29

30 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. 30

31 c/diabetes healthy feet and you/dhf clinicians brochure/835 poster clinician tips en/file Wear proper fitting footwear Length Width Depth Removable insole with good arch support Closed toe & heel Footwear 31

32 Footwear Low heel No seams Velcro or Lace up NO slip ons! Leather or other breathable material 32

33 Rocker bottom shoes Newton, Veronica. Diabetic Foot Canada, 2014, Vol 2, No 1, pages 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 33

34 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 34

35 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 Diabetes Foot Care Clinical Pathway ge10321.aspx 35