Diabetes and Foot Complications

Diabetes and Foot Complications

• UE 2.7 covers organic failures and degenerative processes.
• Capsule 3 specifically addresses diabetes-related foot issues.
• The presentation was prepared by Professor Vincent Rigalleau from CHU Bordeaux in 2023.

Clinical Case 1

• Patient E is a 65-year-old man living alone, consuming 5 glasses of wine daily.
• He has a 10-year history of neglected diabetes.
• He stepped on a dog bone while wearing clogs and noticed it 2 days later.
• The foot is swollen with intermittent discharge, and the patient reports no pain.
• The case requires diagnostic and management considerations.

Diabetic Foot Epidemiology

• 15% of diabetics experience foot complications.
• There are 60,000 cases annually in France.
• The incidence is 2.5% of diabetics per year.
• Amputations are a severe outcome.
• The majority of amputees are diabetic.
• Diabetics have a 15-fold increased amputation risk.
• 2-3% of diabetics will undergo amputation.
• 85% of amputations occur after an ulcer.
• About half of amputations are in the foot, and half are above.

Complications of Diabetic Foot

• Foot issues rarely present in isolation.
• High-risk patients often have other complications such as retinopathy, nephropathy, and macroangiopathy.
• The mortality rate after amputation is 40% within 5 years.
• Isolation is a common issue among patients, especially men, occurring twice as often.
• Those aged 45-65 are also twice as likely to be affected.
• Alcohol and tobacco use are related factors.
• Vitamin deficiencies and social isolation also contribute.
• Access to prevention, care, and offloading possibilities is important.
• Hospitalizations for foot complications are often prolonged
• Average stays are 21 days based on Halimi's 1993 data and 17 days per Girod in 2003.
• The average length of stay for diabetology is 6 days.
• Ambulatory treatment costs 700€ per month for nursing care.
• Hospital treatment costs 2200€ per month, involving specialists and potential amputations.

Central Role of Neuropathy

• Disease duration and imbalance can lead to neuropathy.
• Motor neuropathy leads to amyotrophy, abnormal pressures, and deformities.
• Sensitive neuropathy results in loss of adaptation to walking traumas.
• Vegetative neuropathy causes dry skin.
• A precipitating event can lead to ulceration.

Deformations

• Neuropathy can cause deformities like claw or hammer toes.
• It is a primary cause of hyperpressure.
• Hyperpression leads to erythema, heat, callosities, and hematomas.
• The combination of deformities and neuropathy leads to ulcers.
• Hyperpression is made worse by obesity.
• Reduced joint mobility is a sign of future problems.

Clinical Assessment of the Foot

• Neurogenic foot (3/6 cases): indolent, possibly deformed.
  • MPP is present in high-risk areas due to compression and friction.
  • It will heal but will likely recur; debridement is necessary.
• Arterial foot (1/6 cases; mixed 2/6): painful, necrotic, and not budding.
  • Distal pulses are absent.
  • It will not heal without vascular treatment or debridement. -Infected foot
  • Open with discharge and local inflammatory signs.
  • Antibiotic treatment is necessary.
• Local Evaluation in Clinical Assessment:
  • Size: Length and width and depth, noting involvement of bone or joints.
• Stage of healing includes debridement, budding, and epidermalization.
• Instruments: use of probes, swabs, and scissors. -Assessment value that guides prognosis and therapy.

Diabetic Foot Treatment

• Local treatment involves offloading and dressings.
• General treatment focuses on diabetes control through insulin.
• Vaccinations should be updated if necessary.
• Antibiotics are required for infection management.
• Surgical intervention may include anti-infectious procedures such as debridement and drainage.
• Vascular procedures may also be considered.
• Amputation is can also be a consideration

Education in Foot Care

• Education encompasses diet, self-monitoring, insulin therapy, hypoglycemia management, physical activity, and foot care
• Early detection and screening for complications like retinopathy, nephropathy, and cardiopathy are important.
• Regular foot examinations and patient education can reduce ulcer risk by 60% and amputation risk by 85%.
• Many ulcer patients cannot recall education within the last 10 years.
• It can be difficult to make risk-bearing patients aware of their low-level pain symptoms.

Preventative Education

• Precipitating events are often identifiable.
• 20% of ulcers are linked to trauma.
• There can be trauma from footwear, accidental cuts, nail pathologies, and decubitus ulcers.
• Edema plays a role.

Foot Risk Identification

• Includes annual foot exams, which happen 50% of the time.
• Evaluation includes ulcers and amputations
• This is the first step in education and can result in referrals for podology.
• Screening includes ulcers, amputations, neuropathies, deformities, and arteritis.
• 73% are normal at the time of screening and require education.

Identify Risk Factors

• For prior ulcers or amputations, 5% of all diabetics need to be treated for 20 years.
• There can be spontaneous recurrence of up to 30%.
• Treatment and education is very helpful

Testing and Identifying Neuropathies and Deformations

• Includes 50% of patients
• There is an 8-18x higher risk of ulcers.
• Test for sensitivity
• Use monofilament
• Use a 128 Hz diapasom

Identifying Arteritis

• Includes rare triggering
• Retardance in healing
• Test pulses
• Test for claudications

Diabetic Foot Grading

• Uses a simple clinical grading system to assess severity.
• Grade 0: No neuropathy, no arteritis, and non-specific deformities.
• Grade 1: Neuropathy (monofilament not perceived in two of three points), but no arteritis or deformity.
• Grade 2: Neuropathy with arteritis and/or deformity.
• Grade 3: History of ulceration lasting over 4 weeks or amputation.

Patient Management

• Grade 0: Should have annual foot exams.
• Grade 1: Should have foot and shoe exams, and education for diabetes on a regular schedule.
• Grade 2: Requires routine foot exams and visits to the podiatrist every three months. Orthoses should be addressed.
• Grade 3: Requires reinforcement and surveillance by a specializing center. Podiatrist visits should occur every two months.

Foot Care Education

• Education involves understanding sensitivity to pain, temperature, and touch.
• It also includes security such as protective footwear.
• Education also includes daily cleaning the feet and keeping them dry
• A daily examination of the foot also happens

Footwear Guidance

• Emphasis is placed on wearing the correct socks
• Footwear should be progressive and comfortable

Complications of Ulcers

• Ulcers often need to be treated by a professional

Foot Problems

• Feet have a tendency to develop problems.
• These include intertrigo, fissures, vesicularity, hematomas, plantar perforations, and cellulitis.
• Fissure Diagnostic Value:
  • Dry skin and hyperkeratosis with hypertension.
  • Major risk is Cellulite
  • Patients must moisturize and soften

Foot Problems of Intertrigo

• Not diagnostic
• Poor hygiene
• Risk of Cellulitis
• Patients must keep feet dry

Foot Problems of Vesicules

• From hypertension
• Caused by neuropathy
• Have openings that are dangerous when closed or ruptured

Foot Problems of Hematoma

• Very similar to a foot gangrene infection
• Vascularized
• Major risk of foot gangrene

Foot Problems of Plantar Perforations

• Is a sensitive neuropathy
• Deep extension causing Osteitis
• Must have local care

Foot Problems of Cellulite

• Comes with an infection
• Can turn into Necrosis
• Requires a medical doctor

Conclusion

• Is a clinical diagnosis
• Can be catastrophic for patients
• Focuses on treatments