Foot in Diabetes

Professor Andrew J. M. Boulton, Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK; Consultant Physician, Manchester Royal Infirmary, Manchester, UK; Visiting Professor, Diabetes Research Institute, University of Miami, Miami, FL, USA. Professor Gerry Rayman, The Diabetes Centre, Ipswich Hospital, Ipswich, UK; University of East Anglia, Norwich, UK; University of Suffolk, Ipswich, UK. Dr. Dane K. Wukich, Professor and Chair, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.

• List of Contributors xvPreface xixIntroduction xxi1 Epidemiology and Economic Impact of Foot Ulcers 1Edward J. Boyko and Matilde Monteiro-Soares1.1 Introduction 11.2 Diabetic Foot Ulcer (DFU) Definition 11.3 DFU Classification 21.4 DFU Incidence and Prevalence 31.5 DFU Recurrence 51.6 Risk Factors for Diabetic Foot Ulcers and Lower Extremity Amputation 61.7 Diabetic Foot Ulcer Outcomes 71.8 Economic Considerations 9Reference 102 Cost of Diabetic Foot Disease in England 17Marion Kerr2.1 Introduction 172.2 Human Costs 172.3 Financial Costs 202.4 Why Measure Costs? 222.5 Establishing Healthcare Priorities 222.6 Conclusions 25References 263 Epidemiology of Amputation and the Influence of Ethnicity 31Caroline A. Abbott3.1 Why Study the Epidemiology of LEA? 313.2 LEA Incidence Study Design: The Risk of Bias 323.3 LEA Risk Assessment Study Design 323.4 Risk Factors for LEA 333.5 Incidence Rates of LEA 343.6 International and Regional Differences 343.7 Time Trends in LEA Rates 343.8 Ethnic Differences in Diabetes-Related LEA 353.9 Ethnic Differences in Diabetes-Related LEA Risk 353.10 Indian Asians 38References 384a The Diabetic Foot Worldwide: India 43M. Viswanathan4a.1 Introduction 434a.2 Epidemiology of Diabetes in India 434a.3 Socio Economic Burden Due to Diabetes 434a.4 Common Risk Factors for Amputation in India 434a.5 Diagnosing High Risk Feet in Developing Countries 444a.6 Comparison in Risk Factors between India and the Western World 444a.7 DFI as a Cause for Declining Kidney Function 444a.8 Helping People with Amputation Cope Up with the Disability 44References 454b The Diabetic Foot Worldwide: Pakistan 47Abdul Basit4b.1 Introduction 474b.2 Concept of Multidisciplinary Diabetic Foot Care Team (MDFCT) 474b.3 Nationwide Diabetic Foot Programme (Step by Step-[SbS]) 484b.4 Footwear for Every Diabetic (FED) 484b.5 Further Steps Ahead of SbS 49References 494c The Diabetic Foot Worldwide: Sub-Saharan Africa 51Zulfiqarali G. Abbas4c.1 Introduction 514c.2 Pathophysiology of Foot Ulcers 524c.3 Peripheral Neuropathy (PN) 524c.4 Peripheral Arterial Diseases (PAD) 534c.5 Foot Ulceration in SSA 544c.6 Foot Infection 554c.7 Amputation 564c.8 Mortality 564c.9 Prevention 564c.10 Conclusions 58References 584d Burden of Diabetic Foot Disease in Brazil 61Hermelinda C. Pedrosa and Luciana R. BahiaReferences 644e Diabetic Foot in Romania and Eastern Europe 67Norina Alinta Gâvan and C. I. Bondor4e.1 Introduction 674e.2 The Aim 674e.3 Diabetic Foot in Romania 674e.4 Diabetic Foot in Eastern Europe 704e.5 Conclusions 71References 714f Diabetic Foot Worldwide: Pacific Region 75Shigeo KonoReferences 764g The Diabetic Foot Worldwide: Middle East 79Samir H. Assaad-Khalil4g.1 The Burden of Diabetic Foot Disease (DFD) in the Middle East (ME) 794g.2 Specific Regional Barriers to Healthy Feet and Foot Care 804g.3 Misconceptions 814g.4 Footwear 814g.5 Foot Care, Education and Awareness 81References 824h The Diabetic Foot Worldwide: Australasia 85Peter A. Lazzarini4h.1 Introduction 854h.2 Australia 854h.3 New Zealand 864h.4 Pacific Islands 864h.5 Conclusion 87References 875 Diabetic Neuropathy 89Dinesh Selvarajah, Gordon Sloan, and Solomon Tesfaye5.1 Epidemiology 895.2 Classification 895.3 Symmetrical Neuropathies 915.4 Asymmetrical Neuropathies 955.5 Pathogenesis of Distal Symmetrical Neuropathy 975.6 Management of Diabetic Neuropathy 98References 1016 The Pathway to Ulceration: Aetiopathogenesis and Screening 105Andrew J.M. Boulton6.1 Introduction 1056.2 Peripheral Arterial Disease (PAD) 1066.3 Diabetic Neuropathy 1076.4 Neuropathy: The Major Contributory Factor in Ulceration 1096.5 Other Risk Factors for Foot Ulceration 1096.6 Assessment of Foot Ulcer Risk 1116.7 The Pathway to Ulceration 1166.8 Mechanical Factors and Neuropathic Foot Ulceration 1186.9 The Patient with Sensory Loss 120References 1207 Biomechanics of the Diabetic Foot for the Uninitiated 125S.A. Bus and J.S. Ulbrecht7.1 Introduction 1257.2 The Concept of Pressure and its Measurement 1257.3 The Role of Elevated Plantar Pressure in Foot Ulceration 1267.4 Mechanisms of Elevated Plantar Pressure 1287.5 Foot Biomechanics in Treating a Plantar Foot Ulcer 1307.6 Biomechanical Issues in Preventing a Foot Ulcer 1327.7 Summary 133References 1348 Psychological and Behavioural Aspects of Diabetic Foot Ulceration 139Loretta Vileikyte and Ryan T. Crews8.1 The Role of Psychological and Behavioural Factors in DFU Development 1398.2 The Role of Psychological and Behavioural Factors in DFU Healing 1428.3 The Impact of DFUs on Patients’ Health Status and QoL 1468.4 Measuring QoL in DFU Patients: Generic, DFU-Specific or Combined Approach? 147References 1489 What Role for the Plain Radiograph of the Diabetic Foot? 153Richard William Whitehouse9.1 Introduction 1539.2 Pathologies 1579.3 Summary 166References 16710 Advanced Cross-Sectional Radiology-Ultrasound, Computed Tomography and Magnetic Resonance Imaging of the Diabetic Foot 169Aparna Komarraju and Avneesh Chhabra10.1 Introduction 16910.2 Pathophysiology of Diabetic Foot Disease 170References 18311 Gait and Exercise Training in Diabetic Peripheral Neuropathy 187Neil D. Reeves11.1 Introduction 18711.2 Gait Characteristics of People with Diabetes 18711.3 Muscle Forces and the Biomechanics of Gait in Diabetes 18811.4 Biomechanical Strategies to Alter Gait in Diabetic Peripheral Neuropathy 19011.5 Falls and Diabetic Peripheral Neuropathy 19311.6 Biomechanical Factors Leading to Increased Fall Risk 19311.7 Diabetic Peripheral Neuropathy and Balance during Gait 19411.8 Exercise and Diabetic Peripheral Neuropathy 19611.9 Effects of Exercise in Patients with Diabetic Peripheral Neuropathy on Gait and Balance 19711.10 The Case for Resistance Exercise Training 198References 19812 Smart Technology for the Diabetic Foot in Remission 201Bijan Najafi and David G. Armstrong12.1 Background 20112.2 Technologies to Guide the Prescription of Footwear-Related Offloading Treatments 20312.3 Technologies to Facilitate Triaging those at High Risk of DFU 20412.4 Technologies to Manage Dose of Physical Activities in People with Diabetes and Insensate Foot 21112.5 Using Technology to Improve Patient Education for Effective Prevention of Diabetic Foot Ulcers 21412.6 Mobile Health (mHealth) to Manage Diabetic Foot Ulcers 21512.7 Internet of Things and Remote Management of Diabetic Foot Ulcers 21612.8 Technologies to Facilitate Delivering of Therapy at Home and Reduce Risk of DFU 21712.9 Conclusion 218References 21913 How to Assess the Quality of Clinical Trials for Diabetic Foot Ulcer Therapies 225Fran Game and William Jeffcoate13.1 Introduction 22513.2 Hierarchy of Evidence 22613.3 Items to Be Considered in Assessing Trials of Diabetic Foot Ulcer Therapies 22713.4 The Population 22713.5 The Person and Limb 22813.6 The Ulcer 22913.7 The Therapy 23013.8 Outcomes 23013.9 Adverse Events 23113.10 21 Point Checklist 231References 23314a Bypass in Diabetic Peripheral Artery Disease 235Neal R. Barshes and Joseph L. Mills14a.1 Identifying Significant PAD Amongst Patients Presenting with Foot Ulcers 23514a.2 Relative Benefits and Risks: Identifying Patients Who May Benefit from a Leg Bypass Operation 23714a.3 Evaluating Relevant Vascular Anatomy for Planning a Bypass Operation 23914a.4 The Operation and Early In-Hospital Recovery 24114a.5 Follow-Up After a Leg Bypass Operation 243References 24314b Surgery or Endovascular Intervention in Diabetic Peripheral Vascular Disease 247Edward Y. Woo and Misaki M. Kiguchi14b.1 Introduction 24714b.2 Background 24714b.3 Diagnosis 24814b.4 Management 25014b.5 Endovascular Revascularization 25014b.6 Results 25314b.7 Complications 25414b.8 Conclusion 254References 25515 Inpatient Diabetic Foot Care: A UK Perspective 259Gerry Rayman15.1 Introduction 25915.2 The Burden of Inpatient Diabetes 26015.3 The Burden of Inpatient Diabetic Foot Disease 26015.4 Recommended Foot Care for Inpatients with Diabetes 26115.5 Summary 262References 26316 Diagnosis and Management of Infection in the Diabetic Foot 265Edgar J.G. Peters and Benjamin A. Lipsky16.1 Introduction 26516.2 Pathophysiology of Infections in Persons with Diabetes Mellitus 26516.3 Risk Factors for DFI 26616.4 Clinical Signs and Symptoms 26616.5 Classification 26716.6 Microbiology 26816.7 Treatment 26916.8 IWGDF Grade 4 (Severe) Infections 27416.9 Osteomyelitis 275References 28017 Surgical Approach to Diabetic Foot Infections 287Katherine M. Raspovic, Javier La Fontaine, and Lawrence Lavery17.1 Introduction 28717.2 Initial Evaluation 28817.3 Initial Surgical Intervention 29017.4 After Initial Surgical Intervention 29317.5 Staged Surgical Intervention and Wound Closure 29417.6 Surgical Offloading 29617.7 Soft Tissue/Tendon Balancing and Definitive Osseous Surgical Reconstruction 29617.8 Decision for Proximal Level Amputation 29717.9 Conclusions 298References 29818 The Evidence Base for the Choice of Dressings in the Management of Diabetic Foot Ulcers 301William J. Jeffcoate, Patricia E. Price, and Frances L. Game18.1 The Problems 30118.2 Quality of Evidence 30218.3 The Definition of a Dressing 30218.4 The Roles of the Dressing 30318.5 Basic Aspects of Wound Care 30418.6 Evidence for Potential Contributions of Dressings and Wound Applications to Improve Wound Healing 30418.7 Other Therapies which May Modulate Healing of Chronic Wounds 30618.8 Summary 307References 30819 Pathogenesis of Charcot Neuroarthropathy and Acute Management 311N.L. Petrova and Michael E. Edmonds19.1 Introduction 31119.2 Pathogenesis of CN 31119.3 Acute Management of CN 31619.4 Conclusions 318References 31920 Surgical Reconstruction of the Charcot Foot 323George Liu, Katherine Raspovic, and Dane Wukich20.1 Introduction 32320.2 Indications for Surgical Reconstruction 32320.3 Radiographic Predictors for Ulceration 32520.4 Timing of Surgery 32620.5 Preoperative Medical Workup 32720.6 Glycemic Control 32720.7 Vitamin D 32820.8 Renal Function 32820.9 Procedures/Outcome Studies 32820.10 Outcomes of Charcot Reconstruction 33420.11 Summary of Evidence Based Recommendations 335References 33621 Amputation in the Diabetic Foot 345Michael S. Pinzur and Adam P. Schiff21.1 Introduction 34521.2 Impediments to Rehabilitation in the Diabetic Amputee 34521.3 The Lower Extremity as an Organ of Weight Bearing 34621.4 Metabolic Cost of Walking with an Amputation 34621.5 Limb Salvage vs. Amputation 34721.6 Amputation Level Selection 34821.7 The Terminal Organ of Weight Bearing 34821.8 The Soft Tissue Envelope 35121.9 Tissue Management 35121.10 Outcomes Following Amputation 35221.11 Surgical Amputation Levels 35221.12 Lesser Toe Amputation 35321.13 Ray Resection 35321.14 Midfoot Amputation 35521.15 Hindfoot Amputation 35521.16 Symes’s Ankle Disarticulation Amputation 35621.17 Transtibial Amputation 35721.18 Knee Disarticulation Amputation 35921.19 Transfemoral Amputation 35921.20 Conclusions 360References 36022 Rehabilitation of the Amputee 363Karen Kowalske and Merrine Klakeel22.1 Lower Limb Amputation and Prosthetics 36322.2 Foot Amputations 36422.3 Foot Orthotics 36522.4 Transtibial Amputations 36622.5 Ankle/Foot Components 36922.6 Conclusion 372References 37223 Surgery for the Diabetic Foot: Prophylactic and Osteomyelitis Surgery – Is there an Evidence Base? 375Javier Aragón-Sánchez23.1 The Role of Surgery Preventing Occurrence and Recurrence of Foot Ulcers 37623.2 Preoperative Care 37623.3 Hallux and First Metatarsal Head Procedures 37723.4 Lesser Toes 38023.5 Lesser Metatarsal Heads 38123.6 Tendon Achilles Lengthening 38323.7 Curative Surgery for Treating Diabetic Foot Osteomyelitis 38523.8 Surgery of Forefoot Osteomyelitis 38623.9 Surgery of Midfoot Osteomyelitis 38823.10 Surgery of Rear Foot Osteomyelitis 388References 38924 Footwear and Orthoses for People with Diabetes 395J.S. Ulbrecht and S.A. Bus24.1 Introduction 39524.2 What is a Therapeutic Shoe for a Person Living with Diabetes? 39524.3 Who Needs Therapeutic Shoes? 40224.4 Choosing the Appropriate Footwear for the Patient with LOPS 40324.5 Summary and Future Trends 406References 40625 The Diabetic Foot in Remission 409Tanzim Khan, Sicco A. Bus, Andrew J.M. Boulton, and David G. Armstrong25.1 The Diabetic Foot in Remission 40925.2 Maintaining Remission 41025.3 Conclusion 413References 41426 Setting up a Diabetic Foot Clinic 417Michael E. Edmonds and N.L. Petrova26.1 Natural History of the Diabetic Foot 41726.2 Principles of Care of the Diabetic Foot 41826.3 Space for the Diabetic Foot Clinic 41826.4 Personnel for the Diabetic Foot Clinic 41926.5 Organisation of the Diabetic Foot Clinic 42226.6 Conclusion 426References 42627 National Audit of Diabetic Foot Care: Continuing Audit is Essential for the Delivery of Optimal Care of Diabetic Foot Ulcers 429William Jeffcoate, Gerry Rayman, and Bob Young27.1 Why Should We Document the Outcome of Routine Care? 42927.2 General Principles of Clinical Audit 43027.3 National Diabetes Foot Care Audit of England and Wales 433References 43728 Regenerative Medicine and the Diabetic Foot 439Zachary A. Stern-Buchbinder, Babak Hajhosseini, and Geoffrey C. Gurtner28.1 Introduction 43928.2 Stem Cells 43928.3 Diabetes and Healing Impairment 44228.4 Diabetes and Vascular Dysfunction 44328.5 Functional Heterogeneity of Stem Cells 44628.6 Advances in Regenerative Therapy 44728.7 Conclusion 449References 44929 Role of the Plastic Surgeon in Diabetic Foot Care 457Joon Pio (Jp) Hong and Hyunsuk Peter Suh29.1 Introduction 45729.2 Multidisciplinary Approach and the Spectrum of Care 45829.3 Reconstruction Algorithm 45929.4 Debridement (this is Covered in Detail in another Chapter) 46029.5 Evaluating and Enhancing the Vascular Status 46129.6 Skin Grafts and Substitutes 46229.7 Local Flaps 46329.8 Free Flaps 46429.9 Amputation 46629.10 Conclusion 467References 46930a Algorithms for Diabetic Foot Care: Management of the Hot Swollen Foot 473Michael E. Edmonds, Chris Manu, and Nina PetrovaReferences 48030b Approach to a New Diabetic Foot Ulceration 481Prashanth R.J. Vas and Michael E. Edmonds30b.1 Introduction 48130b.2 Clinical Care for the Management of DFU 48230b.3 Management of DFU 48530b.4 Structural Care Process in DFU Management 490References 49130c Algorithms for Diabetic Foot Care: Vascular Evaluation 495G. Dovell and R.J. Hinchliffe30c.1 Introduction 49530c.2 Methods of Vascular Evaluation – Detecting Peripheral Artery Disease 49630c.3 Vascular Imaging 49830c.4 Conclusions 500References 50330d Algorithms for Diagnosis and Management of Infection in the Diabetic Foot 507Edgar J.G. Peters and Benjamin A. Lipsky30d.1 Diagnosis of Infection 50730d.2 Therapy of Infection 509References 514Index 515