The 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 xv


Preface xix


Introduction xxi


1 Epidemiology and Economic Impact of Foot Ulcers 1
Edward J. Boyko and Matilde Monteiro-Soares


1.1 Introduction 1


1.2 Diabetic Foot Ulcer (DFU) Definition 1


1.3 DFU Classification 2


1.4 DFU Incidence and Prevalence 3


1.5 DFU Recurrence 5


1.6 Risk Factors for Diabetic Foot Ulcers and Lower Extremity Amputation 6


1.7 Diabetic Foot Ulcer Outcomes 7


1.8 Economic Considerations 9


Reference 10


2 Cost of Diabetic Foot Disease in England 17
Marion Kerr


2.1 Introduction 17


2.2 Human Costs 17


2.3 Financial Costs 20


2.4 Why Measure Costs? 22


2.5 Establishing Healthcare Priorities 22


2.6 Conclusions 25


References 26


3 Epidemiology of Amputation and the Influence of Ethnicity 31
Caroline A. Abbott


3.1 Why Study the Epidemiology of LEA? 31


3.2 LEA Incidence Study Design: The Risk of Bias 32


3.3 LEA Risk Assessment Study Design 32


3.4 Risk Factors for LEA 33


3.5 Incidence Rates of LEA 34


3.6 International and Regional Differences 34


3.7 Time Trends in LEA Rates 34


3.8 Ethnic Differences in Diabetes-Related LEA 35


3.9 Ethnic Differences in Diabetes-Related LEA Risk 35


3.10 Indian Asians 38


References 38


4a The Diabetic Foot Worldwide: India 43
M. Viswanathan


4a.1 Introduction 43


4a.2 Epidemiology of Diabetes in India 43


4a.3 Socio Economic Burden Due to Diabetes 43


4a.4 Common Risk Factors for Amputation in India 43


4a.5 Diagnosing High Risk Feet in Developing Countries 44


4a.6 Comparison in Risk Factors between India and the Western World 44


4a.7 DFI as a Cause for Declining Kidney Function 44


4a.8 Helping People with Amputation Cope Up with the Disability 44


References 45


4b The Diabetic Foot Worldwide: Pakistan 47
Abdul Basit


4b.1 Introduction 47


4b.2 Concept of Multidisciplinary Diabetic Foot Care Team (MDFCT) 47


4b.3 Nationwide Diabetic Foot Programme (Step by Step-[SbS]) 48


4b.4 Footwear for Every Diabetic (FED) 48


4b.5 Further Steps Ahead of SbS 49


References 49


4c The Diabetic Foot Worldwide: Sub-Saharan Africa 51
Zulfiqarali G. Abbas


4c.1 Introduction 51


4c.2 Pathophysiology of Foot Ulcers 52


4c.3 Peripheral Neuropathy (PN) 52


4c.4 Peripheral Arterial Diseases (PAD) 53


4c.5 Foot Ulceration in SSA 54


4c.6 Foot Infection 55


4c.7 Amputation 56


4c.8 Mortality 56


4c.9 Prevention 56


4c.10 Conclusions 58


References 58


4d Burden of Diabetic Foot Disease in Brazil 61
Hermelinda C. Pedrosa and Luciana R. Bahia


References 64


4e Diabetic Foot in Romania and Eastern Europe 67
Norina Alinta Gavan and C. I. Bondor


4e.1 Introduction 67


4e.2 The Aim 67


4e.3 Diabetic Foot in Romania 67


4e.4 Diabetic Foot in Eastern Europe 70


4e.5 Conclusions 71


References 71


4f Diabetic Foot Worldwide: Pacific Region 75


Shigeo Kono


References 76


4g The Diabetic Foot Worldwide: Middle East 79
Samir H. Assaad-Khalil


4g.1 The Burden of Diabetic Foot Disease (DFD) in the Middle East (ME) 79


4g.2 Specific Regional Barriers to Healthy Feet and Foot Care 80


4g.3 Misconceptions 81


4g.4 Footwear 81


4g.5 Foot Care, Education and Awareness 81


References 82


4h The Diabetic Foot Worldwide: Australasia 85
Peter A. Lazzarini


4h.1 Introduction 85


4h.2 Australia 85


4h.3 New Zealand 86


4h.4 Pacific Islands 86


4h.5 Conclusion 87


References 87


5 Diabetic Neuropathy 89
Dinesh Selvarajah, Gordon Sloan, and Solomon Tesfaye


5.1 Epidemiology 89


5.2 Classification 89


5.3 Symmetrical Neuropathies 91


5.4 Asymmetrical Neuropathies 95


5.5 Pathogenesis of Distal Symmetrical Neuropathy 97


5.6 Management of Diabetic Neuropathy 98


References 101


6 The Pathway to Ulceration: Aetiopathogenesis and Screening 105
Andrew J.M. Boulton


6.1 Introduction 105


6.2 Peripheral Arterial Disease (PAD) 106


6.3 Diabetic Neuropathy 107


6.4 Neuropathy: The Major Contributory Factor in Ulceration 109


6.5 Other Risk Factors for Foot Ulceration 109


6.6 Assessment of Foot Ulcer Risk 111


6.7 The Pathway to Ulceration 116


6.8 Mechanical Factors and Neuropathic Foot Ulceration 118


6.9 The Patient with Sensory Loss 120


References 120


7 Biomechanics of the Diabetic Foot for the Uninitiated 125
S.A. Bus and J.S. Ulbrecht


7.1 Introduction 125


7.2 The Concept of Pressure and its Measurement 125


7.3 The Role of Elevated Plantar Pressure in Foot Ulceration 126


7.4 Mechanisms of Elevated Plantar Pressure 128


7.5 Foot Biomechanics in Treating a Plantar Foot Ulcer 130


7.6 Biomechanical Issues in Preventing a Foot Ulcer 132


7.7 Summary 133


References 134


8 Psychological and Behavioural Aspects of Diabetic Foot Ulceration 139
Loretta Vileikyte and Ryan T. Crews


8.1 The Role of Psychological and Behavioural Factors in DFU Development 139


8.2 The Role of Psychological and Behavioural Factors in DFU Healing 142


8.3 The Impact of DFUs on Patients' Health Status and QoL 146


8.4 Measuring QoL in DFU Patients: Generic, DFU-Specific or Combined Approach? 147


References 148


9 What Role for the Plain Radiograph of the Diabetic Foot? 153
Richard William Whitehouse


9.1 Introduction 153


9.2 Pathologies 157


9.3 Summary 166


References 167


10 Advanced Cross-Sectional Radiology-Ultrasound, Computed Tomography and Magnetic Resonance Imaging of the Diabetic Foot 169
Aparna Komarraju and Avneesh Chhabra


10.1 Introduction 169


10.2 Pathophysiology of Diabetic Foot Disease 170


References 183


11 Gait and Exercise Training in Diabetic Peripheral Neuropathy 187
Neil D. Reeves


11.1 Introduction 187


11.2 Gait Characteristics of People with Diabetes 187


11.3 Muscle Forces and the Biomechanics of Gait in Diabetes 188


11.4 Biomechanical Strategies to Alter Gait in Diabetic Peripheral Neuropathy 190


11.5 Falls and Diabetic Peripheral Neuropathy 193


11.6 Biomechanical Factors Leading to Increased Fall Risk 193


11.7 Diabetic Peripheral Neuropathy and Balance during Gait 194


11.8 Exercise and Diabetic Peripheral Neuropathy 196


11.9 Effects of Exercise in Patients with Diabetic Peripheral Neuropathy on Gait and Balance 197


11.10 The Case for Resistance Exercise Training 198


References 198


12 Smart Technology for the Diabetic Foot in Remission 201
Bijan Najafi and David G. Armstrong


12.1 Background 201


12.2 Technologies to Guide the Prescription of Footwear-Related Offloading Treatments 203


12.3 Technologies to Facilitate Triaging those at High Risk of DFU 204


12.4 Technologies to Manage Dose of Physical Activities in People with Diabetes and Insensate Foot 211


12.5 Using Technology to Improve Patient Education for Effective Prevention of Diabetic Foot Ulcers 214


12.6 Mobile Health (mHealth) to Manage Diabetic Foot Ulcers 215


12.7 Internet of Things and Remote Management of Diabetic Foot Ulcers 216


12.8 Technologies to Facilitate Delivering of Therapy at Home and Reduce Risk of DFU 217


12.9 Conclusion 218


References 219


13 How to Assess the Quality of Clinical Trials for Diabetic Foot Ulcer Therapies 225
Fran Game and William Jeffcoate


13.1 Introduction 225


13.2 Hierarchy of Evidence 226


13.3 Items to Be Considered in Assessing Trials of Diabetic Foot Ulcer Therapies 227


13.4 The Population 227


13.5 The Person and Limb 228


13.6 The Ulcer 229


13.7 The Therapy 230


13.8 Outcomes 230


13.9 Adverse Events 231


13.10 21 Point Checklist 231


References 233


14a Bypass in Diabetic Peripheral Artery Disease 235
Neal R. Barshes and Joseph L. Mills


14a.1 Identifying Significant PAD Amongst Patients Presenting with Foot Ulcers 235


14a.2 Relative Benefits and Risks: Identifying Patients Who May Benefit from a Leg Bypass Operation 237


14a.3 Evaluating Relevant Vascular Anatomy for Planning a Bypass Operation 239


14a.4 The Operation and Early In-Hospital Recovery 241


14a.5 Follow-Up After a Leg Bypass Operation 243


References 243


14b Surgery or Endovascular Intervention in Diabetic Peripheral Vascular Disease 247
Edward Y. Woo and Misaki M. Kiguchi


14b.1 Introduction 247


14b.2 Background 247


14b.3 Diagnosis 248


14b.4 Management 250


14b.5 Endovascular Revascularization 250


14b.6 Results 253


14b.7 Complications 254


14b.8 Conclusion 254


References 255


15 Inpatient Diabetic Foot Care: A UK Perspective 259
Gerry Rayman


15.1 Introduction 259


15.2 The Burden of Inpatient Diabetes 260


15.3 The Burden of Inpatient Diabetic Foot Disease 260


15.4 Recommended Foot Care for Inpatients with Diabetes 261


15.5 Summary 262


References 263


16 Diagnosis and Management of Infection in the Diabetic Foot 265
Edgar J.G. Peters and Benjamin A. Lipsky


16.1 Introduction 265


16.2 Pathophysiology of Infections in Persons with Diabetes Mellitus 265


16.3 Risk Factors for DFI 266


16.4 Clinical Signs and Symptoms 266


16.5 Classification 267


16.6 Microbiology 268


16.7 Treatment 269


16.8 IWGDF Grade 4 (Severe) Infections 274


16.9 Osteomyelitis 275


References 280


17 Surgical Approach to Diabetic Foot Infections 287
Katherine M. Raspovic, Javier La Fontaine, and Lawrence Lavery


17.1 Introduction 287


17.2 Initial Evaluation 288


17.3 Initial Surgical Intervention 290


17.4 After Initial Surgical Intervention 293


17.5 Staged Surgical Intervention and Wound Closure 294


17.6 Surgical Offloading 296


17.7 Soft Tissue/Tendon Balancing and Definitive Osseous Surgical Reconstruction 296


17.8 Decision for Proximal Level Amputation 297


17.9 Conclusions 298


References 298


18 The Evidence Base for the Choice of Dressings in the Management of Diabetic Foot Ulcers 301
William J. Jeffcoate, Patricia E. Price, and Frances L. Game


18.1 The Problems 301


18.2 Quality of Evidence 302


18.3 The Definition of a Dressing 302


18.4 The Roles of the Dressing 303


18.5 Basic Aspects of Wound Care 304


18.6 Evidence for Potential Contributions of Dressings and Wound Applications to Improve Wound Healing 304


18.7 Other Therapies which May Modulate Healing of Chronic Wounds 306


18.8 Summary 307


References 308


19 Pathogenesis of Charcot Neuroarthropathy and Acute Management 311
N.L. Petrova and Michael E. Edmonds


19.1 Introduction 311


19.2 Pathogenesis of CN 311


19.3 Acute Management of CN 316


19.4 Conclusions 318


References 319


20 Surgical Reconstruction of the Charcot Foot 323
George Liu, Katherine Raspovic, and Dane Wukich


20.1 Introduction 323


20.2 Indications for Surgical Reconstruction 323


20.3 Radiographic Predictors for Ulceration 325


20.4 Timing of Surgery 326


20.5 Preoperative Medical Workup 327


20.6 Glycemic Control 327


20.7 Vitamin D 328


20.8 Renal Function 328


20.9 Procedures/Outcome Studies 328


20.10 Outcomes of Charcot Reconstruction 334


20.11 Summary of Evidence Based Recommendations 335


References 336


21 Amputation in the Diabetic Foot 345
Michael S. Pinzur and Adam P. Schiff


21.1 Introduction 345


21.2 Impediments to Rehabilitation in the Diabetic Amputee 345


21.3 The Lower Extremity as an Organ of Weight Bearing 346


21.4 Metabolic Cost of Walking with an Amputation 346


21.5 Limb Salvage vs. Amputation 347


21.6 Amputation Level Selection 348


21.7 The Terminal Organ of Weight Bearing 348


21.8 The Soft Tissue Envelope 351


21.9 Tissue Management 351


21.10 Outcomes Following Amputation 352


21.11 Surgical Amputation Levels 352


21.12 Lesser Toe Amputation 353


21.13 Ray Resection 353


21.14 Midfoot Amputation 355


21.15 Hindfoot Amputation 355


21.16 Symes's Ankle Disarticulation Amputation 356


21.17 Transtibial Amputation 357


21.18 Knee Disarticulation Amputation 359


21.19 Transfemoral Amputation 359


21.20 Conclusions 360


References 360


22 Rehabilitation of the Amputee 363
Karen Kowalske and Merrine Klakeel


22.1 Lower Limb Amputation and Prosthetics 363


22.2 Foot Amputations 364


22.3 Foot Orthotics 365


22.4 Transtibial Amputations 366


22.5 Ankle/Foot Components 369


22.6 Conclusion 372


References 372


23 Surgery for the Diabetic Foot: Prophylactic and Osteomyelitis Surgery - Is there an Evidence Base? 375
Javier Aragon-Sanchez


23.1 The Role of Surgery Preventing Occurrence and Recurrence of Foot Ulcers 376


23.2 Preoperative Care 376


23.3 Hallux and First Metatarsal Head Procedures 377


23.4 Lesser Toes 380


23.5 Lesser Metatarsal Heads 381


23.6 Tendon Achilles Lengthening 383


23.7 Curative Surgery for Treating Diabetic Foot Osteomyelitis 385


23.8 Surgery of Forefoot Osteomyelitis 386


23.9 Surgery of Midfoot Osteomyelitis 388


23.10 Surgery of Rear Foot Osteomyelitis 388


References 389


24 Footwear and Orthoses for People with Diabetes 395
J.S. Ulbrecht and S.A. Bus


24.1 Introduction 395


24.2 What is a Therapeutic Shoe for a Person Living with Diabetes? 395


24.3 Who Needs Therapeutic Shoes? 402


24.4 Choosing the Appropriate Footwear for the Patient with LOPS 403


24.5 Summary and Future Trends 406


References 406


25 The Diabetic Foot in Remission 409
Tanzim Khan, Sicco A. Bus, Andrew J.M. Boulton, and David G. Armstrong


25.1 The Diabetic Foot in Remission 409


25.2 Maintaining Remission 410


25.3 Conclusion 413


References 414


26 Setting up a Diabetic Foot Clinic 417
Michael E. Edmonds and N.L. Petrova


26.1 Natural History of the Diabetic Foot 417


26.2 Principles of Care of the Diabetic Foot 418


26.3 Space for the Diabetic Foot Clinic 418


26.4 Personnel for the Diabetic Foot Clinic 419


26.5 Organisation of the Diabetic Foot Clinic 422


26.6 Conclusion 426


References 426


27 National Audit of Diabetic Foot Care: Continuing Audit is Essential for the Delivery of Optimal Care of Diabetic Foot Ulcers 429
William Jeffcoate, Gerry Rayman, and Bob Young


27.1 Why Should We Document the Outcome of Routine Care? 429


27.2 General Principles of Clinical Audit 430


27.3 National Diabetes Foot Care Audit of England and Wales 433


References 437


28 Regenerative Medicine and the Diabetic Foot 439
Zachary A. Stern-Buchbinder, Babak Hajhosseini, and Geoffrey C. Gurtner


28.1 Introduction 439


28.2 Stem Cells 439


28.3 Diabetes and Healing Impairment 442


28.4 Diabetes and Vascular Dysfunction 443


28.5 Functional Heterogeneity of Stem Cells 446


28.6 Advances in Regenerative Therapy 447


28.7 Conclusion 449


References 449


29 Role of the Plastic Surgeon in Diabetic Foot Care 457
Joon Pio (Jp) Hong and Hyunsuk Peter Suh


29.1 Introduction 457


29.2 Multidisciplinary Approach and the Spectrum of Care 458


29.3 Reconstruction Algorithm 459


29.4 Debridement (this is Covered in Detail in another Chapter) 460


29.5 Evaluating and Enhancing the Vascular Status 461


29.6 Skin Grafts and Substitutes 462


29.7 Local Flaps 463


29.8 Free Flaps 464


29.9 Amputation 466


29.10 Conclusion 467


References 469


30a Algorithms for Diabetic Foot Care: Management of the Hot Swollen Foot 473
Michael E. Edmonds, Chris Manu, and Nina Petrova


References 480


30b Approach to a New Diabetic Foot Ulceration 481
Prashanth R.J. Vas and Michael E. Edmonds


30b.1 Introduction 481


30b.2 Clinical Care for the Management of DFU 482


30b.3 Management of DFU 485


30b.4 Structural Care Process in DFU Management 490


References 491


30c Algorithms for Diabetic Foot Care: Vascular Evaluation 495
G. Dovell and R.J. Hinchliffe


30c.1 Introduction 495


30c.2 Methods of Vascular Evaluation - Detecting Peripheral Artery Disease 496


30c.3 Vascular Imaging 498


30c.4 Conclusions 500


References 503


30d Algorithms for Diagnosis and Management of Infection in the Diabetic Foot 507
Edgar J.G. Peters and Benjamin A. Lipsky


30d.1 Diagnosis of Infection 507


30d.2 Therapy of Infection 509


References 514


Index 515