2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S142 5. Tesfaye S, Chaturvedi N, Eaton SE, et al; EURODIAB Prospective Complications Study Group. Vascular risk factors and diabetic neuropathy. N Engl J Med. 2005;352:341-350. 6. Young MJ, Breddy JL,Veves A, et al.The prediction of diabetic neuropathic foot ulceration using vibration perception thresholds. A prospective study. Diabetes Care. 1994;17:557-560. 7. Reiber GE, Boyko EJ, Smith DG. Lower extremity foot ulcers and amputations in diabetes. In: Diabetes in America. 2nd ed. Bethesda, MD: National Diabetes Data Group, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 1995:409-428. 8. Perkins BA, Olaleye D, Bril V. Carpal tunnel syndrome in patients with diabetic polyneuropathy. Diabetes Care. 2002; 25:565-569. 9. Herman WH, Kennedy L. Underdiagnosis of peripheral neuropathy in type 2 diabetes. Diabetes Care. 2005;28:1480-1481. 10. Perkins BA, Olaleye D, Zinman B, et al. 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Foot Care Canadian Diabetes Association Clinical Practice Guidelines Expert Committee The initial draft of this chapter was prepared by Keith Bowering MD FRCPC FACP, Jean-Marie Ekoé MD CSPQ and Timothy P. Kalla BSc DPM FACFAS KEY MESSAGES • Foot problems are a major cause of morbidity and mortality in people with diabetes and contribute to increased healthcare costs. • Management of foot ulceration requires an interdisciplinary approach that addresses glycemic control, infection, lower extremity vascular status and local wound care. • Uncontrolled diabetes can result in immunopathy with a blunted cellular response to foot infection. INTRODUCTION Foot problems are a major cause of morbidity and mortality in people with diabetes and contribute to increased healthcare costs (1,2). The sequence of events leading to lowerextremity amputation is well known. In people with neuropathy (3) or peripheral vascular disease (4), minor trauma to the foot leads to skin ulceration, infection and ultimately gangrene, resulting in amputation (5-9). Foot complications are a major reason for admission to the hospital for people with diabetes, accounting for approximately 20% of all diabetes-related admissions in the North American population (7,8,10-12).After amputation of 1 limb, the prognosis for the contralateral limb is poor (13,14). RISK ASSESSMENT AND PREVENTIVE CARE A number of wound classification systems exist for documentation of diabetic foot ulcers. Of these, the University of Texas Diabetic Wound Classification System has been validated as a predictor of serious outcomes in patients with diabetes with foot ulcers (15) (Table 1). Characteristics that have been shown to confer high risk of ulceration include previous ulceration, neuropathy, structural deformity and limited joint mobility, peripheral vascular disease and microvascular complications (16,17). Noninvasive assessments for peripheral arterial disease in diabetes include the use of the ankle-brachial index, determination of systolic toe pressure by photoplethysmography (measurement of the intensity of light reflected from the skin surface and the red cells below, which is indicative of arterial pulse flow in the arterioles of the respective area), transcutaneous oximetry (tcPO2), and Doppler arterialflow studies (18,19).The ankle-brachial index may be arti- ficially high in some individuals with diabetes due to medial arterial-wall calcification in lower-extremity arteries (20). Iodinated contrast arteriography has provided the most definitive evaluation of peripheral atherosclerosis, but can precipitate renal failure in individuals with renal insufficiency. Advanced magnetic resonance angiography has been used as an alternative to iodinated contrast studies in people at risk for renal complications (21,22), although caution may be necessary in view of a possible association with the gadolinium-based contrast agents used in magnetic resonance angiography and the development of nephrogenic systemic fibrosis in individuals with poor renal function (23,24). Prevention of amputations necessitates the use of various measures, including regular foot examination and evaluation of amputation risk, regular callus debridement, education, professionally fitted therapeutic footwear to reduce plantar pressure and accommodate foot deformities, and early detection and treatment of diabetic foot ulcers (10,25-28). Callus should be considered a sign of increased pressure and risk for ulceration (29). Foot examination should also include skin temperature assessment. Increased warmth is the first indicator of inflammation in an insensate foot and may be the first sign of acute Charcot neuroarthropathy as a complication of loss of protective sensation in the foot (30- Table 1. University of Texas Diabetic Wound Classification System (15) Stage Grade A (no infection or ischemia) 0 I II III Pre- or postulcerative lesion completely epithelialized Superficial wound not involving tendon, capsule or bone Wound penetrating to tendon or capsule Wound penetrating to bone or joint B Infection Infection Infection Infection C Ischemia Ischemia Ischemia Ischemia D Infection and ischemia Infection and ischemia Infection and ischemia Infection and ischemia S143 COMPLICATIONS AND COMORBIDITIES
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