2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S144 32). In addition, an acute Charcot foot may be associated with erythema and swelling, with overall clinical characteristics very similar to cellulitis (33,34). MANAGEMENT Appropriate management can prevent or heal diabetic foot ulcers, thereby greatly reducing the amputation rate (6,9,10,25,26,35,36). All people with diabetes should be instructed on proper foot care (including smoking cessation strategies) (Appendix 5), should strive to reach recommended glycemic targets, and should receive early referrals to a healthcare professional trained in foot care management if problems occur (37). Management of foot ulceration requires an interdisciplinary approach (38) that addresses glycemic control, infection, lower-extremity vascular status and local wound care (39). Essentials of good wound care involve provision of an optimal wound environment, off-loading of the ulcer site, and, in nonischemic wounds, regular debridement of nonviable tissue. In general, wound dressings that maintain a moist wound environment should be selected (40) (Appendix 6). Expeditious debridement may be performed with sharp instruments or biologically with medical-grade maggots (41,42). Pressure offloading may be achieved with temporary footwear until the ulcer heals and the character of the foot stabilizes. Removable and irremovable cast-walkers and total-contact casting have demonstrated proven efficacy as pressure-reducing devices in plantar-surface ulcers (43- 45). Although very effective in healing noninfected, nonischemic plantar-surface neuropathic ulcers, total-contact casting requires careful individual selection and personnel trained specifically in its application due to its potential for complications (46). Infections that complicate diabetic foot ulcers occur frequently and may be imminently limb threatening (47). Surface cultures (as opposed to cultures of deeper tissues) of ulcers in people with diabetes have produced inconsistent results in determining the bacterial pathogens involved (48-50). Initial antibiotic therapy is typically empiric and broad spectrum, with subsequent antibiotics tailored to results from appropriate cultures. Studies to date do not clearly identify a particular antibiotic agent that is more efficacious in reducing amputation, accelerating ulcer healing or resolving infection (51). Uncontrolled diabetes can result in immunopathy with a blunted cellular response to infection. Up to 50% of patients with diabetes who have a significant limb infection may not have systemic signs of fever or leukocytosis at presentation (52). Deep infections require prompt surgical debridement in addition to appropriate antibiotic therapy (53). In medically suitable individuals with peripheral arterial disease, distal limb revascularization has proven benefit in longterm limb salvage (54).Where bony foot deformities prevent fitting of appropriate footwear and/or offloading of pressurerelated ulcers, consultation from a surgeon skilled in foot sur- gery may be considered to address the deformity (55-57). Hyperbaric oxygen therapy may be useful as an adjunct to systemic antibiotics in individuals with deep, long-standing, nonhealing foot infections, provided there is an adequate perfused capillary bed in the wound area (i.e. by measuring tcPO2 response to 100% oxygen challenge). Few studies support its use in treating uncomplicated neuropathic or ischemic diabetic foot ulcers. There are no evidence-based criteria to select people for hyperbaric oxygen therapy and to predict their response (58). RECOMMENDATIONS 1. In people with diabetes, foot examinations by both the individual and healthcare providers should be an integral component of diabetes management to decrease the risk of foot lesions and amputations [Grade B, Level 2 (26,37)], and should be performed at least annually and at more frequent intervals in those at high risk [Grade D, Consensus].Assessment by healthcare providers should include structural abnormalities (e.g. range of motion of ankles and toe joints, callus pattern, bony deformities, skin temperatures), evaluation for neuropathy and peripheral arterial disease, ulcerations and evidence of infection [Grade D, Level 4 (9,50)]. 2. People at high risk of foot ulceration and amputation should receive foot care education (including counselling to avoid foot trauma), professionally fitted footwear, smoking cessation strategies and early referrals to a healthcare professional trained in foot care management if problems occur [Grade B, Level 2 (37)]. 3. Individuals who develop a foot ulcer should be managed by a multidisciplinary healthcare team with expertise in the management of foot ulcers to prevent recurrent foot ulcers and amputation [Grade C, Level 3 (38)]. 4.Any infection in a diabetic foot must be treated aggressively [Grade D, Level 4 (53)]. OTHER RELEVANT GUIDELINES Targets for Glycemic Control, p. S29 Neuropathy, p. S140 RELEVANT APPENDICES Appendix 5: Diabetes and Foot Care: A Patient’s Checklist Appendix 6: Diabetic Foot Ulcers: Essentials of Management REFERENCES 1. American Diabetes Association: clinical practice recommendations 2004. Diabetes Care. 2004;27(suppl 1):S63-64. 2. 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. 3. Eastman RC. Neuropathy 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; 1995:339-348. 4. Palumbo PJ, Melton LJ III. Peripheral vascular disease and 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; 1995:401-408. 5. Boyko EJ, Lipsky BA. Infection and 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; 1995:485-499. 6. Frykberg RG. Diabetic foot ulcerations. In: Frykberg RG, ed. The High Risk Foot in Diabetes Mellitus. New York, NY: Churchill Livingstone; 1991:151-195. 7. Frykberg RG,Veves A. Diabetic foot infections. Diabetes Metab Rev. 1996;12:255-270. 8. Gibbons GW, Eliopoulos GM, Kozak GP, et al. Infection of the diabetic foot. In: Kozak GP, Campbell DR, Frykberg RG, et al, eds. Management of Diabetic Foot Problems. Philadelphia, PA:WB Saunders; 1995:121. 9. Reiber GE, Pecoraro RE, Koepsell TD. Risk factors for amputation in patients with diabetes mellitus. A case-control study. Ann Intern Med. 1992;117:97-105. 10. Bild DE, Selby JV, Sinnock P, et al. Lower-extremity amputation in people with diabetes. Epidemiology and prevention. Diabetes Care. 1989;12:24-31. 11. Reiber GE. Epidemiology of the diabetic foot. In: Levin ME, O’Neal LW, Bowker JH, eds. The Diabetic Foot. 5th ed. St. Louis, MO: Mosby; 1993:1-15. 12. Crude and age-adjusted hospital discharge rates for a lower extremity condition as the first-listed or any-listed diagnosis per 1,000 diabetic population, United States, 1980-2003. Atlanta, GA: Department of Health & Human Services, Centers for Disease Control and Prevention; 2007. Available at: http://www.cdc.gov/diabetes/statistics/hosplea/diabetes_ complications/fig6.htm. Accessed September 1, 2008. 13. Ebskov B, Josephsen P. Incidence of reamputation and death after gangrene of the lower extremity. Prosthet Orthot Int. 1980; 4:77-80. 14. Most RS, Sinnock P. The epidemiology of lower extremity amputations in diabetic individuals. Diabetes Care. 1983;6:87-91. 15. Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care. 1998;21:855-859. 16. Boyko EJ, Ahroni JH, Stensel V, et al. A prospective study of risk factors for diabetic foot ulcer. The Seattle Diabetic Foot Study. Diabetes Care. 1999;22:1036-1042. 17. Fernando DJ, Masson EA,Veves A, et al. Relationship of limited joint mobility to abnormal foot pressures and diabetic foot ulceration. Diabetes Care. 1991;14:8-11. 18. Kalani M, Brismar K, Fagrell B, et al. Transcutaneous oxygen tension and toe blood pressure as predictors for outcome of diabetic foot ulcers. Diabetes Care. 1999;22:147-151. 19. Faglia E, Caravaggi C, Marchetti R, et al; SCAR (SCreening for ARteriopathy) Study Group. Screening for peripheral arterial disease by means of the ankle-brachial index in newly diagnosed type 2 diabetic patients. Diabet Med. 2005;22:1310-1314. 20. Young MJ, Adams JE, Anderson GF, et al. Medial arterial calcification in the feet of diabetic patients and matched non-diabetic control subjects. Diabetologia. 1993;36:615-621. 21. Brillet PY,Vayssairat M,Tassart M, et al. Gadolinium-enhanced MR angiography as first-line preoperative imaging in high-risk patients with lower limb ischemia. J Vasc Interv Radiol. 2003; 14:1139-1145. 22. Lapeyre M, Kobeiter H, Desgranges P, et al. Assessment of critical limb ischemia in patients with diabetes: comparison of MR angiography and digital subtraction angiography. AJR Am J Roentgenol. 2005;185:1641-1650. 23. Pedersen M. Safety update on the possible causal relationship between gadolinium-containing MRI agents and nephrogenic systemic fibrosis. J Magn Reson Imaging. 2007;25:881-883. 24. Centers for Disease Control and Prevention (CDC). Nephrogenic fibrosing dermopathy associated with exposure to gadolinium-containing contrast agents – St. Louis, Missouri, 2002-2006. MMWR Morb Mortal Wkly Rep. 2007;56:137-141. 25. Assal JP, Mühlhauser I, Pernet A, et al. Patient education as the basis for diabetes care in clinical practice and research. Diabetologia. 1985;28:602-613. 26. Litzelman DK, Slemenda CW, Langefeld CD, et al. Reduction of lower extremity clinical abnormalities in patients with noninsulin-dependent diabetes mellitus.A randomized, controlled trial. Ann Intern Med. 1993;119:36-41. 27. Malone JM, Snyder M,Anderson G, et al. Prevention of amputation by diabetic education. Am J Surg. 1989;158:520-524. 28. Viswanathan V, Madhavan S, Gnanasundaram S, et al. Effectiveness of different types of footwear insoles for the diabetic neuropathic foot: a follow-up study. Diabetes Care. 2004; 27:474-477. 29. Sage RA,Webster JK, Fisher SG. Outpatient care and morbidity reduction in diabetic foot ulcers associated with chronic pressure callus. J Am Podiatr Med Assoc. 2001;91:275-279. 30. Lavery LA, Higgins KR, Lanctot DR, et al. Preventing diabetic foot ulcer recurrence in high-risk patients: use of temperature monitoring as a self-assessment tool. Diabetes Care. 2007; 30:14-20. 31. Armstrong DG, Lavery LA. Monitoring healing of acute Charcot’s arthropathy with infrared dermal thermometry. J Rehabil Res Dev. 1997;34:317-321. 32. Yu GV, Hudson JR. Evaluation and treatment of stage 0 Charcot’s neuroarthropathy of the foot and ankle. J Am Podiatr Med Assoc. 2002;92:210-220. 33. Frykberg RG, Zgonis T, Armstrong DG, et al; American College of Foot and Ankle Surgeons. Diabetic foot disorders. A clinical practical guideline (2006 revision). J Foot Ankle Surg. 2006;45(5 suppl):S1-S66. 34. Ledermann HP, Morrison WB. Differential diagnosis of pedal S145 COMPLICATIONS AND COMORBIDITIES
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