Management of diabetic foot complications. Pathways of care

Public and political concern about the increasing prevalence of diabetes has prompted major concern about treatment of patients with the condition. Foot complications are some of the commonest causes of hospitalisation of people with diabetes and if not treated well often lead to amputation. There is evidence that 85% of these amputations can be prevented by better understanding of the problem and by multi-disciplinary teams working more effectively together. This has been recognised and NICE have recently published guidelines on diabetic foot complications as have Diabetes UK and NHS Diabetes. These have been successful in raising awareness of the problem but the local multi-disciplinary teams need clear practical advice on how to manage the foot in diabetes and deliver high quality care. With the current interest in improving outcomes for patients with foot complications this is an ideal time to make a practical evidence-based handbook available. This book will provide clear practical guidelines on how to manage all aspects of the foot in diabetes as well as an in-depth analysis of the most recent evidence. The book will be based on care pathways with algorithms for each section so it would be of practical value in any clinic in primary or secondary care. It will appeal to a wide range of health care professionals treating people with diabetes: vascular surgeons and trainees, orthopaedic surgeons, diabetes specialist nurses, podiatrists and tissue viability nurses.​ Preface 6 Contents 8 Contributors 10 Chapter 1: Foot Complications in Diabetes: The Problem 13 Background 13 The At-Risk Foot 14 Diabetic Foot Ulcers 15 Foot Complications and Amputation 15 Diabetic Foot Ulcers: The Economic Impact 16 The Solution 17 References 18 Suggested Reading 19 Chapter 2: Screening and Treatment of Early Complications in the Diabetic Foot 20 Introduction 20 Need for Foot Care Service 21 Podiatry Foot Risk Guidance 23 General Management Approach 23 At Low Risk 24 At Increased Risk 25 At High Risk 26 Ulcerated/Acute Foot Complication 27 Management of the Diabetic Foot 27 Diabetes Foot Protection Team 29 Appendix 2.1: Foot Care Pathway for People with Diabetes and Foot Complications (Courtesy of Diabetes UK) 31 References 32 Suggested Reading 33 Chapter 3: Emergency Management of the Acute Diabetic Foot 34 Introduction 34 Immediate Care 35 Initial Assessment 35 History 37 Examination 37 Investigations 39 Management 41 Intermediate Phase (4–48 h) 42 Indications for Surgical Management 42 Revascularisation 45 Ongoing Care (48 h Onwards) 45 Summary 46 References 47 Suggested Reading 48 Chapter 4: Managing Diabetes in People with Foot Complications 49 Introduction 49 Acute Presentation 51 Acute Hyperglycaemia 52 Recovering from Acute Diabetic Foot Disease 54 Post Hospital Discharge 55 Summary 57 References 58 Chapter 5: Predicting Wound Healing in the Diabetic Foot: Measuring Skin Viability 60 Introduction 60 Peripheral Neuropathy 61 Peripheral Arterial Disease 63 Once an Ulcer Appears 66 Discussion 68 References 71 Chapter 6: Imaging in the Patient with Foot Complications 73 Overview 73 Plain Radiographs 74 Magnetic Resonance Imaging 77 Nuclear Medicine Scintigraphy 79 Computed Tomography 80 Ultrasound 80 Critical Limb Ischaemia 81 References 84 Suggested Reading 84 Chapter 7: Treatment of Infection in the Diabetic Foot: The Use of Antibiotics 85 Introduction 85 The Ten Essential Steps in Managing Infection in the Diabetic Foot 86 Step-by-Step Management of Infection in the Diabetic Foot 86 Summary 99 References 100 Suggested Reading 100 Chapter 8: Endovascular Revascularisation: When and How 101 Introduction 101 Diabetic Vascular Disease 102 Treatment Options 103 Endovascular Treatment 106 Pre-procedure 106 Treatment Site 107 Arterial Access 108 Crossing Lesions 108 Angioplasty or Stent? 110 Drug-Eluting Technologies 112 Complications 115 Post-procedure Care 116 Drug Therapy 116 References 118 Chapter 9: Surgical Revascularisation of the Diabetic Foot 120 Background 120 Introduction 121 Goals of Revascularisation 121 Indications for Revascularisation 121 Diagnosis of Pad 122 Principles of Revascularisation 122 Pre-treatment Work-Up 122 Surgical Bypass 124 Choice of Bypass Conduit 126 The Inflow Vessel 126 The Outflow Target Vessel 127 Technical Considerations During Bypass Surgery 127 Post-operative Surveillance and Follow Up 129 Novel Concepts in Revascularisation 130 References 131 Suggested Reading 132 Chapter 10: Amputation Above the Ankle: Achieving the Best Outcome for the Patient 133 Introduction 133 Factors Affecting the Decision to Offer Amputation 134 Assessment of Co-morbidity and Functional Status 135 Assessment of Cognitive Ability and Motivation 135 Assessment Functional Requirements 136 Indication for Amputation: Ischaemia Versus Sepsis 136 Deciding on the Level of Amputation 137 Expected Level of Function 137 Healing Potential 138 General Factors 139 Pre-operative Assessment and Education 139 Amputation Procedures: Surgical Tips 140 Tissue Cover 141 Trans-tibial 141 Knee Disarticulation 143 Trans-femoral 143 Post Operative Management 145 Wound Management 145 Rehabilitation 146 Care of the Contra-lateral Limb 146 Acute Pain Management 147 References 148 Suggested Reading 148 Chapter 11: Neuro-osteoarthropathy: The Charcot Foot – Pathology, Diagnosis, and Treatment 149 Description 149 History 150 Names 150 Causes 150 Neuropathy 150 Sensory Neuropathy 151 Motor Neuropathy 151 Vasomotor Neuropathy 151 Loss of Neuropeptide Release 151 Inflammation 152 Predisposition to Inflammation in Diabetes 152 Factors Encouraging Persistence of Inflammation 152 Other Factors Linked to the Onset of Charcot Disease 153 Epidemiology 153 Diagnosis 153 Treatment 155 Surgery 156 Active Phase 156 Inactive Phase 156 Major Amputation 156 Complications 157 Ulceration and Infection 157 Psychosocial 157 Aspects of Long-Term Management 157 Prevention of Late Ulceration 157 Cardiovascular Risk 158 References 159 Suggested Reading 159 Chapter 12: The Role of the Orthopaedic Surgeon in Diabetic Foot Complications 160 Introduction 160 Recognizing the Diabetic and the Foot at Risk 161 Clinical Management 162 The Infected Diabetic Foot 162 Suspected Charcot Disease 164 Established Charcot Disease 165 Foot Ulceration 166 Ankle Fractures 166 References 168 Suggested Reading 168 Chapter 13: Cardiovascular Risks in People with Diabetes Foot Complications 169 Overview: Defining the Main Issues 169 Who Is Responsible for CV Risk Management in People with Foot Disease? 170 CV Exercise: Are We Actually Resting Our Diabetic Foot Patients to Death? 172 How Do We Best Communicate with Patients About CV Risks Factor Management? 174 How to Tackle These Issues: Putting CV Risk Management at the Forefront of Diabetes Foot Care 176 Summary 179 References 180 Suggested Reading 181 Chapter 14: Foot Care and the Prevention of Recurrent Ulcers 182 Introduction 182 The Issues 183 Who Provides the Foot Care? 183 What Foot Care Should Be Provided? 184 What Standard of Care? 184 Preventative Education 184 Solution to the Problems of Preventing Foot Ulceration 185 Realistic Integrated Pathways 185 Standardised Care 187 Preventative Diabetic Foot Care 188 Engagement and Empowerment of Patients 189 References 191 Chapter 15: Foot Deformity and Pressure Management in the Diabetic Foot 193 Introduction 193 Foot Deformity in the Diabetic Foot 194 Neuropathy 194 Tissue Glycosylation 194 Charcot Neuropathic Osteoarthropathy 195 Minor Amputations 195 Pressure Management in the Diabetic Foot 196 Off-Loading Footwear 197 Surgical Off-Loading 199 Digital Ulcers 200 Plantar Forefoot Ulcers 200 Charcot Foot 201 References 201 Suggested Reading 202 Chapter 16: The Role of the Multidisciplinary Team in the Management of Diabetic Foot Complications 203 Introduction 203 How Should This Work? 204 Patient Education 206 The Foot Protection Team 206 The Multidisciplinary Team 208 The Foot Care Pathway 209 References 214 Suggested Reading 215 Index 216 1. Foot Complications In Diabetes: The Problem / Clifford P. Shearman -- 2. Screening And Treatment Of Early Complications In The Diabetic Foot / Graham C. Bowen -- 3. Emergency Management Of The Acute Diabetic Foot / Abigail H. M. Morbi And Clifford P. Shearman -- 4. Managing Diabetes In People With Foot Complications / Mayank Patel And Keith G. Mc Cormick -- 5. Predicting Wound Healing In The Diabetic Foot: Measuring Skin Viability / Javier Aragón-sánchez And Rajgopal Mani -- 6. Imaging In The Patient With Foot Complications / Duncan F. Ettles And Lynn Ling -- 7. Treatment Of Infection In The Diabetic Foot: The Use Of Antibiotics / Anthony R. Berendt -- 8. Endovascular Revascularisation: When And How / Andrew J. Wigham And Raman Uberoi -- 9. Surgical Revascularisation Of The Diabetic Foot / Paul W. Moxey And Patrick F. S. Chong -- 10. Amputation Above The Ankle: Achieving The Best Outcome For The Patient / Nicola Storer , Marie Hulse , Ian M. Nordon , And Stephen J. Baxter -- 11. Neuro-osteoarthropathy: The Charcot Foot -- Pathology, Diagnosis, And Treatment / William J. Jeffcoate -- 12. The Role Of The Orthopaedic Surgeon In Diabetic Foot Complications / Gavin W. Bowyer -- 13. Cardiovascular Risks In People With Diabetes Foot Complications / Martin Fox And Lisa Jane Lainton -- 14. Foot Care And The Prevention Of Recurrent Ulcers / Laurie King -- 15. Foot Deformity And Pressure Management In The Diabetic Foot / David A. Russell -- 16. The Role Of The Multidisciplinary Team In The Management Of Diabetic Foot Complications / Stella Vig And Kathryn H. Waite. Clifford P. Shearman, Editor. Includes Bibliographical References And Index. Mode Of Access: World Wide Web. Front Matter....Pages i-xi Foot Complications in Diabetes: The Problem....Pages 1-7 Screening and Treatment of Early Complications in the Diabetic Foot....Pages 9-22 Emergency Management of the Acute Diabetic Foot....Pages 23-37 Managing Diabetes in People with Foot Complications....Pages 39-49 Predicting Wound Healing in the Diabetic Foot: Measuring Skin Viability....Pages 51-63 Imaging in the Patient with Foot Complications....Pages 65-76 Treatment of Infection in the Diabetic Foot: The Use of Antibiotics....Pages 77-92 Endovascular Revascularisation: When and How....Pages 93-111 Surgical Revascularisation of the Diabetic Foot....Pages 113-125 Amputation Above the Ankle: Achieving the Best Outcome for the Patient....Pages 127-142 Neuro-osteoarthropathy: The Charcot Foot – Pathology, Diagnosis, and Treatment....Pages 143-153 The Role of the Orthopaedic Surgeon in Diabetic Foot Complications....Pages 155-163 Cardiovascular Risks in People with Diabetes Foot Complications....Pages 165-177 Foot Care and the Prevention of Recurrent Ulcers....Pages 179-189 Foot Deformity and Pressure Management in the Diabetic Foot....Pages 191-200 The Role of the Multidisciplinary Team in the Management of Diabetic Foot Complications....Pages 201-213 Back Matter....Pages 215-226 "This book explores the challenges of treating foot complications associated with diabetes, a major challenge for societies the world over Authors include experienced podiatrists, nurses and doctors, all of whom work in the field of diabetes foot care The book is divided into prevention and early management, management of major complications, prevention of recurrence and how to structure a team In each area, the authors describe their practical experiences and discuss how they have addressed clinical challenges Management of Diabetic Foot Complications provides useful information for anyone responsible for the care of people with diabetes who may be at risk of developing foot complications - Font no determinada This book explores the challenges of treating foot complications associated with diabetes, ℗l a major challenge for societies the world over. Authors include experienced podiatrists, nurses and doctors, ℗l all of whom℗l work in the field of diabetes foot care. The book is divided into prevention and early management, management of major complications, prevention of recurrence and how to structure a team.℗l In each area, the authors describe their practical experiences and discuss how they have addressed clinical challenges. Management of Diabetic Foot Complications provides useful information for anyone responsible for the care of people with diabetes who may be at risk of developing foot complications