Lesions in the feet caused by diabetes mellitus · Cost of foot ulcers Atlas of the Diabetic Foot, 2nd Edn, 2010, Wiley-Blackwell . Dry gangrene . Wet gangrene . Colour change of

Lesions in the feet caused by

diabetes mellitus

N. Tentolouris

1st Dept. of Internal Medicine

Athens University Medical School

Laiko General Hospital

Athens, Greece

Prevalence of the diabetic foot

Diabetic foot. In: Vascular Surgery, Liapis Ch (Eds), Sringer-Verlag, Berlin, 2005

Prevalence and incidence of the

diabetic foot worldwide

•Prevalence 4-10%

Age < 45 yrs 1.7-3.3%

Age > 60 yrs 5-10%

•Incidence 2.2-5.9% per year

Which is the most common cause

of diabetic foot problems?

EURODIALE Study (2006)

A total of 1229 patients with a new ulcer between September 1 2003 and October 1 2004

Ιschaemia: 49%

Ischaemia and infection: 31%

Σακσαπώδηρ Διαβήηηρ Κάπνιζμα

δςζλιπιδαιμία

Πεπιθεπική

Απηηπιοπάθεια Αιζθηηικοκινηηική

νεςποπάθεια

Νεςποπάθεια

Αςηονόμος ΝΣ Πεπιοπιζμένη

κινηηικόηηηα απθπώζεων

Ελαηηωμένη

εθίδπωζη

Μεηαβολέρ

αιμαη. ποήρ

Διάηαζη

θλεβών

Θεπμό

πόδι

Ξηπό δέπμα

Κάλορ

Αςξημένερ

Πιέζειρ

ζηο πόδι

Νεςποπαθηηικό

Πόδι ζε κίνδςνο

Απώλεια

μεζοζηέων

μςών

Ελαηη αίζθηζη πόνος

& ιδιοδεκηική αίζθηζη

Νεςποϊζσαιμικό

Πόδι ζε κίνδςνο

Τπαύμα

Ιζσαιμικό

Έλκορ Νεςποϊζσαιμικό

Έλκορ

Νεςποπαθηηικό

Έλκορ

Ψςσοκοινωνικά πποβλήμαηα

Πποβλήμαηα ζςμπεπιθοπάρ

.

Παπαμοπθώζειρ

Why diabetic foot matters?

• 50-70% of the amputations are performed in patients with diabetes

• The RR of amputation is 10-15 times higher in persons with diabetes

• USA: ~80.000 amputations per year in patients with diabetes

• In 85% of the amputations the cause is a foot ulcer

• Ischaemia and non-healing ulcers: – Cause of amputation in 50-70% in patients with diabetes

• Infections complicated ulcers: – Cause of amputation in 20-50% in patients with diabetes

Reiber et al. National Institute of Health, 1995

Diabetes Care,

2004, 271: 1598-1604

High prevalence rates of co-morbidity in

diabetic patients with foot ulcers

0

5

10

15

20

25

30

35

40

CAD LEAD Retinopathy Nephropathy

Pre

va

lnc

e (

%)

No ulcer

Ulcer

Tentolouris N et al., Wounds (2008)

Blue columns: Diabetic patients without ulcer (n=508)

Red columns: Diabetic patients with ulcer (n=234)

* *

*

*

*P<0.05

Even higher prevalence rates of co-morbidity

in diabetic patients with neuroischaemic foot

ulcers

0

10

20

30

40

50

60

CAD Retinopathy Nephropathy

Pre

vale

nce

(%

)

Neuropathic

Neuroischaemic

Blue columns: Diabetic patients without ulcer (n=152)

Red columns: Diabetic patients with ulcer (n=82)

Tentolouris N et al., Wounds (2008)

* *

*

*P<0.001

Cost of foot ulcers

Atlas of the Diabetic Foot, 2nd Edn, 2010, Wiley-Blackwell

Dry gangrene

Wet

gangrene

Colour change of NEUROPAD

The performance of Neuropad for the diagnosis of neuropathy

FULL PUBLICATIONS

ZICK et al, 2003 Sensitivity: 90%, Specificity: 74%

PAPANAS et al, 2005 Sensitivity: 94.4%, Specificity: 69.7%

PAPANAS et al, 2007

SHEN et al, 2007

PAPANAS et al, 2007, in press

Sensitivity: 95%, Specificity: 69.8%

Sensitivity: 92.8%, Specificity: 78.5%

Sensitivity: 97.8%, Specificity: 67.2%

ABSTRACTS

MANES et al, 2004 Sensitivity: 90%, Specificity: 66%

MARINOU et al, 2005 Sensitivity: 86%, Specificity: 68.2%

MALIK et al, 2006

DIDANGELOS et al, 2006

Sensitivity: 86%, Specificity: 60%

Sensitivity: 95%, Specificity: 69%

Excellent (κ= 0.88) agreement between the health care

professional and the patients

What will you suggest to a patient with

neuropathy?

• Education in foot care

• Proper shoes and insoles

Orthotics

Therapeutic shoes

Callosities

1) Off-loading

2) Callus removal

3) Reduction of skin dryness using creams containg

urea 10-20%

4) Regular podiatry follow up

A patient with long-standing diabetes attends the

foot clinic with a foot which is red, swollen and

warm: what is your diagnosis?

Neuro-osteoarthropathy

Definition

• Charcot neuropathic osteoarthropathy

(CN), commonly referred to as the Charcot

foot, is a condition affecting the bones,

joints, and soft tissues of the foot and

ankle, characterized by inflammation in the

earliest phase.

Prevalence: 0.8-8%

Risk factors of CN

1) Long duration of diabetes

2) Dense peripheral somatic neuropathy

3) Autonomic neuropathy

4) Adequate blood supply to the feet

5) Osteoporosis

6) Other microangiopathic complications

7) Kidney tranplantation

8) Anorexia nervosa

Typical chronic CN deformity

Typical chronic CN deformity

Chronic CN deformity

Chronic CN deformity with relapsing

pedal ulcers

Chronic CN deformity with a relapsing

pedal ulcer

Dry skin, callosities and claw toe

deformity

Neuropathic ulcers

Neuroischaemic ulcers

Dry gangrene

Τσαπόγας

Septic arteritis

How will you manage these patients?