The Foot in Diabetes, 5th Edition

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 Gâvan 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 Aragón-Sánchez

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