The Foot in Diabetes Third Edition The Foot in Diabetes. Third Edition. Edited by A.J.M. Boulton, H. Connor, P.R. Cavanagh Copyright  2000 John Wiley & Sons, Inc. ISBNs: 0-471-48974-3 (Hardback); 0-470-84639-9 (Electronic) The Foot in Diabetes Third Edition Edited by Andrew J. M. Boulton Manchester Royal In®rmary, UK Henry Connor County Hospital, Hereford, UK Peter R. Cavanagh Pennsylvania State University, USA JOHN WILEY & SONS, LTD Chichester . New York . Weinheim . Brisbane . Singapore . Toronto The Foot in Diabetes. Third Edition. Edited by A.J.M. Boulton, H. Connor, P.R. Cavanagh Copyright  2000 John Wiley & Sons, Inc. ISBNs: 0-471-48974-3 (Hardback); 0-470-84639-9 (Electronic) Copyright & 2000 by John Wiley & Sons, Ltd., Baf®ns Lane, Chichester, West Sussex PO19 1UD, UK National 01243 779777 International (+44) 1243 779777 e-mail (for orders and customer service enquiries): cs-books@wiley.co.uk Visit our Home Page on: http://www.wiley.co.uk or http://www.wiley.com All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, scanning or otherwise, except under the terms of the Copyright, Designs and Patents Act 1988 or under the terms of a licence issued by by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 9HE, UK, without the permission in writing of the publisher. 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Contents List of Contributors ix Preface xiii 1 Introduction: The Diabetic FootÐThe Good News, The Bad News 1 John D. Ward 2 The Size of the Problem: Epidemiological and Economic Aspects of Foot Problems in Diabetes 3 Rhys Williams and Mark Airey 3 The Pathway to Ulceration: Aetiopathogenesis 19 Andrew J. M. Boulton 4 What the Practising Physician Should Know about Diabetic Foot Biomechanics 33 Peter R. Cavanagh, Jan S. Ulbrecht and Gregory M. Caputo 5 Classi®cation of Ulcers and Its Relevance to Management 61 Matthew J. Young 6 Providing a Diabetes Foot Care Service (a) Barriers to Implementation 73 Mary Burden (b) Establishing a Podiatry Service 81 David J. Clements The Foot in Diabetes. Third Edition. Edited by A.J.M. Boulton, H. Connor, P.R. Cavanagh Copyright  2000 John Wiley & Sons, Inc. ISBNs: 0-471-48974-3 (Hardback); 0-470-84639-9 (Electronic) (c) The Exeter Integrated Diabetic Foot Project 87 Molly Donohoe, John Fletton and John E. Tooke 7 The Diabetic Foot in Primary Care: A UK Perspective 95 Roger Gadsby 8 Podiatry and the Diabetic Foot: An American Perspective 105 Larry B. Harkless and David G. Armstrong 9 EducationÐCan It Prevent Diabetic Foot Ulcers and Amputations? 111 Maximilian Spraul 10 Psychological and Behavioural Issues in Diabetic Neuropathic Foot Ulceration 121 Loretta Vileikyte 11 Footwear for the High-risk Patient 131 Ernst Chantelau 12 The Rational use of Antimicrobial Agents in Diabetic Foot Infection 143 Gregory M. Caputo 13 Use of Dressings: Is there an Evidence Base? 153 Nicky Cullum, Mariam Majid, Susan O'Meara and Trevor Sheldon 14 New Treatments for Diabetic Foot Ulcers (a) Growth Factors 169 Vincent Falanga (b) Dermagraft and Granulocyte-colony Stimulating Factor (GCSF) 179 Michael E. Edmonds (c) Larval Therapy 185 Stephen Thomas vi Contents 15 The Role of Radiology in the Assessment and Treatment of the Diabetic Foot 193 John F. Dyet, Duncan F. Ettles and Anthony A. Nicholson 16 Peripheral Vascular Disease and Vascular Reconstruction 215 Kevin G. Mercer and David C. Berridge 17 Charcot Foot: An Update on Pathogenesis and Management 235 Robert G. Frykberg 18 Prophylactic Orthopaedic SurgeryÐIs There A Role? 261 Patrick Laing 19 Amputations in Diabetes Mellitus: Toes to Above Knee 279 John H. Bowker and Thomas P. San Giovanni 20 Rehabilitation after Amputation 309 Ernest Van Ross and Stuart Larner 21 The International Consensus and Practical Guidelines on the Diabetic Foot 323 Karel Bakker 22 The Foot in LeprosyÐLessons for Diabetes 345 Grace Warren 23 Conclusions 363 Henry Connor, Andrew J. M. Boulton and Peter R. Cavanagh Index 367 Contents vii Contributors Dr C. Mark Airey Division of Public Health, Nuf®eld Institute for Health, 71± 75 Clarendon Road, Leeds LS2 9PL, UK Dr David G. Armstrong University of Texas Medical School, Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78284-7776, USA Dr Karel Bakker International Working Group on the Diabetic Foot, PO Box 9533, 1006 GA Amsterdam, The Netherlands Mr David C. Berridge Department of Vascular and Endovascular Surgery, St James's University Hospital, Beckett Street, Leeds LS9 7TF, UK Professor Andrew J. M. Boulton Department of Medicine, Manchester Royal In®rmary, Oxford Road, Manchester M13 9WL, UK Professor John H. Bowker Jackson Memorial Rehabilitation Center, 1611 NW 12th Avenue, Suite 303, Miami, FL 33136, USA Mrs Mary Burden Research and Development Diabetes Care, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK Dr Gregory M. Caputo The Center for Locomotion Studies, Pennsylvania State Diabetes Foot Clinics, Pennsylvania State University, University Park, PA 16802, USA Professor Peter R. Cavanagh The Center for Locomotion Studies, Pennsylvania State Diabetes Foot Clinics, Pennsylvania State University, University Park, PA 16802, USA Professor Ernst Chantelau Klinik fur Stoffwechselkrankheiten und Ernahrung, Heinrick Heine Universitat, Postfach 10 10 07, D-40001 Dusseldorf, Germany The Foot in Diabetes. Third Edition. Edited by A.J.M. Boulton, H. Connor, P.R. Cavanagh Copyright  2000 John Wiley & Sons, Inc. ISBNs: 0-471-48974-3 (Hardback); 0-470-84639-9 (Electronic) Mr David J. Clements Portsmouth Health Care NHS Trust, Kingsway House, 130 Elm Grove, Southsea, Portsmouth PO5 1LR, UK Dr Henry Connor The County Hospital, Union Walk, Hereford HR1 2ER, UK Dr Nicky Cullum Centre for Evidence-based Nursing, Department of Health Studies, University of York, York YO10 5DQ, UK Dr Molly Donohoe Department of Diabetes & Vascular Medicine, University of Exeter, Barrack Road, Exeter EX2 5DW, UK Dr John F. Dyet Hull Royal In®rmary, Anlaby Road, Hull HU3 2JZ, UK Dr Michael E. Edmonds Diabetic Department, King's College Hospital, Denmark Hill, London SE5 9RS, UK Dr Duncan F. Ettles Hull Royal In®rmary, Anlaby Road, Hull HU3 2JZ, UK Professor Vincent Falanga Department of Dermatology and Skin Surgery, Roger Williams Medical Center, Elmhurst Building, 50 Maude Street, Providence, RI 02908, USA Mr John Fletton Plymouth School of Podiatry, North Road West, Plymouth PL1 5BY, UK Professor Robert G. Frykberg 3200 Grand Avenue, Des Moines, IA 50312, USA Dr Roger Gadsby Redroofs Surgery, 31 Coton Road, Nuneaton CV11 5TW, UK Professor Larry B. Harkless University of Texas Medical School, Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78284- 7776, USA Mr Patrick Laing Wrexham Maelor Hospital, Wrexham, Clwyd LL13 7TD, UK Dr Stuart Larner Manchester Royal In®rmary, Oxford Road, Manchester M13 9WL, UK Dr Mariam Majid NHS Centre for Reviews and Dissemination, University of York, York YO10 5DQ, UK Dr Kevin G. Mercer Yorkshire Surgical Rotation Department of Vascular and Endovascular Surgery, St James Hospital, Beckett Street, Leeds LS9 7TF, UK Dr Anthony A. Nicholson Hull Royal In®rmary, Anlaby Road, Hull HU3 2JZ, UK Dr Susan O'Meara NHS Centre for Reviews and Dissemination, University of York, York YO10 5DG, UK x Contributors Dr Thomas P. San Giovanni Harvard Medical School, Boston Children's Hospital, Boston, MA, USA Dr Trevor Sheldon York Health Policy Group, Institute for Research in Social Sciences, University of York, York YO10 5DQ, UK Dr Maximilian Spraul Heinrich-Heine-Universitat Dusseldorf, Klinik fur Stoff- wechsel und Ernahrung, Moorenstrasse 5, D-40225 Dusseldorf, Germany Dr Stephen Thomas Biosurgical Research Unit, Surgical Material Testing Laboratory, Princess of Wales Hospital, Bridgend, UK Dr Jan S. Ulbrecht The Center for Locomotion Studies, Pennsylvania State Diabetes Foot Clinics, Pennsylvania State University, University Park, PA 16802, USA Professor John E. Tooke Department of Diabetes & Vascular Medicine, University of Exeter, Barrack Road, Exeter EX2 5DW, UK Dr Ernest Van Ross Withington Hospital and Manchester Royal In®rmary, Oxford Road, Manchester M13 9WL, UK Dr Loretta Vileikyte Department of Medicine, M7 Records, Manchester Royal In®rmary, Oxford Road, Manchester M13 9WL, UK Professor John D. Ward 68 Dore Road, Shef®eld S17 3NE, UK Dr Grace Warren Westmead Hospital, Sydney, New South Wales, Australia Professor D. Rhys Williams Division of Public Health, Nuf®eld Institute for Health, 71±75 Clarendon Road, Leeds LS2 9PL, UK Dr Matthew J. Young Department of Diabetes, Royal In®rmary of Edinburgh, Lauriston Place, Edinburgh EH3 9YW, UK Contributors xi Preface There can be little doubt that foot lesions and amputation represent the most important of all the long-term problems of diabetes medically, socially and economically. The risk of developing foot ulceration, which can be regarded as the end-stage complication of neuropathy and vascular disease, is much greater than that of reaching the end-stage sequelae of retinopathy and nephropathy. There have been encouraging developments in the last six years since the publication of the second edition. The International Consensus Group on the diabetic foot was founded and has already produced published guidelines on the diagnosis and management of diabetic foot problems. In 1998, the foot study group of the European Association for the Study of Diabetes was founded, and has its ®rst main meeting prior to the Jerusalem EASD congress in 2000. In the area of treatment, we now have the ®rst speci®c therapies for foot ulceration (e.g., topically applied growth factors). It is therefore clear that interest, both clinical and research, in the diabetic foot is increasing, a fact con®rmed by the large number of presentations on the topic of the diabetic foot at international diabetes meetings, and also by the increasing popularity of meetings such as the Malvern Diabetic Foot Conference and the International Conference on the Diabetic Foot. However, there is always the danger of complacency, and the fact that the diabetic foot remains a major medical problem throughout the world must not be forgotten. There are a number of new additions to this edition, including the logistics of providing a diabetic foot service, a paper on the increasingly recognized importance of psychological and behavioural issues in diabetic foot ulceration, and a chapter devoted to advances in treatment. Finally, remembering that much of what we learned about the management of the neuropathic foot originated from observations made by physicians and surgeons on the insensitive foot in leprosy, we are glad to welcome Dr Grace Warren, AM, FRCS to our team of authors. She provides a unique insight into the insensitive foot in leprosy and how this can be translated to The Foot in Diabetes. Third Edition. Edited by A.J.M. Boulton, H. Connor, P.R. Cavanagh Copyright  2000 John Wiley & Sons, Inc. ISBNs: 0-471-48974-3 (Hardback); 0-470-84639-9 (Electronic) [...]... imipenem-cilistatin 14 8 incidence of diabetic foot 9 11 infection (wet gangrene) 14 3±50, 19 5±7, 279±80, 283±6 mild cellulitis 14 5±6, 14 6 limb-threatening soft-tissue 14 7±9, 14 8 osteomyelitis 14 9 pre-operative assessment 223±4 insulin receptor substrate -1 (IRS -1 ) 17 2 integrated diabetic foot care model (Exeter) 89±92, 90 International Working Group on the Diabetic Foot 323±44 ``Full Working Party'' 325±6... 363 Stainsby-type procedure 269 Staphylococcus aureus 14 3, 14 5, 14 7 methicillin-resistance (MRSA) 14 5, 18 6 streptodornase 18 5 streptokinase 18 5, 208 stump dressing 313 stump pain 314 stump volume, ¯uctuating 319 surgery 360 1 Syme procedure 269, 2 81, 285, 3 01 3, 317 , 360 1 sympathectomy 232±3 syphilis, tertiary 236 syringomyelia 236 radiology 19 3± 211 infection 19 5±7 interventional procedures 203 11 pathogenesis... 0-4 7 1- 4 897 4-3 (Hardback); 0-4 7 0-8 463 9-9 (Electronic) Index Note: Page references in italics refer to Figures; those in bold refer to Tables 2 minute foot examination 44±7, 46 30 second foot examination 43±4, 45 abscess 14 7 amoxicillin 14 6 amoxicillin-clavulanate 14 6, 14 8 ampicillin-sulbactam 14 8 amputation 279±306 determining the level 2 81 function and cosmesis 282 incidence 8, 9, 10 11 , 210 , 363 knee... disarticulation (through-knee amputation) 305, 318 levels of 316 19 morbidity 10 on-going maintenance and follow-up 319 ±20 open 286±7 partial foot 49, 287±98, 316 17 patient assessment and management 311 Pirogoff 360 post-operative management 282±3, 286±7 post-surgical phase 313 14 pre-amputation phase 311 12 prevalence 8±9 psychological assessment 314 16 rates 10 11 ray 288, 2 91 4, 316 rehabilitation after... construction 11 5 18 curriculum 11 5, 11 6 educational aids 11 8 educational process 11 7 practical skills 11 8 programme 11 5 17 staff 99 10 0 369 of surgeons 11 4 endovascular stent insertion 205±8, 207 Escherichia coli 14 7 ethnic variation foot ulceration and 24 prevalence 8 examination 3 31 2 Exeter Integrated Diabetic Foot Project 87±92 impact of model of care 91 2 integrated diabetic foot care model 89± 91, 90... Diabet Res Clin Pract 19 98; 39: 69±74 31 Williams DRR, Anthony P, Young RJ, Tomlinson S Interpreting hospital È admissions data across the Korner divide: the example of diabetes in the North Western Region Diabet Med 19 94; 11 : 16 6±9 32 Edmonds ME Experience in a multidisciplinary diabetic foot clinic In Connor H, Boulton AJM, Ward JD (eds), The Foot in Diabetes, 1st edn Chichester: Wiley, 19 87; 12 1±33 33... of life 12 13 scintigraphy 19 6±7 screening for ``at-risk'' feet 99 Semmes±Weinstein mono®lament 90, 3 41, 347 sensory testing 332, 3 41 2, 347 sexual dysfunction, amputation and 315 Short Form Health Survey Questionnaire 13 signal transducers and activators or transcription (STATs) 17 2 SMADs proteins 17 2 smoking 215 , 2 81 2 sodium hypochlorite 18 5 split-skin grafting 2 31 St Vincent Declaration 19 , 74,... factors (FGFs) 17 0 ¯uoroquinolone 14 8 Folstein (Mini-Mental Score) examination 315 Foot Health Questionnaire (FHQ) 12 3±4 Foot Problems Questionnaire (FPQ) 12 4 foot- care programmes 340 footwear 13 1±40, 335, 359±60 assessment of forces from shoe upper 13 6 in Charcot foot 255, 256 clinical effectiveness 13 5 extra-depth shoe 54±5, 55 failure rate 262 lasts for ``diabetic'' shoes 13 7±8 outlook 13 9±40 peak... 288± 91, 289 doctor±patient relationship 12 5±6 Doppler pressures 220 Doppler waveform analysis 2 21 dressings 15 3±66 adhesive zinc oxide tape vs hydrocolloid dressings 16 0 alginate vs hydrocellular 15 8±9 DMSO vs standard treament 15 9 glycyl-L-histidine-L-lysine±Copper (GHK±Cu) gel 15 9 randomized controlled trials (RCT) 15 4±8 studies 16 1±5 topical phenytoin vs dry occlusive dressing 15 9±60 duplex scanning... Mek (MAPK/Erk) kinase 17 3 metatarsal head prominence 25, 48 metatarsophalangeal joint, ®rst, excision of 296 Index Metformin 202±3 microalbuminuria 24 Mini-Mental Score (Folstein) examination 315 È Monckeberg's medial calci®cation 19 4 È Monckeberg's sclerosis 217 morbidity 4, 12 13 amputations 10 foot ulceration 9 Morton's toe 37 multi-disciplinary specialist team 75, 311 , 311 myocardial infarction 222 . 11 4 of health care providers and carers 11 3 15 of health carers 11 5 limitations of studies 12 2 patient 11 1 18 of primary care physicians 11 3 14 programme construction 11 5 18 curriculum 11 5, 11 6 educational. 215 hypertriglyceridaemia 216 imipenem-cilistatin 14 8 incidence of diabetic foot 9 11 infection (wet gangrene) 14 3±50, 19 5±7, 279±80, 283±6 mild cellulitis 14 5±6, 14 6 limb-threatening soft-tissue 14 7±9, 14 8 osteomyelitis. (FGFs) 17 0 ¯uoroquinolone 14 8 Folstein (Mini-Mental Score) examination 315 Foot Health Questionnaire (FHQ) 12 3±4 Foot Problems Questionnaire (FPQ) 12 4 foot- care programmes 340 footwear 13 1±40,