Description
Book SynopsisFully revised and updated edition of this popular book, addressing all issues concerning the diabetic foot, one of the most prevalent problems in diabetes, with a strong emphasis on practical aspects of delivering care.
Table of ContentsList 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
