The Diabetic Foot

Aziz Nather

• Publisher: WSPC
• Year: 2012
• ISBN:
  9789814417020
• Topic: Medizin
• Subtopic: Innere Medizin & Diagnose

This book provides a comprehensive guide for all healthcare professionals managing diabetic foot problems including general practitioners, nurses, podiatrists, orthopaedic surgeons, vascular surgeons and endocrinologists. It is also written in an easy to read fashion so that patients and caregivers will also find it useful.

It covers a wide range of topics on the Diabetic Foot starting with an Introductory Section on “Overview of Diabetes”. Topics include ‘What is Diabetes?’, ‘Complications of Diabetes’ and ‘Management of Diabetes’. The section on “Basic Science of Diabetic Foot” covers Anatomy, Biomechanics and Pathogenesis: the Diabetes Foot Triad of Neuropathy, Vasculopathy and Immunopathy. Other Sections include Classification, Clinical Presentation and Treatment.

A highlight of the book is the large “Guide to Operative Surgery” section. This section covers Major Amputations, Minor Amputation and other Diabetic Foot Surgeries. The latter details Surgical Debridement and Split Skin Grafting — two of the commonest operations performed. This operative manual is also useful to residents and registrars.

The section on Wound Care has also been carefully assembled to meet the needs of nurses, podiatrists and general practitioners, performing day to day dressing of diabetic wounds. It focuses on the use of New Generation Dressings including Silver and Iodine Dressings and Advances in Wound Healing. Patients and Care-givers will also find this useful.

The last section “A Patient's Guide” is especially written to benefit patients and care-givers. It includes ‘Care of Diabetes’, ‘Care of the Foot’, ‘Choosing your own Footwear’, ‘Doing your own Dressing’ and ‘Rehabilitating your Below Knee Amputation’.

Finally, the Appendix includes details of the formation of NUH Diabetic Foot Team, Asia Pacific Association of Diabetic Limb Problems and the ASEAN Plus Expert Group Forum on the Management of Diabetic Foot Wounds.

Contents:

• Overview of Diabetes:
  • Diabetes and Its Complications: A Global Problem (Aziz Nather, April Voon Siew Lian and Joanna Chan Wei Ying)
  • What is Diabetes? (Sharlene Ho, Quah Yan Ling and Aziz Nather)
  • Complications of Diabetes Mellitus (Quah Yan Ling, Sharlene Ho, Ruth Chen Wei Xian and Aziz Nather)
  • Management of Diabetes Mellitus (Aziz Nather, Sharlene Ho and Quah Yan Ling)
• Basic Science of Diabetic Foot:
  • Anatomy of the Foot (Aziz Nather, Amaris Lim Shu Min and Zameer Aziz)
  • Biomechanics of the Foot (Aziz Nather, Amaris Lim Shu Min and Johan Steenkamp)
  • Pathogenesis (Aziz Nather and Amaris Lim Shu Min)
  • Basic Science of Wound Healing (Teo Zhen Ling, Aziz Nather and Hey Hwee Weng Dennis)
• Classification:
  • Classification Systems (April Voon Siew Lian and Aziz Nather)
  • Foot At Risk (Aziz Nather and April Voon Siew Lian)
• Clinical Presentation:
  • Types of Clinical Presentation (Aziz Nather and Amaris Lim Shu Min)
  • Clinical Examination of a Diabetic Foot Problem (Aziz Nather and Amy Pannapat Chanyarungrojn)
  • Foot Screening (Aziz Nather and April Voon Siew Lian)
  • Investigations (Aziz Nather and Amy Pannapat Chanyarungrojn)
  • Charcot Joint Disease (Aziz Nather and Amaris Lim Shu Min)
  • Necrotising Fasciitis (Aziz Nather and Amy Pannapat Chanyarungrojn)
• Treatment of Diabetic Foot:
  • Value of a Team Approach in Managing Diabetic Foot Problems (Chin Yu Xuan and Aziz Nather)
  • Role of Revascularization in Management of Diabetic Foot Problems (Jackie Ho Pei)
  • Antibiotics for Diabetic Foot Infections (Hey Hwee Weng Dennis and Aziz Nather)
  • Role of Chinese Medicine in Managing Diabetic Foot Ulcers (Ping-Chung Leung)
  • Reducing the Pain of Diabetic Neuropathy: What Works (Mary Suma Cardosa)
• Guide to Operative Surgery:
  • Major Amputations in Diabetics (Aziz Nather, Gurpal Singh, Amy Pannapat Chanyarungrojn and Andrew Horg Choon Chiet)
  • Minor Amputations (Aziz Nather, Gurpal Singh, Teo Zhen Ling and Francis Wong Keng Lin)
  • Other Diabetic Foot Surgery (Aziz Nather, April Voon Siew Lian, Amy Pannapat Chanyarungrojn, Lim Chin Tat and Andrew Hong Choon Chiet)
• Wound Care:
  • Assessment of Diabetic Wounds (Aziz Nather and Teo Zhen Ling)
  • Types of Dressings for Diabetic Foot Ulcers (Tiffany Tsao)
  • New Generation Dressings (Aziz Nather and Chris Lee Choon Wei)
  • Advances in Wound Management (Aziz Nather and Teo Zhen Ling)
  • Wound Products for Diabetic Foot Problems (Geoff Sussman)
• Footwear:
  • Diabetic Footwear (Aziz Nather and Gurpal Singh)
  • What is in the Market at the Moment? A Look at the Industry (Adam Jorgensen)
• A Patient's Guide:
  • Caring for Your Diabetes (Teo Zhen Ling, Chin Yu Xuan and Aziz Nather)
  • Care of Your Foot (Lynn Li Toh)
  • Choosing Your Own Footwear (Jun Morimoto)
  • Footwear for Diabetic Foot (Harikrishna K R Nair)
  • Doing Your Own Dressings (Yuen Fun Alexis Lai and Aziz Nather)
  • Rehabilitating Your Below Knee Amputation (Lim Kean Seng Andrew and Aziz Nather)
• Appendices:
  • NUH Diabetic Foot Team (Aziz Nather)
  • Publications by NUH Diabetic Foot Team
  • APADLP
  • ASEAN Plus Expert Group Forum on Management of Diabetic Foot Wounds

Readership: Endocrinologists, orthopedic surgeons, podiatrists, infectious disease consults, nurse educators, specialized wound care nurses, foot screen nurses, counselors, rehabilitation professionals, dietitians, vascular surgeons and skin cover surgeons. Patients and caregivers dealing with the management of Diabetes Foot Problems, undergraduate medical students and postgraduate students.

Section 1

Overview of Diabetes

1

Diabetes and Its Complications: A Global Problem

Aziz Nather, April Voon Siew Lian and Joanna Chan Wei Ying

Department of Orthopaedic Surgery
Yong Loo Lin School of Medicine
National University of Singapore

Diabetes

Diabetes currently affects 366 million people worldwide or 8.3% of the world's adult population (Fig. 1). This figure is expected to increase to 9.9% by 2030 (Fig. 2, Table 1), owing to environmental factors such as sedentary lifestyles and changing dietary patterns.¹ Now the fourth leading cause of death in most developed countries, diabetes has been considered the “global epidemic of the 21^st century”.

Singapore has one of the highest prevalence of diabetes in the developed world. 11.3% of residents aged between 18 and 69 years old had diabetes in 2010² (Table 2). It is one of the top ten causes of death locally³ (Table 3).

Complications

Raised blood glucose levels associated with diabetes may damage the heart and blood vessels (cardiovascular disease and peripheral vascular disease), kidneys (nephropathy), eyes (retinopathy) and nerves (neuropathy). Peripheral vascular disease and neuropathy can lead to serious foot problems in diabetic patients.

Figure 1. Prevalence (%) of diabetes (20–79 years) in 2011

Figure 2. Prevalence (%) of diabetes (20–79 years) in 2030

Source: http://www.idf.org/diabetesatlas/5e/diabetes.

Such complications of diabetes can reduce the quality of life of the patient and his family. They may also cause severe disability or death. Every year, approximately 3.8 million adults die from diabetes-related causes.⁴

Table 1. Global prevalence of diabetes (2011 and 2030)

Table 2. Disease burden in Singapore

Table 3. Principal causes of death in Singapore

Ulceration

Foot ulcers are very common among diabetic patients, affecting about 15% of all diabetic patients in developed countries. They are a major cause of amputations. Approximately 85% of all amputations begin with an ulcer.⁵

Amputation

A diabetic patient is up to 40% more likely to receive a lower limb amputation.⁵ Currently, it is estimated that every 20 seconds a lower leg is lost due to diabetes globally.⁴ In Singapore, 700 lower limb amputations are performed annually due to diabetes.⁶

Lower limb amputations often cause mortality in diabetic patients: 70% of them die within five years after an amputation.⁵

Social Impact

Patients with amputation are often unable to work. They have limited mobility and lead a less active social life. Patients with chronic foot ulcers face similar problems. Many are permanently disabled. There is a high incidence of depression. Their quality of life is significantly reduced as a result.⁵

Economic Impact

Diabetic foot complications are a significant economic burden for both the patient and society. This is due to the cost of long-term treatment of ulcers, hospitalisation and surgery, rehabilitation and the increased need for home care and social services.

3–4% of all diabetics have a foot problem and use 12–15% of the healthcare resources. The average cost for primary healing in the USA ranges between US$7,000 and US$10,000. The cost of an amputation due to diabetes is estimated to be between US$30,000 and US$60,000. The estimated cost of the diabetic foot in the USA is some US$6 billion a year if one includes the cost to the individual and the loss in quality of life.⁷

Conclusion

Foot complications are one of the most serious and costly complications of diabetes. A good national programme is required for the management of diabetic foot problems. One must employ a two-pronged strategy. The most important strategy is prevention with the use of education programmes for diabetes as well as programs for care of the foot and footwear. This must be directed nation-wide to the whole community. In addition, where we have failed to prevent the complication, such complications must be handled by a multi-disciplinary team in hospitals running a diabetic foot clinic and diabetic foot ward rounds.

In National University Hospital (NUH) in Singapore, the NUH Diabetic Foot Team was able to reduce the below knee amputation rate from 31.15% in 2002 (pre-diabetic foot team formation) to 11.01% in 2007 (post team formation). Efforts are now directed to make sure that all patients diagnosed with diabetes must receive annual foot screening in order to reduce the development of foot complications.⁸

References

1. The Global Burden, Diabetes Atlas, International Diabetes Federation (2011).

2. Disease Burden, Singapore Health Facts, Ministry of Health Singapore (2012).

3. Principal Causes of Death, Singapore Health Facts, Ministry of Health Singapore (2012).

4. Diabetes: The Epidemic of the 21^st Century, International Working Group on the Diabetic Foot (2011).

5. International Diabetes Federation and International Working Group on the Diabetic Foot, Diabetes and Foot Care: Time to Act (International Diabetes Federation, 2005).

6. 2001 Annual Report, Ministry of Health Singapore.

7. 2005 World Diabetes Day on Diabetic Foot Care, International Working Group on the Diabetic Foot (2005).

8. A. Nather, S. B. Chionh, K. L. Wong, X. B. Chan, L. Shen, P. A. Tambyah, A. Jorgensen and A. Nambiar, Value of team approach combined with clinical pathway for diabetic foot problems: a clinical evaluation, Diabet. Foot Ankle 1:5731-5 (2010).

2

What is Diabetes?

Sharlene Ho, Quah Yan Ling and Aziz Nather

Department of Orthopaedic Surgery
Yong Loo Lin School of Medicine
National University of Singapore

Definition

Diabetes mellitus is a chronic disease, which occurs when the pancreas does not produce enough insulin, or when the body cannot effectively use the insulin it produces. This leads to an increased concentration of glucose in the blood (hyperglycaemia) (World Health Organisation).

Understanding blood glucose and insulin

After a meal, a portion of food a person eats is digested in the intestine (Fig. 1) into glucose, which is then absorbed into the bloodstream. Some of it will be taken up by cells to...