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Diagnosis and Management of Diabetic Foot Complications” Is Published by the American Diabetes Association, 2451 Crystal Drive, Arlington, VA 22202

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Diagnosis and Management of Diabetic Foot Complications” Is Published by the American Diabetes Association, 2451 Crystal Drive, Arlington, VA 22202 Diagnosis and 2018 Management of CONTRIBUTING AUTHORS ANDREW J.M. BOULTON, MD, DSC (HON), FACP, FRCP Diabetic Foot Professor of Medicine, University of Manchester, Manchester, U.K., and Visiting Professor of Medicine, University of Miami Miller School of Medicine, Complications Miami, FL DAVID G. ARMSTRONG, DPM, MD, PHD Professor of Surgery, Keck School of Medicine of the University of Southern California and Director, Southwestern Academic Limb Salvage Alliance (SALSA), Los Angeles, CA ROBERT S. KIRSNER, MD, PHD Chairman and Harvey Blank Professor, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL CHRISTOPHER E. ATTINGER, MD Professor of Plastic Surgery, Georgetown University School of Medicine and MedStar Health, Washington, DC LAWRENCE A. LAVERY, DPM, MPH Professor of Plastic Surgery, Orthopaedic Surgery, and Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX BENJAMIN A. LIPSKY, MD, FACP, FIDSA, FRCP (LONDON), FFPM RCPS (GLASG) Green Templeton College, University of Oxford, U.K., and Emeritus Professor of Medicine, University of Washington College of Medicine, Seattle, WA JOSEPH L. MILLS, SR., MD, FACS Reid Professor of Surgery and Chief, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX JOHN S. STEINBERG, DPM, FACFAS Professor of Plastic Surgery, Georgetown University School of Medicine and This publication has been supported by unrestricted educational grants to the MedStar Health, Washington, DC American Diabetes Association from Healogics, Inc., and Organogenesis, Inc. “Diagnosis and Management of Diabetic Foot Complications” is published by the American Diabetes Association, 2451 Crystal Drive, Arlington, VA 22202. Contact: 1-800-DIABETES, professional.diabetes.org. The opinions expressed are those of the authors and do not necessarily reflect those of Healogics, Inc., Organogenesis, Inc., or the American Diabetes Association. The content was developed by the authors and does not represent the policy or position of the American Diabetes Association, any of its boards or committees, or any of its journals or their editors or editorial boards. © 2018 by American Diabetes Association. All rights reserved. None of the contents may be reproduced without the written permission of the American Diabetes Association. Andrew J.M. Boulton, MD, DSc (Hon), FACP, FRCP1,2 Diagnosis and David G. Armstrong, DPM, MD, PhD3,4 Robert S. Kirsner, MD, PhD2 Christopher E. Attinger, MD5,6 Management of Lawrence A. Lavery, DPM, MPH7 Benjamin A. Lipsky, MD, FACP, FIDSA, FRCP (London), FFPM, Diabetic Foot RCPS (Glasg)8,9 Joseph L. Mills, Sr., MD, FACS10 Complications John S. Steinberg, DPM, FACFAS5,6 ABSTRACT | At least half of all amputations occur in people with diabe- tes, most commonly because of an infected diabetic foot ulcer. A thor- ough understanding of the causes and management of diabetic foot ulceration is essential to reducing lower-extremity amputation risk. This compendium elucidates the pathways leading to foot ulcers and enumer- ates multiple contributory risk factors. The authors emphasize the impor- tance of appropriate screening and wound classification and explain when patients should be referred for specialist care, targeted education, or therapeutic shoes or insoles. They provide a comprehensive review of treatment approaches, including devices for foot lesion off-loading and aggressive wound debridement through mechanical, enzymatic, autolytic, biologic, and surgical means. Because infection and peripheral artery disease are key contributors to amputation risk, the authors dis- cuss the diagnosis and management of these conditions in detail. They also review the expanding armamentarium of evidence-based adjunc- tive treatments for foot ulcers, including growth factors, skin substitutes, stem cells, and other biologics. Because Charcot neuroarthropathy is a 1 serious but frequently missed condition in people with diabetic neuropa- University of Manchester, Manchester, U.K. 2University of Miami Miller School of thy, the authors explain the differential diagnosis of the hot, swollen foot Medicine, Miami, FL that is a hallmark of this condition. The article ends with an overview of 3Keck School of Medicine of the University four strategies for maintaining a foot in remission, followed by a brief of Southern California, Los Angeles, CA look at the future of diabetic foot care. 4Southwestern Academic Limb Salvage Alliance (SALSA), Los Angeles, CA 5Georgetown University School of oot problems in diabetes are common and costly, and people Medicine, Washington, DC 6MedStar Health, Washington, DC Fwith diabetes make up about half of all hospital admissions for 7University of Texas Southwestern Medical amputations. In the United Kingdom, people with diabetes account Center, Dallas, TX for more than 40% of hospitalizations for major amputations and 8Green Templeton College, University of Oxford, Oxford, U.K. 73% of emergency room admissions for minor amputations. Because 9University of Washington College of most amputations in diabetes are preceded by foot ulceration, a Medicine, Seattle, WA thorough understanding of the causes and management of ulceration 10Baylor College of Medicine, Houston, TX is essential. Address correspondence to The annual incidence of foot ulcers in diabetes is approximately 2% Andrew J.M. Boulton, in most Western countries, although higher rates have been reported [email protected], in certain populations with diabetes, including Medicare beneficia- and David G. Armstrong, ries (6%) and U.S. veterans (5%) (1). Although the lifetime risk of foot [email protected]. ulcers until recently was generally believed to be 15–25%, recent data suggest that the figure may be as high as 34% (1). It was the famous di- ©2018 by the American Diabetes abetes physician Elliott P. Joslin who, having observed many clinical Association, Inc. cases of diabetic foot disease, re- The Scottish poet Thomas bination of infection, foot ul- marked that “diabetic gangrene Campbell wrote, “Coming events ceration, and peripheral artery is not heaven-sent, but earth- cast their shadows before.” Al- disease (PAD) often results in born.” Thus, foot ulceration is though he was not referring to amputation, additional sections not an inevitable consequence foot ulcers at the time, these cover these pivotal areas of man- of having diabetes; rather, ul- words can usefully be applied to agement. cers develop as a consequence of the breakdown of the diabetic The number of available topi- an interaction between specific foot. Ulcers do not occur spon- cal treatments for foot ulcers has lower-limb pathologies and envi- taneously, but rather as a con- rapidly increased in recent years. ronmental hazards. sequence of a combination of We explore these options in de- This treatise will therefore fo- factors. These contributory fac- tail, including growth factors, cus on the pathways that result in tors are summarized in the next skin substitutes, stem cells, and foot ulcer development, the im- section. This is followed by a dis- other biologics. portance of regular screening to cussion of foot screening to iden- No treatise on the diabetic foot identify members of the at-risk tify individuals who are at risk would be complete without men- population, and multiple aspects of ulceration. We then describe tion of Charcot neuroarthropa- of novel treatment approaches. the importance of wound classi- thy, so our next section is devot- Care of the foot in diabetes often fication systems and answer the ed to the differential diagnosis of falls between specialties, and a questions of when and where to the hot, swollen foot in diabetes. team approach is required. Thus, refer diabetic foot problems. It is increasingly recognized we have assembled a team of It is often stated that what you that foot ulcer recurrence is com- experts in the care of diabetes- take off a foot ulcer is as important mon, occurring in up to 50% of related foot conditions from a as what is placed on the wound. cases, and using the term “in re- variety of specialties, including Therefore, we also include dis- mission” has been deemed more endocrinology; dermatology and cussions of various methods for appropriate than describing an wound healing; infectious dis- off-loading foot lesions and the ulcer as “healed.” Thus, in our eases; and podiatric, plastic, and importance of aggressive wound penultimate section, we describe vascular surgery. debridement. Because the com- methods to maintain a foot in DIABETES Peripheral artery disease Somatic sensory Somatic motor Autonomic neuropathy neuropathy neuropathy Decreased pain, Small-muscle Foot Decreased Altered temperature, and wasting deformities Dry skin sweating blood flow proprioception Increased Distended foot veins: foot pressures Callus “warm feet” FOOT AT RISK Repetitive trauma (e.g., ill-fitting shoes, barefoot gait, or foreign body in shoe) FOOT ULCERS FIGURE 1 Pathways to diabetic foot ulceration. 2 | DIAGNOSIS AND MANAGEMENT OF DIABETIC FOOT COMPLICATIONS remission. A brief look into po- sweating (i.e., dry foot skin, ⊲ Other microvascular compli- tential future developments in increasing the risk of callus cations. Several other condi- the care of the foot in diabetes formation) and, in the absence tions are known to be associ- brings the monograph to a close. of PAD, warm feet due to the ated with an increased risk of We hope this succinct mono- release of vasoconstriction. foot
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