The Foot in DiabetesPennsylvania State University, USA JOHN WILEY & SONS, LTD Chichester.New York.Weinheim.Brisbane.Singapore.Toronto The Foot in Diabetes.. Armstrong 9 EducationÐCan It
Trang 1The 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)
Trang 2The Foot in Diabetes
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)
Trang 3Copyright & 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
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Trang 42 The Size of the Problem: Epidemiological and Economic
Aspects of Foot Problems in Diabetes 3Rhys Williams and Mark Airey
3 The Pathway to Ulceration: Aetiopathogenesis 19Andrew J M Boulton
4 What the Practising Physician Should Know about Diabetic
Peter R Cavanagh, Jan S Ulbrecht and Gregory M Caputo
5 Classi®cation of Ulcers and Its Relevance to Management 61Matthew J Young
6 Providing a Diabetes Foot Care Service
(a) Barriers to Implementation 73Mary Burden
(b) Establishing a Podiatry Service 81David 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)
Trang 5(c) The Exeter Integrated Diabetic Foot Project 87Molly Donohoe, John Fletton and John E Tooke
7 The Diabetic Foot in Primary Care: A UK Perspective 95Roger Gadsby
8 Podiatry and the Diabetic Foot: An American Perspective 105Larry B Harkless and David G Armstrong
9 EducationÐCan It Prevent Diabetic Foot Ulcers and
Maximilian Spraul
10 Psychological and Behavioural Issues in Diabetic
Neuropathic Foot Ulceration 121Loretta Vileikyte
11 Footwear for the High-risk Patient 131Ernst Chantelau
12 The Rational use of Antimicrobial Agents in Diabetic Foot
Gregory M Caputo
13 Use of Dressings: Is there an Evidence Base? 153Nicky Cullum, Mariam Majid, Susan O'Meara and Trevor Sheldon
14 New Treatments for Diabetic Foot Ulcers
Trang 615 The Role of Radiology in the Assessment and Treatment of
John F Dyet, Duncan F Ettles and Anthony A Nicholson
16 Peripheral Vascular Disease and Vascular Reconstruction 215Kevin G Mercer and David C Berridge
17 Charcot Foot: An Update on Pathogenesis and Management 235Robert G Frykberg
18 Prophylactic Orthopaedic SurgeryÐIs There A Role? 261Patrick Laing
19 Amputations in Diabetes Mellitus: Toes to Above Knee 279John H Bowker and Thomas P San Giovanni
20 Rehabilitation after Amputation 309Ernest Van Ross and Stuart Larner
21 The International Consensus and Practical Guidelines on
Trang 7Dr C Mark Airey Division of Public Health, Nuf®eld Institute for Health, 71±
75 Clarendon Road, Leeds LS29PL, UK
Dr David G Armstrong University of Texas Medical School, Health ScienceCenter 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, StJames's University Hospital, Beckett Street, Leeds LS9 7TF, UK
Professor Andrew J M Boulton Department of Medicine, Manchester RoyalIn®rmary, Oxford Road, Manchester M13 9WL, UK
Professor John H Bowker Jackson Memorial Rehabilitation Center, 1611 NW12th Avenue, Suite 303, Miami, FL 33136, USA
Mrs Mary Burden Research and Development Diabetes Care, Leicester GeneralHospital, Gwendolen Road, Leicester LE5 4PW, UK
Dr Gregory M Caputo The Center for Locomotion Studies, Pennsylvania StateDiabetes 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 undErnahrung, 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)
Trang 8Mr 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 HealthStudies, University of York, York YO10 5DQ, UK
Dr Molly Donohoe Department of Diabetes & Vascular Medicine, University
of Exeter, Barrack Road, Exeter EX25DW, 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, UKProfessor Vincent Falanga Department of Dermatology and Skin Surgery,Roger Williams Medical Center, Elmhurst Building, 50 Maude Street, Providence,
Mr Patrick Laing Wrexham Maelor Hospital, Wrexham, Clwyd LL13 7TD, UK
Dr Stuart Larner Manchester Royal In®rmary, Oxford Road, ManchesterM13 9WL, UK
Dr Mariam Majid NHS Centre for Reviews and Dissemination, University ofYork, York YO10 5DQ, UK
Dr Kevin G Mercer Yorkshire Surgical Rotation Department of Vascular andEndovascular Surgery, St James Hospital, Beckett Street, Leeds LS9 7TF, UK
Dr Anthony A Nicholson Hull Royal In®rmary, Anlaby Road, HullHU3 2JZ, UK
Dr Susan O'Meara NHS Centre for Reviews and Dissemination, University ofYork, York YO10 5DG, UK
Trang 9Dr Thomas P San Giovanni Harvard Medical School, Boston Children'sHospital, Boston, MA, USA
Dr Trevor Sheldon York Health Policy Group, Institute for Research in SocialSciences, University of York, York YO10 5DQ, UK
Dr Maximilian Spraul Heinrich-Heine-Universitat Dusseldorf, Klinik fur wechsel und Ernahrung, Moorenstrasse 5, D-40225 Dusseldorf, Germany
Stoff-Dr Stephen Thomas Biosurgical Research Unit, Surgical Material TestingLaboratory, Princess of Wales Hospital, Bridgend, UK
Dr Jan S Ulbrecht The Center for Locomotion Studies, Pennsylvania StateDiabetes 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 EX25DW, 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 RoyalIn®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, AustraliaProfessor D Rhys Williams Division of Public Health, Nuf®eld Institute forHealth, 71±75 Clarendon Road, Leeds LS29PL, UK
Dr Matthew J Young Department of Diabetes, Royal In®rmary of Edinburgh,Lauriston Place, Edinburgh EH3 9YW, UK
Contributors xi
Trang 10There can be little doubt that foot lesions and amputation represent themost important of all the long-term problems of diabetes medically, sociallyand economically The risk of developing foot ulceration, which can beregarded as the end-stage complication of neuropathy and vascular disease,
is much greater than that of reaching the end-stage sequelae of retinopathyand nephropathy There have been encouraging developments in the lastsix years since the publication of the second edition The InternationalConsensus Group on the diabetic foot was founded and has alreadyproduced published guidelines on the diagnosis and management ofdiabetic foot problems In 1998, the foot study group of the EuropeanAssociation for the Study of Diabetes was founded, and has its ®rst mainmeeting prior to the Jerusalem EASD congress in 2000 In the area oftreatment, we now have the ®rst speci®c therapies for foot ulceration (e.g.,topically applied growth factors) It is therefore clear that interest, bothclinical and research, in the diabetic foot is increasing, a fact con®rmed bythe large number of presentations on the topic of the diabetic foot atinternational diabetes meetings, and also by the increasing popularity ofmeetings such as the Malvern Diabetic Foot Conference and theInternational Conference on the Diabetic Foot However, there is alwaysthe danger of complacency, and the fact that the diabetic foot remains amajor medical problem throughout the world must not be forgotten.There are a number of new additions to this edition, including thelogistics of providing a diabetic foot service, a paper on the increasinglyrecognized importance of psychological and behavioural issues in diabeticfoot ulceration, and a chapter devoted to advances in treatment Finally,remembering that much of what we learned about the management of theneuropathic foot originated from observations made by physicians andsurgeons on the insensitive foot in leprosy, we are glad to welcome
Dr Grace Warren, AM, FRCS to our team of authors She provides a uniqueinsight 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)
Trang 11better the future for our patients with diabetic foot problems The questionnow is how these advances can be translated to routine clinical practice inevery hospital and healthcare district: it is with this question that our bookcontinues to be primarily concerned.
Trang 12Note: 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
determining the level 281
function and cosmesis 282
transtibial (below-knee) 304±5,317±18
wound healing 281±2see also disarticulation; Symeprocedure
angiography 202±3ankle brachial pressure index (ABPI)
63, 217, 220, 263ankle neuro-arthropathy 240, 241ankle pressures, healing and 220antibiotics 143±50
for cellulitis 147±8, 148atherosclerosis see peripheral vasculardisease
``at-risk'' foot, recognition of 96±8Bacteroides fragilis 147
balloon angioplasty (PTA) 203±5, 205,206
barefoot walking 36, 38, 40, 41, 43becaplermin 175±6
Beck Inventory 314beta-lactam 148biomechanics 33±57mechanisms for elevated pressure36±43
behavioural factors 43extrinsic factors 39intrinsic factors 37±9neuropathy and high pressure 34±6primary prevention
30 second foot examination 43±4,45
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)
Trang 13biomechanics (cont.)
primary prevention (cont.)
2 minute foot examination 44±7, 46
action based on ``at-risk''
examination 47
stress and stress concentration 34
treating a plantar ulcer 47±52
bunion see hallux valgus
calcaneal insuf®ciency avulsion (CIA)
Chopart's joint 248, 251, 315cipro¯oxacin 148
classi®cation, ulcer 61±71based on aetiology 63±4based on foot ulcer descriptioncategories 67
based on foot ulcer risk categories 68based on infection 64±5
based on size and extent 63based on ulcer location 62improving 68±9
non-healing 66systems 66±7value 69±70clawed toes 25, 37, 48, 268±9
in leprosy 347±8clindamycin 148Clostridium dif®cile 143colour duplex sonography (CDS) 221contrast angiography 221±2
cost see economic burdencounter-transference 314±15critical limb ischaemia, chronic 201cytomegalovirus (CMV) 180debridement, ulcer 51surgical 263±5debriding agents 185deformity 25, 97denial 123, 124±6Dermagraft 179±82diabetic control 223diabetic foot care service 73±85barriers to implementing 75±8care vs working practices 77cultural 75
funding 75integration 78managerial 75±7Exeter Integrated Diabetic FootProject 87±92
perception of service providers 78±9philosophy for 73±4
quality of care 79diabetic osteopathy 194±5dicloxacillin 148
Trang 14ethnic variationfoot ulceration and 24prevalence 8
examination 331±2Exeter Integrated Diabetic Foot Project87±92
impact of model of care 91±2integrated diabetic foot care model89±91, 90
®broblast growth factors (FGFs) 170
¯uoroquinolone 148Folstein (Mini-Mental Score)examination 315Foot Health Questionnaire (FHQ)123±4
Foot Problems Questionnaire (FPQ)124
foot-care programmes 340footwear 131±40, 335, 359±60assessment of forces from shoe upper136
in Charcot foot 255, 256clinical effectiveness 135extra-depth shoe 54±5, 55failure rate 262
lasts for ``diabetic'' shoes 137±8outlook 139±40
peak pressure distribution and 39plantar pressure reduction 132±4for planar ulcer 47±52
toe box area 54, 55, 268toe-caps in 136, 137weight relieving window 270, 271for wound healing 50±1
footwear pyramid 53, 53forefoot arthroplasty 266±8, 267free tissue transfer 231±2Gaenslen's incision 271±2, 272
Trang 15in human acute wounds 173
in human chronic wounds 173±5
Health Belief Schema 312
Health Beliefs Questionnaire 126±7
hepatitis viruses 180
herpes simplex virus (HSV) 180
high-risk vs low-risk foot 131, 133
incidence of diabetic foot 9±11
infection (wet gangrene) 143±50, 195±7,
insulin receptor substrate-1 (IRS-1) 172
integrated diabetic foot care model
ischaemic heart disease 222Janus factors (JAKs) 172keto-acidosis 223knee disarticulation (through-kneeamputation) 305, 318larval therapy 185±90
¯ies used in 187history 185±7method of use 188±9mode of action of sterile larvae187±8
leprosy 236
cf diabetes 345±61levo¯oxacin 148limited joint mobility (LJM) 27±8Lisfranc (tarsometatarsal)
disarticulation 298, 299, 31 6Lisfranc's joint 247, 248
Liverpool classi®cation of diabetic footulcers 263
lobster foot 263, 263
``Locus of Control'' measures 315long saphenous vein (LSV), ipsilateral,
as conduit 229loss of protective sensation (LOPS)34±6
Lucilia sericata 187±8maggots see larval therapymagnetic resonance angiography(MRA) 200±1, 200, 222magnetic resonance imaging 197±201MAP kinase kinase (MAPKK) 173MAP pathway 173
matrix-degrading metalloproteinases(MMPs) 170
Meggitt±Wagner classi®cation 62, 63,
64, 66, 70limitations 67Mek (MAPK/Erk) kinase 173metatarsal head prominence 25, 48metatarsophalangeal joint, ®rst, excision
of 296
Trang 16peripheral vascular disease (PVD)215±17
as cause of foot ulceration 20±1clinical presentation 218±19, 218acute 218±19
incidence 9multidisciplinary team and 217±18,217
prevalence 8Peto ®xed effects model 156phantom pain 314
photoplethysmography 220Pirogoff amputation 360plantar pressure
reduction 132±4, 135ulceration and 27plastic surgery 230±2platelet-derived growth factor (PDGF)
169, 170foot ulcers and 175±6pneumatic post-amputation mobility(PPAM) aid 313
podiatry service 81±5access 83±4advanced practice team 84assessment 83
general podiatry team 84guidelines 84±5
specialist team 84structure 82±3training 82±3
in the USA 105±8postural instability, foot ulceration and25
povidone iodine 185Practical Guidelines on diabetic foot,international consensus on 323±44,327±44
funding 326implementation 326prevalence 4±9ethnic variation 8lower extremity amputation 8±9peripheral vascular disease (PVD) 8ulceration 6±8
Trang 17primary care
daily care for persons with
neuropathic limbs 348±50
GP involvement 95±6
guidelines for foot care 102
patient education materials 101±2
referral to specialist care 100±1
to whom to refer 100±1
when to refer 101
screening and intervention in patients
with ``at-risk'' feet 99
second limb (bilateral) 319
for Syme amputation 317
``rocker bottom'' deformity 39, 41, 62,
240, 240Rothman model for causation 25±6scintigraphy 196±7
screening for ``at-risk'' feet 99Semmes±Weinstein mono®lament 90,
341, 347sensory testing 332, 341±2, 347sexual dysfunction, amputation and315
Short Form Health Survey naire 13
Question-signal transducers and activators ortranscription (STATs) 172SMADs proteins 172
smoking 215, 281±2sodium hypochlorite 185split-skin grafting 231
St Vincent Declaration 19, 74, 79, 87, 96,
222, 363Stainsby-type procedure 269Staphylococcus aureus 143, 145, 147methicillin-resistance (MRSA) 145,186
streptodornase 185streptokinase 185, 208stump dressing 313stump pain 314stump volume, ¯uctuating 319surgery 360±1
Syme procedure 269, 281, 285, 301±3,
317, 360±1sympathectomy 232±3syphilis, tertiary 236syringomyelia 236tabes dorsalis 236tarsometatarsal (Lisfranc)disarticulation 298, 299, 31 6temperature perception 353±4Texas classi®cation 68, 70thrombolysis 208±11toe
clawing see clawed toesdisarticulation 269±70, 288±91, 289
Trang 18footwear provision 107±8
in minority populations 107training 105±6
USA primary care 95±6vascular disease, imaging 201±3patterns 203
vascular endothelial growth factor(VEGF) 170
vascular reconstruction 219±20, 224±30choice of conduit 228±9
emergency 224±5infra-inguinal reconstruction 226±8,
227, 229±30planning 225±30, 225plastic surgery 230±2free tissue transfer 231±2split-skin grafting 231pre-operative assessment 222±4surveillance 229
sympathectomy 232±3vibration perception, impaired 6, 97Wagner modi®cation of Symeamputation 317
wilful self-neglect 123windlass mechanism 288Index compiled by Annette Musker