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VOLUME 11 NUMBER 4 • NOVEMBER 2014
CURRENT TOPICS
SA JOURNAL OF DIABETES & VASCULAR DISEASE
The foot attack: where are the defense mechanisms?
STELLA VIG, TALAL ALCHIKHAL, BRIDGET TURNER, ON BEHALF OF DIABETES UK
Correspondence to: Stella Vig
Croydon University Hospital, Croydon, UK
E-mail:
svig@doctors.org.ukTalal Alchikhal
Croydon University Hospital, Croydon, UK
Bridget Turner
Policy and Care Improvement, Diabetes UK, London, UK
Previously published in
Br J Diabetes Vasc Dis
2014;
14
: 72–74
S Afr J Diabetes Vasc Dis
2014;
11
: 160–162
Abstract
There is a need to raise awareness of foot complications and to
decrease amputations in people with diabetes. The cost of care
for these patients is highonce they develop foot complications.
With the correct management, up to 80% of amputations are
preventable, and decisionmakers are acknowledging that they
can play an important role in the prevention and treatment
of foot complications and thereby reduce the amputation
rate. Commissioning high-quality foot-care and auditing
standards of foot management pathways will be beneficial,
as will prompt patient referral to a multidisciplinary foot-care
team. Signposting of these services to patients and carers may
be the most important factor in preventing a minor foot
problem escalating to an amputation.
Keywords:
amputation, ulcers, foot, diabetes
Introduction
In 2001 the Diabetes National Service Framework announced
12 standards for the achievement of high-quality diabetes care,
consequent to which several documents have been published to
assist in the attainment of these standards. The National Diabetes
Support Team guide for the care of the diabetic foot considered
screening, prevention, care pathways and multidisciplinary care
provision to assist in strategic development and implementation to
achieve high-quality care.
1
However the challenge remains.
In addition to healthcare systems improving, patient awareness
(e.g. regular self/carer inspection of feet) can prevent and reduce the
progression of several conditions. Indeed, lack of sensation in the
foot can result in unrecognised injury.
2
Neuropathy is a precipitator of
foot deformity as well as being the underlying cause of about 60%of
foot ulcers. Peripheral vascular disease is a major contributor to 50%
of foot ulcers and is associated with reduced healing and increased
susceptibility to infection leading to gangrene and amputation.
3
The
commissioning of high-quality foot-care and auditing standards
of foot management pathways offer significant benefits, as does
prompt patient referral to a multidisciplinary foot-care team.
4
In 2010–11, the NHS in England spent around £650 million on
diabetic foot ulcers and amputation; this estimate equates to 0.6–
0.7% of its budget.
5
In England > 6 000 major amputations are
carried out each year in patients with diabetes and, if the current
rate continues, the number of amputations will rise to > 7 000
in 2015/16.
6
People with diabetes are more likely to be admitted
to hospital with a foot ulcer than with any other complication of
diabetes. If infection and ischaemia are not addressed promptly,
this may result in a minor or major amputation. Between 2006 and
2011 there has been a 46% increase in amputations.
7
Amputations
and foot ulcers have a huge impact on quality of life and the
mortality rate remains high with up to 80% of people dying within
five years of having an amputation. This is a higher mortality rate
than colon, breast or prostate cancer, compared with which there is
relatively little investment in public awareness and screening.
Foot screening
Feet are examined as part of the diabetes annual review and a
foot risk status assigned.
1
The examination should include a check
for corns, calluses or changes in the shape of the feet as well as
assessment of peripheral nerve function and pulses in the feet
plus advice about foot care, including protection with correctly
fitted footwear. Unfortunately, 15% of people with diabetes are
not getting their annual foot check and there is variation between
regions, ranging from 47–87% and 73–90% of people with type
1 and type 2 diabetes respectively
7
(Fig. 1). Diabetes UK has heard
from patients who have supposedly received their foot check
without being asked to remove their shoes! However the foot
check alone is not enough as there is poor correlation between
screening and amputation rates.
Raising patient awareness
Diabetes increases the risk of amputation 20–30 fold and ampu-
tation rates vary widely from one area to another – in the worst
performing area a person with diabetes is 10 times more likely to
have a major amputation than in the best.
7,8
The foot-care pathway appears to be key to facilitating best
practice. About 15% of patients with diabetes experience serious
foot problems, and foot ulcers lead to about 85% of amputations.
The ideal treatment pathway includes a ‘foot protection team’
and access to a multidisciplinary team within 24 hours of acute
presentation with a foot complication. Surprisingly, more than half
Figure 1.
Patients receiving annual foot checks.
7