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• Diabetic lower-limb problems result in significant social, medical and economic consequences and are the most common cause of hospitalisation for people with diabetes.
  
• In people with diabetes, amputations are 15 times more common than in people without diabetes, and 50% of all amputations occur in people with diabetes.
  
• Peripheral neuropathy, vascular disease, infection and deformity of the feet are the major predisposing factors leading to ulceration or amputation.
  
• All people with diabetes should receive basic footcare education, and regular foot examinations.
  
• The risk for the development of ulceration can be assessed by basic clinical examination of the foot.
  
• Management strategies depend on the risk category, and range from basic education and annual review to specialist care by a multidisciplinary team.

Accurate Australian figures are not available, but a recent estimate of the national incidence of lower-limb amputation is about 2800 per annum.⁶ Amputation rates vary around Australia, with rates in north Queensland being twice that of the rest of the State.⁷ Amputation of one limb increases the risk of loss of the second limb and is associated with a 50% five-year mortality.⁸ In Australia, in 1994, the hospitalisation cost for a diabetic foot ulcer was $12 474, and outpatient treatment of an ulcer by a specialist footcare team was 85% less.⁹ The direct costs of an amputation in the United Kingdom in 1996 were $27 600 for a major amputation and $6900 for a minor amputation,¹⁰ and are estimated to be similar in Australia.

Peripheral neuropathy, which affects about 30% of people with either type 1 or type 2 diabetes, is the major predisposing disorder for diabetic foot disease. Peripheral neuropathy in feet results in loss of sensation and autonomic dysfunction. Neuropathy can occur either alone (neuropathic feet) or in combination with peripheral vascular disease causing ischaemia (neuro-ischaemic feet). Purely ischaemic feet are unusual, but are managed in the same way as neuro-ischaemic feet.¹³ Infection often complicates neuropathy and ischaemia, and may result in considerable damage to the feet.

Foot deformity includes claw or hammer toes, which commonly result from neuropathy, hallux valgus or varus, prominent metatarsal heads (due to subluxation), and Charcot arthropathy. Callosities which form at pressure areas on the plantar surface of the feet can break down through repetitive shearing forces, resulting in a subkeratotic haematoma and ulceration. Infection can then supervene, most commonly with staphylococci, streptococci and anaerobic organisms. Osteomyelitis may occur in deep infections.

Adequate blood supply is essential for healing of a foot ulcer; insufficient blood flow may contribute to prolonged non-healing of an ulcer. Foot ischaemia (usually in combination with neuropathy) is a major factor leading to amputation. However, severe ischaemia alone can cause ulceration on the margins of the foot and may result in gangrene, and ultimately amputation.

An acutely hot, red foot should always raise the suspicion of underlying infection, but in the absence of a break in the skin may represent an "acute Charcot fracture" precipitated by minimal trauma. Initial radiographic examination may be normal, but bone scans reveal new bone formation typical of early Charcot arthropathy. Disorganisation of joints and fragmentation of bones in the foot can follow, leading to a chronic deformity, referred to descriptively as the "Charcot rocker bottom foot", with subsequent pressure-induced plantar ulceration (Box 1).

The neuropathic foot is typically warm, numb, dry and usually painless. Although simple testing of touch, pain, temperature, vibration sense and ankle jerks can be done in the traditional ways, vibration sense can be assessed more quantitatively with a biothesiometer. The presence of protective sensation can be determined by use of the much cheaper Semmes-Weinstein monofilament.¹⁴ The 5.07 monofilament delivers 10 g pressure and is recommended for identifying "at risk" feet as those which fail to register the pressure at one or more testing sites on the plantar surface (Box 3).^15,16

The ischaemic foot is often cold, with absent pulses and atrophic skin and dystrophic nails, although clinical signs may be quite subtle. Intermittent claudication is not always present as a symptom in diabetic people with ischaemia.

Inspection of "at risk" feet is necessary at each visit. Foot-care education of people with diabetes increases podiatry attendance and reduces subsequent foot lesions,¹⁹ including amputation. Instructions should include adequate daily moisturising (eg, emulsifying ointment), avoidance of detergents and prolonged washing, and wearing well-fitted shoes at all times.

Regular podiatry care should provide treatment of foot conditions like callus, corns, ingrown toe-nails and protection of pressure areas (eg, by orthotics) and advice on suitable footwear. The Australasian Podiatry Council, in conjunction with Diabetes Australia, has produced Australian Podiatric Guidelines for Diabetes outlining standards of care for the increasing and important role of the podiatrist in the care of people with diabetes.²⁰ Structured education is an established component of diabetes care and specific footcare education should be provided to all people with diabetes until the person can demonstrate and describe footcare practices.^21-23 A recent review has confirmed the short term benefits of education interventions.²⁴

If a diabetic foot ulcer develops, it may need debridement, appropriate treatment of infection and relief of weight bearing, sometimes by plaster cast or bed rest. If healing is slow despite these measures, vascular assessment is necessary, even in the absence of symptoms of vascular insufficiency. People with disabling intermittent claudication or rest pain require urgent vascular assessment.

Initial investigation for peripheral arterial disease includes doppler studies and measurement of ankle brachial pressure. Angiography can be used to assess the site and extent of vascular blockage and angioplasty or by-pass surgery can improve vascular perfusion. This may allow a non-healing ulcer to heal. In the Charcot foot, after initial immobilisation, lifelong protection of the pressure areas is necessary to prevent ulceration and specialised reconstructive surgery may be needed.²⁵

A number of systematic reviews have identified evidence to support effective interventions.^7,27 "The International Consensus on the Diabetic Foot with Practical Guidelines" was published in 1999²⁸ and, in Australia, evidence-based guidelines for general practitioners regarding management of the diabetic foot will soon be submitted to the National Health and Medical Research Council (NHMRC) for national endorsement. The New South Wales Health Department has published Clinical Management Guidelines for the treatment of diabetic foot ulcers.²⁹

The National Diabetes Strategy and Implementation Plan has successfully piloted two programs: one for community-based health service providers, including general practitioners, and one for specialist care of active diabetic foot problems.

The Australian Diabetes Society recommendations for reducing diabetic foot disease are shown in Box 4.

1. Young MJ, Veves A, Boulton AJM. The diabetic foot: aetiopathogensis and management. Diabetes Metab Rev 1993; 9: 109-127.
2. Most RS, Sinnock P. The epidemiology of lower limb extremity amputations in diabetic individuals. Diabetes Care 1983; 6: 87-91.
3. Trautner C, Haastert B, Giani G, Berger M. Incidence of lower limb amputations and diabetes. Diabetes Care 1996; 19: 1006-1009.
4. Morris AD, McAlpine R, Steinke D, et al, for the DARTS/MEMO Collaboration. Diabetes and lower-limb amputations in the community: a retrospective cohort study. Diabetes Care 1998; 21: 738-743.
5. Reiber GE. Epidemiology of the diabetic foot. In: Levin ME, O'Neal LW, Bowker JH, editors. The diabetic foot. 5th ed. St Louis: Mosby Year Book, 1993; 1-5.
6. Colagiuri S, Colagiuri R, Ward J. National Diabetes Strategy and Implementation Plan. Canberra: Diabetes Australia, 1998.
7. Couzos S, Metcalf S, Murray R, O'Rourke S, for the Kimberley Aboriginal Medical Services Council. Systematic review of existing evidence and primary care guidelines on the management of diabetes in Aboriginal and Torres Strait Islander populations. Canberra: Commonwealth Department of Health and Family Services, Office for Aboriginal and Torres Strait Islander Health Services, 1997.
8. Apelqvist J, Larsson J, Agardh C-D. Long term prognosis for diabetic patients with foot ulcers. J Intern Med 1993; 233: 485-491.
9. Connor H. The St Vincent amputation target: the cost of achieving it and the cost of failure. Pract Diabetes Int 1997; 14: 152-153.
10. Hoskins P. Cost-effectiveness analysis of the treatment of diabetes. In: Baba S, Kanedo T, editors. Diabetes 1994. Oxford: Elsevier Sciences BV, 1995; 985-989.
11. Reiber GE, Pecoraro RE, Koepsell TD. Risk factors for amputation in patients with diabetes mellitus. Ann Intern Med 1992; 117: 97-102.
12. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation --basis for prevention. Diabetes Care 1990; 13: 513-521.
13. Edmonds M, Boulton A, Buckenham T, et al. Report of the Diabetic Foot and Amputation Group. Diabet Med 1996; 13: S27-42.
14. Kumar S, Fernando DJS, Veves A, et al. Semmes-Weinstein monofilaments: a simple, effective and inexpensive screening device for identifying diabetic patients at high risk for lower-extremity amputation in a primary health care setting. Diabetes Care 1992; 115: 1386-1389.
15. Kumar S, Fernando DJS, Veves A, et al. Semmes Weinstein monofilaments: a simple effective and inexpensive screening device for identifying patients at risk of foot ulceration. Diabetes Res Clin Pract 1991; 13: 63-68.
16. McGill M, Molyneaux L, Spencer R, et al. Possible sources of discrepancies in the use of the Semmes-Weinstein monofilament. Diabetes Care 1999; 22: 598-602.
17. Edmonds ME, Blundell MP, Morris ME, et al. Improved survival of the diabetic foot: the role of a specialised foot clinic. QJM 1986; 232: 763-771.
18. Larsson J, Apelqvist J, Agardh C-D, Stenstrom A. Decreasing incidence of major amputation in diabetic patients: a consequence of a multidisciplinary foot care team approach? Diabet Med 1995; 12: 770-776.
19. Barth R, Campbell LV, Allen S, et al. Intensive approach to education improves knowledge, compliance and foot problems in Type 2 diabetes. Diabet Med 1991; 8: 111-117.
20. Australian Podiatric Guidelines for Diabetes. 2nd ed. Australasian Podiatry Council and Diabetes Australia, 1997.
21. Thomson FJ, Masson EA. Can elderly diabetic patients cooperate with routine foot care? Age Ageing 1992; 21: 333-337.
22. Davidson, JK, Alogna M, Goldsmith M, Borden J. Assessment of program effectiveness at the Grady Memorial Hospital-Atlanta. In: Steiner G, Lawrence PA, editors. Educating Diabetic Patients. New York: Springer Verlag, 1981; 329-348.
23. Foot Care in Patients with Diabetes Mellitus. American Diabetes Association. Diabetes Care 1998; 20: S1: 531-532.
24. Mason J, O'Keefe C, McIntosh A, et al. A systematic review of foot ulcer in patients with Type 2 diabetes mellitus. 1: prevention. Diabet Med 1999; 16: 801-812.
25. Caputo GM, Cavanagh PR, Ulbrecht JS, et al. Assessment and management of foot disease in patients with diabetes. N Engl J Med 1994; 13: 854-860.
26. Krans HH, Perta M, Keen K, editors. Eurodiabcare. Diabetes Care and Research in Europe. The St Vincent Declaration action programme. Copenhagen: WHO, 1992.
27. Scottish Intercollegiate Guidelines Network. Diabetic Foot Disease. Edinburgh: SIGN, 1997.
28. The international consensus on the diabetic foot and practical guidelines on the management and the prevention of the diabetic foot. Amsterdam: International Working Group on the Diabetic Foot, 1999.
29. Lower limb ulcers in diabetes: a practical approach to diagnosis and management. Sydney: NSW Health, 1998.

This position statement has been prepared by a multidisciplinary committee of the Australian Diabetes Society as a brief summary for healthcare professionals of the common problems which may affect the lower limb in diabetes, and the principles of management of these problems. It makes recommendations for reducing diabetic limb ulceration and amputation in the Australian community, as well as outlining activities already in progress.

Liverpool Hospital, Sydney, NSW.
Rosalind M Kidd, DPodM, Chief Podiatrist.
Edgecliff, Sydney, NSW.
Hugh F Molloy, DDM, FACD, Dermatologist.
Diabetes Centre, Cairns, QLD.
Sharon R O'Rourke, FAFPHM, Public Health Physician.

Prince of Wales Hospital, Sydney, NSW.
Stephen Colagiuri, FRACP, Director, Diabetes Centre.

Reprints will not be available from the authors.
Correspondence: A/Prof L V Campbell, c/- Diabetes Centre, St Vincent's Hospital
372 Victoria Street, Darlinghurst, NSW 2010.
l.campbellATgarvan.unsw.edu.au

©MJA 2000
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