Moderator: I’m happy to present a longtime friend Nick Bevilacqua who is a local Jersey boy, I am a Jersey boy from way back but I left years ago. Nick is a local Jersey boy and I always liked to have bring Nick on, he is very busy, practices here in Teaneck area and he has a great deal of experience in diabetic foot problems. He did a fellowship after his residency in New York City. He did a fellowship back at the Shull school on diabetic lower extremity and limb salvage so I've asked Dr. Bevilacqua to talk on examining the Diabetic Foot, Look, Feel and Listen. So let's welcome Dr. Bevilacqua.

Dr. Bevilacqua: Good morning. Thanks again for the invitation I can always enjoy listening to Dr. Freiberg speak and listen to him talk about the diabetic foot all day but it's also a little frightening when you sort of see the statistics and understand the magnitude of this disease, but I do think as a podiatrist this is sort of where we can make the greatest impact in terms of that multidisciplinary approach and just in the hospital system. So nothing to disclose for this talk learning objectives are published earlier.

So just sort to continue continuing on from what Dr. Freiberg said using the Rothman model for that component cause and sufficient cause, and he talked about Rodger Becquerel's [phonetic] [0:01:32] work in looking at the component causes that lead to amputation. Well this talk is going to focus on the diabetic foot ulceration or the risk assessment so we’ll go to Gayle Reiber’s work where she looked at those seven component causes and found that critical triad of neuropathy, deformity and trauma.

And you are going to see throughout this talk I'm just going to emphasize the critical triad neuropathy, deformity and trauma and we are going to go over each one because as was mentioned you know there is opportunity to sort of intervene and if we can remove one of these component causes we can theoretically lower the risk of developing a foot ulceration which would thereby lower the risk of amputation and some of the other complications that we see.

So when these three factors are put together, the three have that sufficient cause which in this case is going to lead to an ulceration. So we’ll start off with this simple statement, position yourself well enough and circumstances will do the rest so how do we prevent these? Just as Dr. Freiberg mentioned first you have to understand the cause of these complications. When we know what we were looking for it's easier to intervene and prevent complications so we don't end up kind of getting hit in the face like this guy, let’s see if this video plays. There we go.

So we heard a lot about neuropathy and everything you read about the diabetic foot whether it’s risk factors for an ulceration, risk factors for amputation, diabetic foot surgery, risk factors for complications, neuropathy is always a key component so it's important to understand that. And again sensory, motor, autonomic has how does this affect us.

So the title of this silde – Look, Feel, Listen, you know you guys once you get out into practice it's hopefully you are going to be very busy, limited time so you have to use your time efficiently so when you're evaluating these patients obviously the first thing you are doing is you're looking and you looking for signs of that motor neuropathy, do they have foot deformity, the intrinsic minus foot with that capsular tendon imbalance that causes hammer toes and pressure points, autonomic neuropathy, visualize the skin, feel the skin, look for any signs and symptoms of that. But again one of the most important is the sensory neuropathy and it's not so much the diagnosis of peripheral neuropathy, it's really understanding if these patients are at risk if they have the loss of protective sensation.

So how do we evaluate this in the office, this simple exam the Semmes-Weinstein Monofilament. It's an excellent screening tool to determine if they have loss of protective sensation and again it’s not used for the diagnosis of neuropathy but we are just understanding if these patients are at risk. It’s the 5.07-10 gram monofilament wire, you know different reports at least six pressure points sometimes 10 usually you just make contact you get a little bend in that wire, I’ll have the patients close their eyes, I’ll palpate on the forefoot, on the mid-foot heel, sometimes dorsally in that first interspace and seeing if they feel it. If they do not feel one or greater to me they have loss of protective sensation. You know other things that we can do vibratory perception threshold, this is great.

Not everybody in practice is going to have one of these expensive machines you can use a tuning fork or just another sort of modality that we can use to help us determine if they do have peripheral neuropathy whether at risk. So the second component cause deformity again we saw a slide earlier so any foot condition that predisposes a person to increased pressure so this could be an obvious deformity bunions, hammer toes, Charcot foot or sometimes it could be a little bit less obvious.

We are going to think about limited joint mobility as a deformity, limited joint mobility two common things Hallux Rigidus so patients have you know typically most of the studies look at less than 50 degrees dorsiflexion at the first metatarsophalangeal joint so they have limited dorsiflexion when they ambulate that’s going to increase the pressure plantar medial aspect of the Hallux and that’s often cause of ulceration there.

Also equinus we have to evaluate these patients and measure ankle dorsiflexion and if they're not getting pass neutral live they have equinus and that's going to have detrimental effects increasing the plantar pressures of the forefoot. So clinically when these patients come in, of course you know we talked about neuropathy you are visualizing the patient, you are doing your neuropathic or you are ruling out neuropathy now we are looking at deformity so of course you are going to inspect it, look for any obvious deformity.

Like I said sometimes it's not so obvious, put your hands on the patient, feel for any bony prominences and you are going assess for range of motion. You know I talked about first metatarsophalangeal or equinus just do the ankle, the hindfoot, midtarsal, you know just do a good clinical exam. Radiograph the old diabetic patients, if they are new patients they are all getting weight-bearing x-ray sometimes just to use as a baseline but oftentimes you are using that to further evaluate any sort of deformity.

Advanced imaging here I have a question mark. If patient comes in and it’s sort of the diabetic risk for assessment visit I am trying to prioritize these patients and put them in a classification scheme to determine you know what type of care they’ll need moving forward. Oftentimes I'm not going on to any advanced modality usually reserving MRI CT scans. You know there was a patient that have diabetic foot ulcers, possibly complicated Charcot or infection and we are using it more to evaluate extent of infection or further workup for surgery but not so much for that initial risk assessment exam.

So it stands to reason that you know the greater number of deformities that increase in peak plantar pressures and we will see that that's combined that with the neuropathy that's the sufficient cause for ulceration. And you can see just a simple still shot of that pressure mat that spike underneath the fifth metatarsophalangeal joint of the patient and that correlates to exactly his side of skin breakdown.

So just another case showing, this is a patient with actually very, very severe equinus deformity and you can see from the x-ray is actually a weight-bearing lateral with the equines, it has got some mid-foot breakdown there, just a nice sort of dynamic pressure analysis watching him walk, he gets that spike in pressure so initially it looks like it's the heel but it's actually his heel doesn’t even contact the grounds without increasing pressures beneath his mid-foot there. And you can see that's where he breaks down.

So of course you know having this type of equipment makes for a nice fancy slide for a presentation but in reality in the office we don't have these you know, dynamic pressure analysis so that’s where the clinical exam sort of takes over. So the third that we’ll talk about is trauma and again as Dr. Friberg mentioned trauma could just be walking, it’s just that repetitive stress of walking but oftentimes it's ill fitting shoes. So if – you know I just did a quick search on ill fitting shoes and I got a little chuckle.

You know you’d be surprised with these patients try to fit themselves into even in summertime with the sandals so definitely if they have neuropathy and they're wearing these ill fitting shoes they have a deformity, there's pressure they are going to develop skin breakdown. So how do we use this information? So we understand the essential sort of component causes of the factors that we are looking at that lead to ulceration but then how do we kind of use that information to prioritize risk that's usually what I do.

So if a patient comes in I'm thinking sort of like you know how am I going to stratify this patient to a certain risk group so I can prioritize their care, do they need to be seen once a year, every six months, every three months and what type of care do they need moving forward. So this is one of the earlier classifications out of Texas and it looked at sort of, you could see the top two – the two rows risk factors for ulcer, risk factors for amputation below. So we are going to look at the risk factors for ulceration.

They divided patients into three groups: category zero patients without neuropathy and these patients as you can see here this classification scheme is validated so they looked you know a K-series and they found that category zero patients as sort of like you have controlled or at no increased risk for diabetic foot ulceration.

Category one patients with neuropathy without deformity, so these patients are about 1.7 times risk for developing a foot ulceration. Category two here neuropathy with a deformity and you can see here as we move towards category three with history of an ulceration the risk, the odds ratio goes up that develop an ulcer. So the international working group on the diabetic foot very, very similar classification but category two you can see the big difference is that they included peripheral arterial disease and we’ll go into that in a bit more detail because obviously from the previous talk you see the importance of peripheral arterial disease and we haven't discussed that yet.

And as we increase category we increase risk and you know this is continually sort of looked at and modified and then [indiscernible] [0:11:27] and colleagues with the International Workgroup on the Diabetic Foot you know they sort of reevaluated their classification scheme because they felt that it underestimated or undervalued the importance of peripheral arterial disease and even previous history of an amputation so they looked at that second group.

It’s little bit of a busy chart there but if you just look at the different groups; group two was divided into 2A and 2B so 2B was just patients that had peripheral arterial disease by itself and then the subdividing Group 3, previous history of an ulcer and previous history of an amputation, just so they can selectively look at the importance of just peripheral artery disease and then history of an amputation.

You can see here even if you go all the way to the opposite side of the slide hospital admissions and you look at group 3B amputation history were 600 times more likely to be admitted into the hospital. So it's sort of emphasizes the importance of peripheral arterial disease and history of a previous amputation as well. So when we think about PAD again going back Look, Feel, Listen, clinical exam, history and physical we have to first understand the risk factors and as we know diabetes is one of the most important risk factors for peripheral arterial disease.

Patients come to the office first and foremost history and physicals we are going to ask patients if they have any symptoms related to it, you know again if they have neuropathy they may not have the classic intermittent claudication or even rest pain for critical limb ischemia but it's important to sort of probe these patients. The skin just visualizing a patient sitting down, do they have atrophic skin changes, simple, simple thing I always look for distal hair growth, do they have hair growing on the toes, it's like one of my first sort of markers of concern if they don't have it, I will see your palpating pulses Dorsalis Pedis, Posterior Tib, femoral pulse.

And then for me noninvasive vascular studies, so again typically if it’s -- and we’ll sort of recommendations for this but patients with diabetes greater than 50 years old ABI they have previous history of you know foot ulceration or vascular intervention obviously you don’t have to wait till they are 50.

But typically it's Doppler ultrasound so I work in two different hospitals one here in Holy Name which is like couple of miles down the road and the Englewood Hospital, so you are dealing with you know vascular group one is more interventional radiology and I'll send them there to the vascular lab typically you know, noninvasive vascular studies for me Doppler ABIs you know toe pressure segmental PVRs important also but you know, I am using those mostly when patients either have a nonhealing wound or they are possibly you know were contemplating surgical intervention that’s where we really get like the T-coms and the skin perfusion.

So ABI probably the most important just as a screening test and we know normal value is above 0.9 but just be careful when the values are potentially falsely elevated from calcified vessels and it has a very high sensitivity. Invasive vascular studies, you know those are I am sort of relying on the vascular specialist for this [indiscernible] [0:14:59] the noninvasive vascular studies interpret this, talk with the vascular whether it's an interventional radiologist or a vascular surgeon and they're the ones that are usually can move forward and order the MRA or the angiogram.

So this was you know recently published joint publication with the APMA and the society of vascular surgeons and I just included this for two reasons, one just to show that the diabetic foot is going away it's still a hot topic and as I mentioned it’s a joint publication with society of vascular surgeons and you know this is sort of our I guess sort of disease process that we are able to kind of make the greatest impact so it's important really be a specialist in this field.

Summary of their recommendations, we talked about obviously their recommendation first and foremost number one, annual for inspections, for that additional risk assessment visit and then also you want to always look for peripheral neuropathy. [indiscernible] [0:16:01] peripheral arterial disease and diabetic foot ulceration recommendations, you can see recommendation one ABI for anyone over 50, as I mentioned before unless they have had previous ulceration of vascular intervention then you are going to go on ABI then some of those more specialized either toe systolic pressures TCP or tears et cetera.

Alright, so I’ll just finish off quickly with how we sort of take some of these, some of the information even apply to managing a diabetic foot ulceration so ideally we don't get to this point. Ideally we can intervene if they have a deformity we can recognize it, we can either brace it we can put them in a offloading type of shoe to prevent skin breakdown or we could even consider diabetic foot surgery but now when a patient has an ulceration, you know I always go back again I always just try to take a step back try to simplify it and I go back to Larry Harkless VIPs Vascular Infection Pressure.

So vascular we want to make sure they have adequate perfusion and we talked about some of the noninvasive vascular studies that we can do. Infection, we are going to hear about later today, most importantly you have to recognize if there is an infection and then obviously you want to treat it. And then just going to spend the last few minutes just talking about pressure reduction whether externally or internally.

So extrinsically we know a lot about different offloading modalities that we have it can range from bed rest all the way to a shoe, doesn't mean that a shoe is the optimal device but you can see these have all been used to offload. We want to find the best device that’s going to keep these patients active and walking so we don’t want them to sit in bed for 12 weeks to get the wound to heal. And you know all of these devices have been studied in the lab sort of on pressure mats and also you know in clinical practice looking at healing rates.

Just sort of a consensus statement, total contact cast you know usually is recognized as the gold standard, recently PJZ publishing [indiscernible] [0:18:13] go international, I believe it was last year looking at CAM-Boots sort of being just is recognized as the gold standard because oftentimes total contact cast, again busy practice you may not have the time, you may not have the staff and if it is not put on correctly it can sometimes do more harm than good.

So that's when we think about the CAM-Boot the removable walking boot and you can render that your irremovable by wrapping Coban on it. And I’ll just finish off with you know Dr. Freiberg mentioned diabetic foot surgery so if we go back to the critical triad and we think about deformity, neuropathy and trauma sometimes you know patient has neuropathy, we can't reverse that unfortunately so that component causes there to stay. They have trauma they are going to walk ideally so really the one component cause that we can have I think a biggest sort of impact is reducing the deformity or eliminating the deformity because really it's not so much healing the wound that's most important.

I mean if you put these patients in a total contact cast or in a wheelchair and they don't walk they are going to heal but the problem is once they get back ambulating in their shoe they are going to breakdown because they still have the deformity, they still have neuropathy and they are still going to walk.

So when we think about diabetic foot surgery and this has been divided up into different classes: Elective; these are patients that basically have intact sensation so it’s considered an elective procedure and they are at no increased risk for post-op complications. Prophylactic, these are patients that have neuropathy and a deformity so essentially if we can eliminate that deformity we are taking out you know a piece of a that pie so if you go back to Rothman sufficient cause, if we remove the deformity we can theoretically lower them in sort of that risk category. And this is just a simple example bunion hammertoe, they have neuropathy, they are wearing shoes, they get the callous over the dorsal aspect of the PIP J of the second toe, sometimes they get the retrograde pressure beneath the metatarsal head.

Turn to foot surgery, patients have an ulcer so when performing the procedure to help augment healing but again most I think important for me is preventing also occurrence because we know the highest recurrence rate with total contact cast. This has been validated as well so as we go up in class, obviously, we are going up in complications, infection, amputation and ulceration.

So in summary when examining the diabetic foot it's important to sort of know what you're looking for and just go back, you know I try to make it simple even though it's probably the furthest thing from simple. Critical triad, neuropathy, deformity, trauma and then when managing the diabetic foot simplify VIPs, does the patient have adequate blood flow, start with the clinical exam then move towards noninvasive vascular studies. is there an infection, you know recognize that treat it accordingly. And then pressure could be obvious, maybe not so obvious recognize it, treat it whether offloading modalities or consider diabetic foot surgery. Thanks.