Monday, 1 May 2017

Dandenong Hospital team improving outcomes for patients with diabetic foot complications

Associate Professor Parm Naidoo and Professor Tim Buckenham
A unique multidisciplinary team of specialists at Dandenong Hospital is successfully managing a common but not often discussed complication associated with diabetes.

People with diabetes are at a much higher risk of developing atherosclerosis (narrowing and blockages in the arteries of the legs and feet)—and poor blood flow results in delayed healing of minor injuries and ulcers.   

According to Monash University’s Associate Professor Parm Naidoo, being diabetic also means these patients are relatively immunocompromised and thus susceptible to infection. 

“Even minor injuries can result in ulcerations in their feet, leading to deep soft tissue infection, bone infection, gangrene and amputations,” said Associate Professor Parm Naidoo, an Interventional Radiologist and Director of Radiology, Dandenong Hospital, Monash Health.

“Patients with longstanding and/or poorly controlled diabetes are at risk of chronic irreversible damage to the small nerves of the feet (peripheral neuropathy), and are prone to injuries without feeling or realizing it, which in some instances triggers a cascade of inflammatory events resulting in severe and permanent damage to the bones of the foot, known as Charcot’s osteoneuropathy.”

Weekly diabetic foot clinic meeting at Dandenong
The high risk diabetic foot clinic at Dandenong Hospital brings together
subspecialist radiologists, vascular surgeons, podiatrists, infectious disease physicians, endocrinologists, nurses and ultrasonographers to manage these complex and often difficult cases.

Associate Professor Naidoo, who chairs the weekly meeting, said up to 15% of people with diabetes develop a foot ulcer at some point, and left untreated, has the potential to lead to serious complications including amputation.

“These complications of diabetes in the feet can be devastating for these patients. Early diagnosis, intervention and management not only saves limbs but significantly improves quality of life,” said Associate Professor Naidoo.
“Our weekly interdisciplinary meetings started about five years ago, and we discuss around ten to fifteen cases at each sitting.”

“Our aim is to accurately diagnose these patients as early as possible, and to quickly intervene with the highest level of care,” said Associate Professor Naidoo.

“Aggressive treatment is the key to minimising complications and long term morbidity.”

Associate Professor Naidoo said there are huge resultant dollar savings to the health networks in terms of reduced length of inpatient stay and major surgical interventions. 

“Our unique case management saves patients taking time off work to attend multiple appointments, and being assessed by multiple specialists or allied health care providers, which is often spread out over months.”

Professor Tim Buckenham, specialist Vascular and Interventional Radiologist and Head of Vascular Imaging at Monash Health said the clinical leads at the weekly meetings are the podiatrists at Dandenong Hospital, as they are the primary care givers of these patients.

“We have the highest level expertise in the same room, so between the podiatrists, vascular surgeons, diagnostic and interventional radiologists, and other staff, we make a treatment decision about a patient in about ten minutes, rather than two months of consultations with individual specialists,” said Professor Buckenham.

A treatment plan for each patient is decided and activated at the meeting. Treatments include specialised dressings, antibiotics, debridement, orthotics, pressure off-loading and casting of the affected limb.

“Having an adequate blood supply to the affected limb is crucial to the ‘healing process’, and increasingly, these diseased arteries are being treated using minimally-invasive techniques, with excellent results,” said Professor Buckenham.

“We have significant expertise at Dandenong Hospital in treating these types of arteries—these are delicate procedures and the skill level of our interventional radiologists, led by Professor Buckenham, and surgeons is excellent because we are collegial, collaborative and perform so many of these procedures,” said Associate Professor Naidoo.

“While our work is certainly not glamorous, we know we’re providing the best model of care and the best possible outcomes for this very vulnerable patient group.”

Borne out of his experience chairing the high risk diabetic foot meeting at Dandenong hospital and research into this topic, Associate Professor Naidoo has published several articles on the imaging of these disease processes, with an emphasis on the role of MRI in early detection and characterisation of abnormalities in the diabetic foot. Associate Professor Naidoo and his colleagues have published the largest and most up-to-date review paper on the Radiology of the complications of diabetes in the feet (British Journal of Radiology, 2015), and was subsequently invited to lecture on the topic at the world’s largest annual MRI meeting (the International Society of Magnetic Resonance in Medicine, in Honolulu last month, as well as at the Global Foot and Ankle Congress in Chongqing, China in May.

The Diabetic Foot Clinic at Dandenong Hospital is the biggest clinic of its type in Victoria, managing more than 140 patients, including in and out patients.

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