Podiatrist Play a Big role in Diabetes Amputation Prevention:
Despite being one of the most serious and costly complications of diabetes, foot complications can be effectively prevented. By implementing a care strategy that combines prevention, the multidisciplinary treatment of foot ulcers, appropriate organization, close monitoring, and education of people with diabetes and healthcare professionals, it is possible to reduce amputation rates by up to 85%.
International Diabetes Federation (IWGDF), 2011
Diabetes doesn't have to equal amputation!
Every time I meet a new patient that has just been diagnosed with diabetes, usually Type 2 non insulin dependent due to the demographic I see, we usually have some type of conversation about limb loss. It seems that all of these people have an uncle, aunt, parent or grandparent that has had an amputation. So when these people are first diagnosed with diabetes their initial fear becomes the "A" word, amputation.
Sometimes doctors are not the best communicators with this type of patient. With the type two diabetics, their should be some type of discussion about weight loss and the contribution their belly fat has to complicating this disease process. I am always happy to discuss this with the patient when this may have been overlooked by their doctor who is trying to make sure that the patient doesn't die of something else.
How I always describe the process of belly fats roll in the Type 2 non-insulin dependent diabetic to a patient so they can grasp what is going on in simple terms is as follows:
1. Your pancreas is working
2. When you eat, your pancreas is producing insulin
3. The insulin gets trapped in the fat cells closest to the pancreas itself
4. Since the fat cells are trapping your insulin, your blood sugars go up
I also explain the process of diabetic neuropathy to the patient, explaining what happens next, as the sugars
are not being met with the insulin.
1. Our body has a mechanism to try to counter the glucose in the absence of insulin
2. The Polyol Pathway kicks in and tries to reduce glucose but produces sorbitol
3. Our bodies are not efficient at clearing this and its other byproducts
4. The sorbitol will attach to the nerve endings and contribute over time to neuropathy symptoms
Why I explain this has a lot to do with my strong belief that if you can get the patient to understand a little they may be able to help themselves. I am sure the patient will not go home and tell their family all about the Polyol Pathway and sorbitol. But they might just think about it, internalize it and try to help themselves.
When I have the uncomfortable conversation about their belly fat, I discuss the benefits of a simple 10 minute walk a day to start. For some of these people, what comes along with the Type 2 diabetes and belly fat is aching joints and feet. So exercise sometimes needs to be creative. In Florida we have the advantage of almost year round pool usage which is great. I encourage patients to walk in the pool or swim, giving less trauma to their already aching joints and feet. They need to start somewhere and a little will go a long way in the beginning. What the patient is really trying to do here is decrease their amount of insulin resistance. Exercise will help and hopefully help them loose the belly fat.
Diabetes does not have to equal amputation
This again is a topic that becomes paramount for the newly diagnosed Type 2 and Type 1 Diabetic patients. The stigma of limb loss with diabetes is unavoidable. But is has been documented throughout the literature, complications of diabetes to the foot and lower limb can be avoided with good preventive care. Like most anything, at home prevention and patient mind set play an important role in patient outcomes.
I tell all of my newly diagnosed diabetic patients, that the patients that I wind up having to amputate a toe or part of their foot on are usually consults from the hospital, not current or past established patients. The normal scenario is a patient that come through the emergency department of the hospital and gets admitted for a foul smelling wound. The patient may have blood sugars that are regularly in the 300s and does not check their feet on a daily basis. These two things alone are a recipe for disaster and I always stress that to my patients.
Compliance plays a huge role in whether someone I meet as a patient for the first time will actually go on to limb loss. Obviously, if they are admitted with and infection that is so severe that the bone is infected and tissue is destroyed, they have already sealed their fate for potential limb loss. But if the patient can follow instructions and work on improving their blood sugars and be compliant with wound care, they have a chance.
Top 4 reasons wounds do not heal
I preface this with the following, If a patient has any of the following 4 issues, it does not mean that the
pressure, lack of blood supply, infection and smoking.
wound will not heal, as I will explain below. But having any of the following 4 as an issue and not making steps to change the situation will surely complicate the patients situation. So the top 4 reasons wounds do not heal are:
Pressure, I always start with pressure. Since many of our diabetic patients with wounds have neuropathy, I explain this one first. It only takes about 4 minutes of pressure for tissue necrosis and death to start to occur. What that means is that when you are standing on an area that is callused or has an open pressure wound, after about 4 minutes we are starting the process to do further harm. For the callus patient that can mean damaging the skin underneath the callus. This can lead to a wound underneath the callus. For the patient with an open wound this can lead to the wound getting bigger and deeper. When a patient is checking their feet daily, they are more likely to notice and take care of these problems before they become bigger issues. If they already have an established relationship with a foot doctor they can get in to the office be seen and treated. Treatment for wounds caused by pressure revolve around offloading, an external means to remove pressure off the area. We do this with padding, special shoes and special casting when needed.
Lack of blood flow I define as not being able to palpate pedal pulses in the office or a decrease or stenosis of blood flow that is not supplying enough blood to the foot. Many of my diabetic patients I see for preventive foot care have this condition to their extremities but they have no open wound so it becomes less of an issue for them. We focus at that point on prevention. When someone walks in with an open wound and no palpable pulses the game changes. This is the patient that needs a referral to a vascular surgeon before I can help them. I never waste the patients precious time in this scenario. If I can't feel their pulses and they have an open wound, I am sending them to the best vascular surgeons I know. They need blood to heal simple as that.
Infection is another area of the wound that must be assessed. If there is a simple infection sometimes just an
antibiotic will do the job. Often, though, many of these types of infections have a more significant effect on the soft tissue. These wounds requiring multiple debridements to cut away dead tissue from the wound that
the infection has killed. Theses are the patients that are typically admitted to the hospital, placed on IV antibiotics and have multiple trips to the operating room. Until all of the infection is cleared it is impossible for the wound to heal. Once we are certain that the wound is free of infection we can close the wound if there is enough soft tissue, if not we use many different wound care modalities to aid in the closure of their wound.
Smoking is the final topic I speak with my diabetic patients about to decrease their risk of complications. Simply I state to my patients that they need to STOP SMOKING if they want to keep their limbs. The damage that smoking does to the arteries, soft tissue and skin can make the difference between losing a limb or keeping it.
Dead horse but prevention is key
This a topic I literally try and beat into my patients. I want patients to know that most of the terrible infections and amputation I perform are not in the compliant patient. The amputation rate in my practice for established diabetic patients, that were not seen for the first time in the emergency room or hospital, is very close to 0%. My established patients, that are seen for regular diabetic foot check ups do not end up getting amputations. We catch problems on these visits so that problems do not progress to a point where they get out of hand.
Below are my very generic but very effective tips on preventing foot problems when you are diabetic. I encourage patients to follow these guidelines and feel free to share them with friends or family members that also may benefit from this advice. And I always my patients it is always better to be safe than sorry.
What can I do to better take care of my feet?
There are many steps you can take to greatly reduce the chance of major injury to your feet.
- Visually check your feet and toes daily for any cuts, sores, blisters, bruises, bumps, infections, or nail problems, EVERYDAY.
- Wash your feet daily using warm water and mild soap. Check the water temperature with your wrist to make sure it isn't too hot, and do not soak your feet for long periods or at all.
- If you have dry skin, cover your feet — except between your toes — with petroleum jelly or cold cream before putting on shoes and socks.
- Wear thick, soft, and loose-fitting socks and shoes that fit well and allow your toes to move. Rotate your shoes and do not wear new shoes for more than a few hours at a time.
- Watch out for a thick seam in a sock, it can help cause ulcers on the tops or tips of the toes.
- Cut your toenails straight across and don't leave sharp edges that could cut the next toe, they are too difficult to cut yourself or you have neuropathy or peripheral vascular disease, see a podiatrist.
- Never go barefoot on the beach or anywhere else.
- Have your feet checked at every doctor visit.
- Do not sit with your legs crossed. Crossed legs can cut circulation to the feet.
- Do not use tobacco products. Smoking impairs circulation.
- check out more of our tips at: http://centeranklefootcare.com/id7.html
Diabetic foot by the numbers:
- Every 20 seconds a lower leg is lost due to diabetes globally
- A majority of these amputations are preceded by ulcers
- Only two-thirds of ulcers will eventually heal and the remainder may result in some form of amputation
- Median time of healing for an ulcer is approximately six months
- Each year, some 3.8 million adults die from diabetes-related cause
- Diabetes is the fourth leading cause of death by disease globally
- In 2011 it is estimated that 366 million people worldwide have diabetes
- The number is expected to reach some 552 million by 2030
Ref: International Diabetes Federation (IWGDF), 2011 and American Diabetes Association, 2012
2010 United States Census
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If you have just left your doctors office and they have told you that surgery is your best option for your foot deformity, you may want to read this and listen to our latest podcast above first before going through with the surgery. Now full disclosure Dr. Henne and myself are Board Certified in foot surgery and perform surgery weekly. That being said we will be the first people to try and talk you out of having unnecessary surgery. More importantly we make sure you fully understand the post operative course (how bad it really is). We never SUGAR COAT anything.
Hammer toes are a very similar situation to bunions as far as a guide to when to fix and when to just wear a more suitable shoe for your foot type. The hammer toe that is most common is the 2nd metatarsal joint(joint at the base of the 2nd toe) hammer toe. People often come in and complain of a contracted toe that rubs on shoe gear on the top of the toe. After a thorough examination, if they have no pain but just the nuisance of shoes that they want to wear not fitting right, I tell them to get new shoes. I explain that the pain they will have after surgery and the aesthetic result they want to have may not line up to what they expect in their mind. There are many instances where people have hammer toe surgery and their toe is still kind of deformed looking and much stiffer than they would have expected. My criteria, which if you are contemplating foot surgery please read closely, no pain in the toe means shoe gear adjustment and using gel sleeves to protect the toe with activity in enclosed shoes. If there is real pain in the toe and the joint that is unable to be treated with conservative care, then we consider surgical intervention. I tell all of my surgical hammer toe patients, "You may never be able to wear heels again, and all shoes will not be able to fit just because your toe was fixed." I always explain the end result is functionality when you have foot surgery not beauty. 
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