Avoid Amputation: Manage the Diabetic Foot

India is home to the second highest number of people living with diabetes in the world, after China. Today there are over 45 million people grappling with the disease, and the numbers show no signs of reducing. Amongst other health hazards, diabetes often leads to peripheral vascular disease, involving both the macro and micro circulation. Statistics reveal that 15% of all those living with the disease will develop foot problems related to diabetes, and may suffer from various deformities of the toes and feet, commonly called ‘diabetic foot conditions’. These can develop from a combination of causes including neuropathy (nerve damage) and/or poor blood supply to the foot, which creates areas of raised pressures in the soles of the feet, where ulcers develop. These ulcers act as portals for the entry for bacteria leading to serious infections, which in the already immune compromised patients can result in amputations or even death.

Diabetic Neuropathy can cause insensitivity or a loss of ability to feel pain, heat, and cold. This makes matters worse for those suffering from neuropathy as they can develop minor cuts, scrapes, blisters, or pressure sores that they may not even be aware of. If left untreated, these minor injuries can lead to serious limb and life threatening infections. Extensive epidemiological surveys have indicated that between 40% and 70% of all lower extremity amputations are related to diabetes. This means that every 30 seconds a lower limb is lost to diabetes. In India, an estimated 50,000 amputations occur per year due to diabetes related foot problems. A vast majority (85%) of these diabetes-related amputations are preceded by foot ulcers.

Inadequate sanitation, improper foot offloading due to lack of facilities/awareness are fairly common in our country. Rat and insect bites; thermal injuries due to hot fomentation; injuries due to improper footwear; and inter digital fungal infections cause diabetic foot injuries in India, which can become limb and life threatening. In a study conducted at the Amrita Institute of Medical Sciences and Research Centre (AIMS), Kochi it was found that invasive fungal infections accounted for about 29% of diabetic lower limb infections.

When walking even with the best of prosthesis, there is 50% mortality in 3 years after Above Knee Amputation and in 5 years after Below Knee Amputation. This happens because diabetes is a disease of the blood vessels. It thus affects all organs. By the time the blood supply to the foot has been compromised due to peripheral obstructive vascular disease, the heart is also involved. Even with the best of prosthesis the cardiac strain is increased to over 15%, leading to cardiac failure over a period of time, which is the reason of the high mortality rates on using Below Knee or Above Knee prosthesis. Added to this is the damage to all soft tissues of the patient’s body by changes of ‘Non Enzymatic Glycation’ which leads to loss of elasticity of the foot muscles, tendons, ligaments, splinting of joints, limited joint mobility, foot and toe abnormalities, increased plantar pressures, increased propensity for callosities, ulcerations and limb and life threatening infections. Non enzymatic glycation also affects the structure and functions of the white blood cells, leading to suppression of cell mediated immunity.

Dr Ajit Kumar Varma, Professor, Department of Endocrinology, diabetic lower limb and Podiatric Surgery, at AIMS, said in an exclusive interview to Citizen News Service (CNS) that, “Preventing feet complications is more critical for those living with peripheral obstructive vascular disease. However, in selected patients with foot wounds, revascularization techniques, including peripheral angioplasties, bypass surgeries and negative pressure wound therapy can be carried out to improve wound healing. Footwear and orthotics play an important role in diabetic foot care. To reduce the chances of onset of foot complications, wearing the right footwear is crucial as improper footwear contributes significantly to ulceration.”

The concept of surgical reconstruction for destroyed and deformed diabetic foot and ankle has recently evolved as a means to correct foot deformities secondary to long standing diabetes. By employing these novel surgical techniques, a large number of amputations in patients with diabetic foot ulcers and deformed diabetic foot can be prevented. This includes Charcot reconstructive surgeries of the hind-foot, mid-foot and fore-foot. ‘Charcot Foot’ is a severe complication of diabetes, which leads to erosions, and collapse of the foot and ankle bones, which in turn lead to marked deformities and ulcerations. Different types of surgical corrections are carried out so as to normalize the shape and function of these grossly deformed feet.

Dr Varma informs that, “These reconstructive surgeries are performed routinely in high-risk diabetic foot patients at AIMS, which is one of the few institutes where an integrated team approach, so important in the proper management of the diabetic lower limb problems, is available. We have close support of the vascular surgery, and interventional radiology departments, for revascularisation procedures. To avoid the serious complications of pin tract infections, wire breakage and others associated with the application of Illizarov frames and other types of external fixators in patients with the diabetic foot, we have devised a novel technique of foot and ankle stabilization-- ‘The Amrita Sling Technique.’ By comprehensive management, we have been able to maintain a limb salvage rate of 91.5%, in diabetic foot and ankle diseases, comparable to the best centres in the world.”

The Amrita Endocrinology, Diabetes and Diabetic Foot Conference (AEDFC 2012) which is being held from 14th to 16th September 2012, at the Amrita Institute of Medical Sciences Kochi, purports to deliberate upon newer treatment of peripheral vascular disease in diabetes and diabetic foot diseases, and the latest techniques in the management of Charcot Foot and reconstructive foot surgery.

Significant reductions in amputations can be achieved by well-organized diabetic foot care teams, good diabetes control and well-informed self-care. There is need for organized diabetic foot screening programs and a multi-disciplinary team approach of podiatric services to be made available in more hospitals across India.

Shobha Shukla is the Managing Editor of Citizen News Service (CNS). She is a J2J Fellow of National Press Foundation (NPF) USA. She has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also authored a book on childhood TB (2012), co-authored a book (translated in three languages) "Voices from the field on childhood pneumonia" and a report on Hepatitis C and HIV treatment access issues in 2011. www.citizen-news.org

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