DIABETIC FOOT PROBLEMS

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Diabetes Mellitus and the Foot

Diabetes affects more than 60 million Indians, and is the scourge of mankind today. It affects practically every system of the human body and a patient may have more than one organ involved as a side effect of the disease. Diabetes of long duration is known to affect the heart, kidneys eyes and nerves progressively. What are relatively less known are the harmful effects of diabetes on the foot. Long lasting diabetes with preventable/ treatable complications in the foot, if not cared for appropriately, can lead to loss of limb. Majority of the Indians affected with diabetes mellitus are in the 40-60 age group, where the individual is at the peak of one's career, and has a lot of social responsibilities. Imagine a country that can boast of the largest number of amputees due to diabetes!

Problems in the foot.

The foot is the most used but the most neglected area of the human body. Foot problems in diabetics can arise as a result of degeneration of the nerves, dryness of the skin leading to cracks in heel and toes, distortion of bones causing foot deformities, and blocking of the arteries of the legs.
Degeneration of the nerves leads to either numbness or increased sensitivity. Symptoms of these are burning, prickling sensation or feeling of pins and needles in the feet. Sometimes, the hands can also be affected by these nerve disturbances. The involvement of the feet can be unequal, affecting one foot more than the other.
The bones in elderly diabetics start to become brittle and fracture easily. Normally, fractures that occur in healthy individuals are very painful, but not so in diabetics. This is due to the loss of pain perception. As a result, the injury goes unnoticed and the foot gradually becomes deformed in multiple places, either at the toes, or in mid foot. In extreme cases, even the ankle joint can be destroyed.
Deformity of the foot coupled with loss of pain sensation makes the patient more prone to injury. These injuries are more common due to our habit of walking barefoot. Thorns and injury due to small stones etc. thus goes unnoticed until pus starts to develop inside leading to more destruction of the nearby tissue structures. This can in turn lead to blackening of the toes (commonly known as gangrene). Development of gangrene is a critical situation, which if not cared for urgently leads to amputation of toes and even major amputations i.e. below the knee or above the knee if the infection is very severe or the gangrene extensive.
Diabetes is known to cause blockages in the arteries of the heart. What is not known is that it also leads to severe

and long blockages along with extensive calcium deposition in the arteries of the legs below the knees. The problems of arterial clogging along with nerve damage and bone destruction lead to a very high incidence of major amputations in patients with diabetes.

Diabetes related Foot ulcers: A reason to worry!

Foot ulceration is a common cause for a diabetic to get admitted in the hospital. In all, foot related problems account for nearly 40% of the total diabetic admissions in hospitals. The most common cause for foot ulceration in India is external injury, where as in the western world it is due to intrinsic foot deformities. The combination of nerve damage and bony distortion lead to frequent injuries which go unrecognized. As the foot now becomes painless, these injuries can progress rapidly into a severe infection which can be limb and life threatening. The most common causes of injury are thorn pricks, injuries while walking around the house, kickstarting a scooter/motorcycle and wearing new footwear.
Across the world, 85% of amputations in diabetics are due to inadequately treated foot ulcers. 50-75% of all non -traumatic amputations across the world occur in diabetics. Major amputations when performed as a life saving measure are understandable, but undergoing a major amputation is a very traumatic experience for the patient and the family. Major amputation is a life threatening condition in the short term. Less than 50% of patients manage to survive for 2 years after a major amputation.

Prevention

Appropriate and tight control of blood glucose levels is an absolute must. Without this, the problems only grow exponentially and rapidly, not just in the foot but also elsewhere in the body. Diabetics of long standing (>10yrs) must regularly have their feet evaluated for any deformity, loss of sensation, change of pressure points and absence of pulses in the foot. Trauma of any sort must be avoided and barefoot walking whether in or out of the house is only to be condemned. Once deformity begins to occur, foot wear modification is essential which is often custom made according the shape of the foot. Pointed toe shoes should be avoided as they crimp the forefoot. Cotton socks should be used. Feet must be regularly evaluated by a family member for any cracks, blisters, loss of hair and nail care. Fungal infections are common in sweaty feet and cracks in the heel are often a focus for infections. Skin should be kept moist and not wet. Care of the feet in diabetic should be as carefully and comprehensively done as the face of a newlywed bride!

Treatment options

Arterial occlusion in diabetics occurring below the knee was earlier regarded as non treatable and this often led to amputations being recommended as the initial treatment for majority of these patients. But this is not so anymore.
Over the last decade, there have been very significant advances in the treatment of patients with diabetes mellitus affected with arterial blockages and non healing ulcers and gangrene of toes. Non surgical treatment like Angioplasty with the help of special balloons, as performed for the heart, is also performed extensively for opening up of arterial blockages in the legs with excellent long term results such as ulcer healing, preventing major amputations and thus saving the foot.
At times, if angioplasty cannot be performed due to extremely long blockages, surgical bypass procedures are necessary to facilitate ulcer healing, saving the foot, preventing major amputation and helping the patient and family get back to near normal activity levels. Bypass procedures to the foot and legs have been performed since the 1980's across the world and have been performed extensively in India by Peripheral Vascular Surgeons since the 90's. The purpose is not just to fix blocked pipes (read arteries), but more physiological, and to provide for a comprehensive foot and limb salvage.
The treatment of leg ulcers and gangrene does not stop with increasing the vascularity to the foot. Once the circulation is restored, regular dressings of the ulcer with appropriate offloading diabetic footwear are needed in order to prevent recurrent ulcerations.
Until now, there were no dedicated Peripheral Vascular Surgeons in Rajasthan, somebody who would look at the patients problem as a whole and not just look at either the non healing ulcer or the occluded artery, and thus patients had to travel far and wide in search of someone who would be able to recommend the right treatment for the problem and perform limb saving procedures accordingly.