Everyone knows of someone who has had a limb amputated because of diabetes. Perhaps it was a distant relative, or maybe even a more immediate member of the family. Many diagnosed with diabetes years earlier will vaguely know only that limb loss is a concern, but not much more. Clearly, this is a dreadful outcome of the disease, but can these amputations be prevented? And why do they occur so frequently? These are important questions, ones to which we have some answers.
Diabetes, as well as its complications, are a major health issue both here and abroad. And the incidence of diabetes is increasing dramatically as the Western diet of processed, overly-sweetened foods is promoted globally by the corporate food giants. The number of diabetics quadrupled over the quarter century following 1980.
The burden of chronic wounds, and their care, is growing rapidly due to numerous factors. Some major players include obesity, increasing health care costs and an aging population, but likely the primary reason is the epidemic which is diabetes. The numbers are scary: whereas in 2013 about 9% of the US population had diabetes, by 2030 almost 14% will have the disease. Some estimates claim as much as a third of all diabetics develop an ulcer at some point, which leads to infection and amputation far too often.
Diabetes can result in many devastating complications, none more so than limb loss. Amputation of a foot or leg is a life-changing event, unlike any other. Too few are “brace-able”, in that they are typically not able to use a brace to ambulate bi-pedally. This loss of mobility has profound implications, from cardiac effects to mental and emotional. Most frightening of all, diabetics who lose a lower limb, on average, don’t live another five years.
We know full well the usual chain of events leading to this limb loss. Many issues come to play in this outcome, from which there is no return. In the eyes of wound care experts, the altered nerve function, termed neuropathy, is “the first step on the stairway to amputation.” The slow and insidious development of this condition, often unbeknownst to the sufferer, means minor trauma to the skin produces no pain, perhaps from a shoe rubbing or a coin that has fallen inside. The individual is not alerted to the worsening problem. And so nothing is done.
Add in the reduced blood flow generally found in those with diabetes and you have a recipe for limb loss. Those with neuropathy will often buy shoes slightly too small since only then does it feel like they have a shoe on. Any bony prominence or bump may become a site of skin breakdown, an ulcer. This means our critical outer defense system, skin, is breached giving bacteria easy access. Complicating the situation further is the impaired immunity of the diabetic.
Because of the neuropathy, many diabetics develop bent toes or bunion deformities. How could a nerve problem possibly lead to a bony deformity, you might ask. It turns out the small muscles in the feet are essential to alignment and function of the toes, and help maintain their position. Because muscles are controlled by nerves, neuropathy results in a loss of function of these tiny muscles and deformity develops, gradually, slowly.
Those diabetics with problems of the sensory nerves (which is most) usually won’t feel this type of superficial, chronic and recurrent pain. Initially, there are often minimal dangers. With time, skin changes occur which can include callusing and thickening. The sufferer may be completely unaware problems are in the offing. They may have no idea until some drainage appears on their sock, a predictable finding when skin breakdown takes place. A frequent but unnecessary component of the chain of events is inadequate blood flow, something most diabetics experience.
Although this is a common scenario, the ways in which a diabetic can develop a sore that doesn’t heal appropriately are numerous. Unfortunately, most diabetics are uneducated about the complications of their disease when it comes to the feet. They don’t know how to care for them since we do a poor job of educating these individuals how best to protect and maintain these vital structures.
Fortunately, the real purpose of this treatise is to discuss the amazing new methods and therapies leading to healing of these potentially debilitating problems. Fortunate since there are many obstacles to healing in this population. For the average individual afflicted with diabetes, there are numerous issues muddying the process leading to healing. Although we know more than we ever have about these wounds, closing these horrible lesions can be challenging. But you will have to wait for the next issue to learn about some of the amazing new technologies and techniques being used to close these difficult defects in skin. Your homework? Tell everyone you know with diabetes to learn about diabetic foot care. Perhaps not right away, but eventually, they will be glad you did!
Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments firstname.lastname@example.org.