‘Limb-salvage teams’ fight amputations from common diabetic foot sores
October 1, 2007
WASHINGTON – A stubbed toe can lead to having your foot amputated? It can if you’re a longtime diabetic. And it can happen fast.
“Tuesday in the office, they’re fine. Friday, they’re in the emergency room with gangrene in a toe,” says Dr. Peter Sheehan, diabetes chief at New York’s Cabrini Medical Center.
It’s a little-known statistic: Foot problems – wounds that won’t heal, infections, warping bones – are the most common reason diabetics are hospitalized.
And many of the 80,000-plus amputations of toes, feet and lower legs that Americans diabetics undergo each year are preventable, say specialists who brought more than 900 health providers to a meeting last week to figure out how to do just that.
One recommendation: For hospitals to create diabetes limb-salvage teams.
It sounds simple. But it involves pairing specialists who seldom work side-by-side – like podiatrists and vascular surgeons – to shave weeks off the time it can take to get proper care for a festering foot.
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“It gets them everything they need right away, without months of waiting (between doctor appointments) while the wound is going downhill,” says Dr. John Steinberg, a podiatrist with Georgetown University Hospital’s limb-salvage team.
Some 21 million Americans have diabetes, meaning their bodies cannot properly regulate blood sugar, or glucose. Over years, high glucose levels seriously damage blood vessels and nerves, eventually leading to kidney failure, heart disease and other complications.
Among them is a vicious trio: Foot ulcers that strike about 600,000 diabetics annually; loss of sensation in the feet called neuropathy that makes sufferers slow to notice they have a wound; and poor blood flow in the lower legs that makes the ulcers slow to heal.
Amputation may end the grueling cycle of unhealing wounds and infection on one limb. But those patients still face grim odds. About half will develop ulcers and infections in the remaining foot, and undergo more amputations. And within five years, more than 40 percent are dead.
Infection is the chief reason for amputating. But there are no firm guidelines on when a limb is beyond salvaging – and a 2001 study of Medicare-covered diabetics found large differences in amputation rates in different parts of the country.
Until recently, most research into diabetic wounds has focused on methods to clean them out and spur new skin growth.
The newer message: Check blood pressure in a diabetic’s ankle before rushing to foot surgery. One in three diabetics over age 50 has a condition called peripheral arterial disease or PAD, where leg arteries become too clogged to get enough blood to the feet.
That’s one reason that last week’s meeting urged a team approach to saving diabetics’ limbs: Whatever foot surgeons apply to heal a nasty ulcer won’t work unless a vascular surgeon has first cleared clogged leg arteries.
“We are hostage to the blood flow,” is how Dr. David G. Armstrong, a podiatrist at Chicago’s Rosalind Franklin University of Medicine and Science, puts it.
Minimally invasive leg-clearing therapy – propping open clogged arteries with balloons and stents, or rooting out the sludge with tiny razors and lasers – is on the rise. But Dr. Richard Neville, Georgetown’s vascular surgery chief, says many diabetics have such severe blockages that they need blood rerouted, using one of their own clog-free veins or artificial blood vessels.
Then can come what Armstrong calls the variety of “goops and gadgets” to apply straight to the ulcer.
What works best? Studies are under way to try to determine that, but Armstrong and Steinberg recommend old-fashioned debridement – scraping away dead tissue every few days – and a vacuum-sealing device that helps keep the wound moist. Certain dressings can provide a scaffolding for healthy cell growth from the inside-out.
Between those vascular and ulcer-patching surgeries, patients see a lot of other doctors. Endocrinologists get blood sugar controlled enough to allow surgery. Infectious disease specialists find the right antibiotic cocktail. Orthotists design casts and special shoes to keep pressure off the foot’s weak spots.
Treating a simple diabetic foot ulcer can cost $8,000; an infected one, $17,000.
The main message for the average diabetic: Take off your socks and shoes at every visit to the doctor and ask that he or she examine your feet. Many doctors follow this government guideline, but almost half of diabetics don’t get a simple foot check that could spot brewing problems in time to avoid a limb-threatening ulcer.
And ask about the ankle blood pressure test, called an ankle brachial index. New York’s Sheehan says the simple test is a leading predictor of which diabetics will be hospitalized for foot ulcers, and the American Diabetes Association recommends that every diabetic over 50 get checked.