Many Diabetic Amputations are Preventable

Diabetes is an insidious disease that affects more than 18 million Americans over the age of 20. In diabetes, the body cannot make or properly use insulin, a hormone that helps control the sugar (glucose) in blood. Glucose is the body's main source of fuel.

Diabetes carries with it a variety of serious complications including vision changes, kidney disease, and circulatory problems. But for 50,000 diabetics each year, it also can mean the amputation of a toe, foot, or even a leg. Fortunately, people with diabetes do have some options that will help reduce their risk factors for amputation.

Why do so many diabetics have to endure amputations? "Diabetes often affects the nerves and the circulation to the nerves, which causes neuropathy leading to numbness or a loss of feeling in the feet. Diabetics can sustain injuries to their feet and not be aware of it because of that loss of feeling," according to Joseph A. Sizensky, MD, Medical College of Wisconsin orthopedic surgeon and Assistant Professor of Orthopedic Surgery. Dr. Sizensky, who specializes in foot and ankle surgery on patients with diabetes, practices at the Froedtert & the Medical College of Wisconsin Orthopaedic Surgery Clinic.

"Diabetics also may have vascular disease, which slows down circulation and the ability of the body to heal itself," Dr. Sizensky notes. Because healing is slower, injuries or pressure sores on the feet and toes can easily become infected if not treated early, potentially resulting in amputation.

Diabetic neuropathy does not happen overnight; it is a complication that arises over a period of years. "The longer you have diabetes, particularly if it is poorly controlled, your risk for developing neuropathy increases," Dr. Sizensky said. While older people are more frequently affected, it can afflict diabetics of any age.

Increased Mortality Rate
Adjusting to an amputation is difficult enough, but diabetics who have amputations face much more serious problems down the road. After an amputation, many people fall into an accelerated decline, with 70% dying within five years, according to the National Institutes of Health.

"When there is an amputation, it places a much greater strain on the heart. It is much more difficult for the person to function," Dr. Sizensky says. Government statistics show that patients with lung cancer are part of the only major disease group with significantly worse survival rates.

Preventive Measures
The good news is that more than half of all diabetic foot amputations are preventable, beginning with some simple foot hygiene. The bad news is that many people don't take these preventive measures. This is a source of frustration for physicians like Dr. Sizensky, who sees it firsthand. "Unfortunately, patients are typically not very compliant when it comes to taking preventive measures. If your feet look okay and you don't feel bad, you may not think there is anything to worry about. Therefore, you don't take precautions," he said.

Dr. Sizensky urges diabetics to be finicky about their foot care. "Diabetics should wash and dry their feet daily, carefully checking for wounds and calluses and taking good care of the nails. The skin should be kept moist. Dry and cracked skin is a potential breeding ground for infection. Clean, thick socks are also important," he said.

Ulcers can come from common injuries like stepping on a rock in bare feet or getting a splinter from a wood floor, or even dropping something heavy on unprotected toes. "Diabetics should never go barefoot," Dr. Sizensky advises.

Blisters from tight shoes are a common cause of foot wounds. "If you are wearing shoes that don't fit properly, they may cause foot sores to develop," Dr. Sizensky stated. Orthotic shoes with custom foot supports that fit properly and do not rub against the bony protrusions of the feet are one good way to help prevent blisters and other foot sores. In recent years, there have been advances in the design of orthotic shoes that make them more attractive and easier to wear.

Evolving surgical techniques are also helping to avert amputations, according to Dr. Sizensky. "Skin grafting with regenerative tissue matrices and other soft tissue augmentations may work well in the appropriate person. There has been a trend towards a more aggressive surgical approach to patients, including the use of osteotomies or fusions to realign and stabilize the foot, relieve pressure, and prevent recurrence. The use of external fixators has expanded our ability to operate safely and save what were previously thought to be unsalvageable limbs," he explains.

The most important preventive method for diabetics, however, is controlling their blood sugar levels.

About 5% to 10% of people with diabetes have Type 1, in which the body cannot produce insulin. This usually occurs in children, teenagers, or adults under age 30. Type 2 diabetes accounts for up to 95% of all cases of diabetes. With this form of diabetes, the body does not produce enough insulin or does not use insulin efficiently.

Being overweight and inactive increases the chances of developing Type 2 diabetes. The millions of Americans at high risk for Type 2 diabetes can sharply lower their chances of getting the disease with diet and exercise, according to the findings of the National Institute of Diabetes & Digestive & Kidney Diseases.

Pharmaceutical companies are working on more drugs for diabetes, including specially tailored forms of insulin that act more quickly or last longer than regular insulin.

The Goal
Medicare and other insurance plans typically cover foot care for diabetics, so there is little excuse for neglecting foot care. "Medicare will pay for surveillance of diabetic feet every six months. Studies show that with aggressive education about complications of diabetes and long term follow-up every six months, the rate of ulceration and amputation declines significantly," Dr. Sizensky notes.

"Diabetes is a devastating disease on many levels and we see patients with ulcers, infections and deformities every week. It is most frustrating for me to see patients who have a salvageable foot who lose their limb because of a lack of compliance with the treatment plan," Dr. Sizensky said. "Many of these patients can go on to do well with an aggressive approach to treatment and prevention - if the patient is on board with the plan.

"The goal in saving the feet of diabetics is early detection and follow-up. The best treatment is multi-disciplinary, including internists, endocrinologists, and orthopaedic, plastic and vascular surgeons," Dr. Sizensky said.

JoAnn Petaschnick
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.