Diabetic Vignettes

‘I marvel that society will pay a surgeon a great deal of money to amputate a limb but nothing to save it’

George Bernard Shaw

I have seen many patients with diabetes mellitus (DM) who have foot ulcers. Some have been so bad as to require amputation of one or both lower limbs. Yet our focus really should be on preservation of the lower limbs, rather than trying to treat the ulcers. Everyone with diabetes should receive basic foot-care education, and regular foot examinations. Foot examinations can be done very simply. Check out this fabulous informative site from an Australian podiatrist :www.2foot.com.au

I want to share a few interesting pieces from papers found on Medline. I urge you all to read the full texts because the information is not only fascinating but scary. Could the increase in the number of patients with DM mean that there will be an increase in the numbers with foot ulcers leading to amputation?!

Lower extremity amputation is one of the worst complications of diabetes, as it usually has a life expectancy that is below that of most cancers. Four local biologic factors—ulcer, ischemia, neuropathy, and infection—have been shown to be related to amputation. These factors interact with one another, such that neuropathy has been shown to cause ulcers and ischemia and to prevent the healing of ulcers. In addition, ischemia and neuropathy are independent risk factors for infection. Ref: Wachtel , MS & Frezza, EE. Local Biological Factors that Influence Amputations in Diabetic Patients. Southern Medical Journal . Volume 100(2), February 2007, pp 158-161 Obesity and diabetes mellitus (DM) are increasing globally in epidemic proportions across all age groups. Type 2 DM is for the first time being seen frequently in children and young adults in many populations. An increase in the incidence of gestational diabetes mellitus (GDM) has also been well documented in Australia and the United States , and there are some data suggesting the same trend in India. REF: Metzger Boyd E. The global increase in diabetes: Unique issues for mothers and children. International Journal of Diabetes in Developing Countries 2006;26:257-62 One hundred and nineteen (30.5%) patients with diabetes and 271(69.5%) patients without diabetes underwent incident lower extremity amputation during the period studied. Half of all deaths in patients with diabetes had occurred by 27.2 months compared with 46.7 months for patients without diabetes ( P =.01). Therefore, the risk of death in patients with diabetes was 1.55 times that of patients without diabetes. Lower extremity amputation in patients with diabetes has an excess mortality compared with those without diabetes. Ref: Schofield, CJ; Libby, G; Brennan, G; Macalpine, RR; Morris, AD; Leese, GP. Patients with diabetes have an increased incidence of mortality and hospitalisation after incident lower extremity amputation compared to patients without diabetes: P81 [Posters: Clinical care: Cardiovascular disease] Diabetic Medicine Volume 24 Supplement 1, March 2007, p 53–54

Amputation of one limb increases the risk of loss of the second limb and is associated with a 50% five-year mortality. Ref: Apelqvist J, Larsson J, Agardh C-D. Long term prognosis for diabetic patients with foot ulcers. J Intern Med 1993; 233: 485-491.

30% of diabetic patients have contralateral limb amputation within 3 years of the first amputation. Ref: Most RS, Sinnock KP. The epidemiology of lower extremity amputations in diabetic individuals. Diabetes Care 1983; 6:87–91

Peripheral neuropathy, peripheral vascular disease deformities of the feet and infection can lead to ulceration and / or amputation.

Note the ‘clawed toe deformity’ of this diabetic patient.

This patient with peripheral neuropathy presented with a large foreign body in the plantar aspect of the foot and life-threatening infection. The three middle toes required amputation together with deep debridement. The wound healed remarkably!

(Photographs from personal collection)

The risk for the development of ulceration can be assessed by basic clinical examination of the foot. Anyone can learn to do it! Family members, nursing and medical staff, podiatrists, personal care assistants and assistants in nursing in aged care facilities can learn how to do it!! Just use the teaching tools and assessment tools on this excellent website. www.2foot.com.au