When people with diabetes experience complications such as neuropathy (nerve damage), it’s time to start arming themselves with education for protection against even greater complications like amputations.
The chain of events from nerve damage to being at high risk for an amputation can look something like this — first, the nerve damage causes people to lose sensation in their feet, and it also can cause changes to the foot structure as the nerves affect muscle function, leading to foot deformities.
Where the deformities exist (often as buckled joints), callouses can form; these callouses can become sores and get infected.
Lower blood circulation in many diabetics means that these wounds then heal slower or even begin to fester.
“That callous becomes the first warning sign that somebody has got a big problem that’s brewing,” said Dr. Mario Ponticello, chief of Madigan Army Medical Center’s Limb Preservation Service. “If you can get to that person when they have the callous, there’s a good chance that you can prevent the things that happen thereafter.”
While his clinic primarily treats diabetic patients, they take care of all patients at risk of limb loss due to neuropathy including those who undergo chemotherapy or have rheumatic diseases. Feet are more at risk for amputation than other limbs as they are more likely to be injured due to bearing body weight and the pressure of activity, Ponticello said.
“Once you get the wound, the two big factors that are very, very important is infection and a lack of blood supply; either one of those can tip the balance,” said Dr. Charles Andersen, Madigan’s chief of Vascular and Endovascular Surgery.
The warning signs that most people experience when their feet are injured, or are susceptible to becoming injured, are pilfered by nerve damage when sensation is lost.
“They lost that gift of pain,” Andersen said. “If people can feel their feet, then it’s less likely they’re going to get into trouble.”
The key to prevention starts with patient education and awareness, Andersen said.
“Patients have a significant part of this initiative,” he said. “They need to know that as they lose sensation in their feet, or just the fact that they have diabetes, that their feet are at risk. Every diabetic needs to know ‘I am at risk for an amputation.’”
Early detection is the best strategy against needing an amputation. While primary care managers should conduct annual foot exams of all diabetic patients, patients are encouraged to also conduct more regular foot checks themselves. Patients with nerve damage or loss of sensation in their feet should frequently check the bottoms of their feet for sores or callouses; if self-checks prove difficult, they can ask others to check for them.
Patients can also avoid walking barefoot and can check the soles of their shoes to see if items are embedded in them or if they are worn in odd locations — this can be a sign that a different type of shoe should be worn.
“If you wait, if you ignore it, if you turn a blind eye, bad things happen,” Ponticello said. “That’s when new infections set in, and problems develop.”
Not only can ignoring foot wounds and infections lead to amputations for some patients, but that first amputation can lead to even more dire consequences. Patients who undergo one amputation have a 50 percent chance of needing a second amputation within four to five years and have a higher subsequent death rate than their peers, Andersen said.
“If you start early enough and aggressively enough, then you can prevent a very large number of amputations and get these patients back to a functional life,” he said.
For those patients who are at high risk of amputations, Madigan uses a team approach to care for the patient and address the individual risk factors. The wound clinic can heal sores, podiatric surgery offers reconstructive surgery on deformed feet to prevent sores and endovascular therapy addresses a lack of blood supply by directly treating blocked arteries.
The Limb Preservation Service is the central point for monitoring at-risk patients and coordinating all of these and other treatments.
“We have the experience, the skills and the technology to help our patients avoid amputations and live fuller, healthier lives,” Ponticello said.