The Diabetic Foot

Today in India there are over 45 million diabetic patients and an estimated 50,000 amputations occurring per year due to diabetes related foot problems. In the diabetic patients, due to nerve damage and poor blood supply of the foot, various deformities of the toes and feet occur. This causes areas of raised pressures in the soles of the feet, where ulcers develop. These ulcers act as portals for the entry for bacteria leading to serious infections, which in the immuno-compramised diabetic patient, can result in amputations or even death. The commonest cause is the infected neuropathic foot, which is potentially preventable. There are very few organized diabetic foot screening programs and Podiatric services are available only in major centers in India and a multi-disciplinary team approach is mostly lacking. Proper diabetic orthotics are not easily available. Socio-economic factors like barefoot walking, inappropriate footwear usage, lack of awareness of the seriousness of diabetic foot problems amongst doctors and patients and hence late reference to specialty centers, is a matter of concern. 70% of the population in India lives in the rural area and 40% stay in one-room tenements. Inadequate sanitation, improper foot offloading due to lack of facilities and awareness are common. Rat and insect bite, vigorous massage, thermal injuries due to hot fomentation, injuries due to improper footwear and intertrigal fungal infections cause diabetic foot injuries in India. These cause extensive necrotizing fasciitis and other soft tissue and bone infections of the lower limb, which can be limb and life threatening. In India, very few patients are insured, and the vast majority of patients with diabetic foot problems have to pay for the cost of medical care. Hence the cost of treatment and consumables used assumes much greater significance in such circumstances. Neuropathy ---------- Statistics state that 15% of all diabetic patients will develop foot problems related to the disease. Diabetic foot conditions develop from a combination of causes including poor circulation and neuropathy. Diabetic Neuropathy can cause insensitivity or a loss of ability to feel pain, heat, and cold. Diabetics suffering from neuropathy can develop minor cuts, scrapes, blisters, or pressure sores that they may not be aware of due to the insensitivity. If these minor injuries are left untreated, complications may result and lead to ulceration and possibly even amputation. Neuropathy can also cause deformities such as Bunions, Hammer Toes, and Charcots Feet. It is very important for diabetics to take the necessary precautions to prevent all foot related injuries. Due to the consequences of neuropathy, daily observation of the feet is critical. When a diabetic patient takes the necessary preventative foot care measures, he or she reduces the risks of serious foot conditions. Poor Circulation ---------------- Diabetes often leads to peripheral vascular disease that inhibits a person’s blood circulation. With this condition, there is a narrowing of the arteries that frequently leads to significantly decreased circulation in the lower part of the legs and the feet. Poor circulation contributes to diabetic foot problems by reducing the amount of oxygen and nutrition supplied to the skin and other tissue, causing injuries to heal poorly. Poor circulation can also lead to swelling and dryness of the foot. Preventing foot complications is more critical for the diabetic patient because poor circulation impairs the healing process and can lead to ulcers, infection, and other serious foot conditions. * Prevention of foot problems --------------------------- Footwear and orthotics play an important role in diabetic foot care. To reduce the chances of onset of foot complications, wearing the right footwear is crucial. It is well known that improper footwear contributes significantly to ulceration. Shoes must accommodate dorsal deformities and cushion areas of high plantar pressure. In particular, they should relieve excessive pressure on areas that are prominent, such as the metatarsal heads. Shoes must also reduce shock (the vertical pressure on the bottom of the foot caused by the weight of the person) and shear (horizontal movement of the foot within the shoe).Deformities of the foot resulting from loss of fatty tissue, hammer-toes and foot amputations must also be accommodated. Deformities need to be stabilised to relieve pressure and avoid further destruction of tissue. Limiting the motion of certain joints in the foot can often decrease inflammation, relieve pain and result in a more stable and functional foot. Proper footwear is essential for this. Plantar pressure measurements are taken with a ‘mat-type’ pedopodogram. The pedopodogram is an instrument which quantifies plantar-pressures in both static and dynamic patterns of gait, bare-foot and shod. Once these measurements are taken, and the high pressure points detected, appropriate corrective footwear is prescribed. Once the footwear is made, its ability to obviate the high plantar pressures is checked by the ‘in-shoe’ type of pedopodogram. In the manufacturing of diabetic footwear, materials with specific qualities are used. The insole should distribute plantar pressure equally on its surface. Materials used are microcellular rubber, microcellular polymer, poron, ethyl vinelyl acetate, and plastazote. The insole should have a ‘shore-hardness’ of about 24. Of these materials, only plastazote and the like materials can be moulded in the exact shape of the foot. The out-sole should be hard, rigid, lightweight and durable. This is generally made of polyvenyl chloride or high density ethyl vinelyl acetate. The shore-hardness of the out-sole is obout 75. Foot care & Diabetes -------------------- Proper foot care is especially critical for diabetics because they are prone to foot problems such as: • Loss of feeling in their feet • Changes in the shape of their feet • Foot ulcers or sores that do not heal Simple daily foot care can prevent serious problems. The following simple everyday steps will help prevent serious complications from diabetes: 1. Take Care of Your Diabetes Make healthy lifestyle choices to keep your blood sugar close to normal. Work with your health care team to create a diabetes plan that fits your lifestyle characteristics. 2. Check Your Feet Every Day You may have foot problems that you may not be aware of. Check your feet for cuts, sores, red spots, swelling, or infected toenails. Checking your feet should become part of your daily routine. If you have trouble bending over to see your feet, use a plastic mirror to help. You can also ask a family member to help you. Important Reminder: Be sure to call your doctor immediately if a cut, sore, blister, or bruise on your foot does not heal after one day. 3. Wash Your Feet Every Day Wash your feet in warm, NOT HOT, water. Do not soak your feet because your skin will get dry. Before bathing or showering, test the water to make sure it is not too hot. You should use a thermometer or your elbow. Dry your feet well. Be sure to dry between your toes. Use talcum powder to keep the skin dry between the toes. 4. Keep the Skin Soft and Smooth Rub a thin coat of skin lotion or cream on the tops and bottoms of the feet. Do not put lotion between your toes, because this might cause infection. 5. Wear Shoes and Socks At All Times Wear shoes and socks at all times. Do not walk barefoot, not even indoors. It is extremely easy to step on something and hurt your feet. Always wear seamless socks, stockings, and nylons with your shoes to help avoid the possibility of blisters and sores developing. Be sure to choose seamless socks that are made of materials that wick moisture away from your feet and absorb shock and shear. Socks made of these materials help keep your feet dry. Always check the insides of your shoes before putting them on. Make sure the lining is smooth and there are no foreign objects in the shoe, such as pebbles. Wear shoes that fit well and protect your feet. 6. Protect Your Feet From Hot and Cold Always wear shoes at the beach or on hot pavement. Put sunscreen on the tops of your feet for protection from the sun. Keep your feet away from radiators or open fires. DO NOT use hot water bottle or heating pads on your feet. If your feet are cold, wear seamless socks at night. Lined boots are good to keep your feet warm in the winter. Choose socks carefully. DO NOT wear socks with seams or bumpy areas. Choose padded socks to protect your feet and make walking more comfortable. In cold weather, check your feet often to keep your feet warm avoid frostbite. 7. Keep the Blood Flowing to Your Feet Put your feet up when you are sitting. Wiggle your toes for 5 minutes, 2 or 3 times a day. Move your ankles up and down and in and out to improve blood flow in your feet and legs. - DO NOT cross your legs for long periods of time. - DO NOT wear tight socks, elastic, or rubber bands, or garters around your legs. - DO NOT wear restrictive footwear or foot products. Diabetics should not wear foot products that can cut off circulation to the feet, such as products with elastic. - DO NOT smoke. Smoking reduces blood flow to your feet. If you have high blood pressure or high cholesterol, work with your health care team to lower it. 8. Be More Active Ask your doctor to plan an exercise program that is right for you. Walking, dancing, swimming, and bicycling are good forms of exercise that are easy on the feet. Avoid all activities that are hard on the feet, such as running and jumping. Always include a short warm-up or cool-down period. Wear protective walking or athletic shoes that fit well and offer good support. Every 30 seconds a leg is lost to diabetes somewhere in the world Extensive epidemiological surveys have indicated that between 40% and 70% of all lower extremity amputations are related to diabetes. This means that every 30 seconds a lower limb is lost to diabetes. The vast majority (85%) of all diabetes-related amputations are preceded by foot ulcers. In developed countries diabetic foot care accounts for up to 20% of total healthcare resources available for diabetes. In developing countries, it has been estimated that foot problems may account for as much as 40% of the resources available. Significant reductions in amputations can be achieved by well-organized diabetic foot care teams, good diabetes control and well-informed self care There is strong evidence to indicate that foot care is best delivered when it is provided by a multidisciplinary team. This should closely involve the person with diabetes and his or her family, along with healthcare professionals from different specialties. • Annual inspection of the foot • Identification of the foot at risk • Education of people with diabetes and healthcare professionals • Appropriate foot wear • Rapid treatment of all foot problems Only through a multidisciplinary approach addressing the diversity of possible foot problems in people with diabetes can the desired reduction in amputation rates be achieved. Reconstructive Foot and ankle surgeries in Diabetic patients. The concept of surgical correction for the diabetic foot and ankle deformity has recently evolved as a means to correct foot deformities secondary to long standing diabetes. This re-shaping of a deformed foot or toes by surgical correction is presently being done in a few selected centers only in U.S, U.K, Russia, Germany, Spain, and Australia. These surgeries help to prevent the formation of callus and ulcers of the foot and thus, these surgeries can prevent amputations in diabetics. Over-riding of the big toe and crowding of toes can cause skin breakdown thus resulting in ulcers and infection. Corrective surgery is done to bring the toes to their normal position. If the foot is not properly aligned, then again high pressures build-up in the soles causing ulceration. ‘Charcots Foot’ is a severe complication of diabetes, which leads to erosions, and collapse of the foot and ankle bones, which in turn lead to marked deformities and ulcerations. Different types of surgical corrections are carried out so as to normalize the shape and function of these grossly deformed feet. The department of Endocrinology, Diabetic lower limb and Podiatric surgery, Amrita Institute Of Medical Sciences And Research Center, Kochi, Kerala, is the only center in India where these corrective surgeries are being performed exclusively in high-risk Diabetic foot patients. By employing these novel surgical techniques a large number of amputations, in patients with diabetic foot ulcers and deformed diabetic feet can be prevented. In our department we are carrying-out all types of foot and ankle reconstructive and corrective surgeries in diabetic patients. This includes Charcots reconstructive surgeries including Triple arthrodesis, Talo-calcaneal arthrodesis, Naviculo-calcaneal arthrodesis, Plate fixation of Charcots fractures of foot, with or without autogenic, iliac crest bone graft. Bunionectomy & ‘Scarf’ surgery for hallux valgus, Arthroplasty for Hallux limitus/rigidus, Arthroplasty for Hammer, Mallet and Claw toes, Neuromas excision, surgical management of Plantar Fasciitis, Cysts and ganglions, Bone spurs, Open Tendo-achilles lengthening surgery, Tendon transfer surgeries, Repair of ruptured foot & ankle tendons, and Application of Illizarov frame among many others. By comprehensive management, we have been able to maintain a limb salvage rate of 91.5%, in diabetic foot and ankle diseases, comparable to the best centers in he world. ------------- by Dr. Ajit Kumar Varma, Additional Professor, Dept.of Endocrinology, diabetic lower limb and Podiatric Surgery