Diabetes is a well-known disease in Asia. In this instance, we will be focusing on one of its most common and devastating complications: Diabetic Foot Ulcers (DFU).
Cause
The primary complications of diabetes include damage to the eyes (diabetic retinopathy), kidneys (diabetic nephropathy), and nerves (diabetic neuropathy). DFU falls under diabetic neuropathy.
Due to diabetic neuropathy, diabetic patients have a reduced ability to feel pain. This means that minor injuries may remain undiscovered for a long time. Distal nerve damage and low blood flow cause loss of pain or feeling in the toes, feet, legs, and arms. Blisters and sores appear on numb areas of the feet and legs like the metatarsophalangeal joints, heel region and as a result, pressure or injury goes unnoticed and eventually become a portal of entry for bacteria and infections. Although most diabetic foot infections are polymicrobial, the most common causative organisms are staphylococci and streptococci.
Pathophysiology
Most infections typically start with a break in the protective cutaneous envelope of the skin that resulted from trauma or neuropathic ulceration. These open wounds will eventually be colonized by skin flora that in many cases result to infection. Due to hyperglycemia-induced advanced glycation end-products, persistent inflammation and apoptosis (the death of cells), the wounds in the patients’ feet with diabetes become chronic. The infection induces inflammatory response that causes compartmental pressure to exceed capillary pressure, resulting to ischemic tissue necrosis.
Once you develop fever and chills, you will notice that the infection has spread to your body through your blood. The diabetic foot has become the source of infection. When you seek medication at the hospital, the doctors will start with antibiotics to fight the infection and will perform a wound debridement, however it might be too late then. The only intervention that has a chance on saving your life is: Amputation.
Amputation
Based on the 2015 prevalence data from the International Diabetes Federation, foot ulcers develop annually in 9.1 to 26.1 million people with diabetes worldwide. An estimated 10% of patients with diabetes will have DFU that precedes more than 80% of non-traumatic amputations. If the patient has gas gangrene, abscess or necrotizing fasciitis, compartment syndrome or systemic sepsis, immediate surgery is recommended .
The goals of performing a surgical treatment is:
- to drain any deep pus;
- to minimize tissue necrosis by decompressing foot compartments; and
- to remove devitalized and infected tissue.
Diabetic foot infection surgical intervention should be done by a surgeon with thorough knowledge of the anatomy of the foot and the path in which infection spreads through its fascial planes.
Three types of amputation are used for diabetic foot infection, depending on how extensive the disease is and the neurovascular status of the patient’s limb(s), such as:-
- Ray’s Amputation
- When the dorsalis pedis pulse and posterior tibial pulse are still felt, but you have a ‘dead’ toe, Ray’s Amputation is the best surgical intervention for this case. A ‘dead’ toe is one in which the blood supply is completely impeded that infarction and necrosis develop.
A post Ray Amputation of the big toe, but without compliance to sugar control and daily wound dressing. The infection has come back and spread, resulting to gangrenous of the index and middle toe and up to the midfoot. This patient would probably consulted for a Below Knee Amputation since the neurovascular status of the lower limb is weak.
- Below-Knee-Amputation (BKA)
- In circumstances where the dorsalis pedis pulse and posterior tibial pulse aren’t felt till the point the foot has turned gangrenous, plus blood investigations and clinical assessments indicated the worsening of the infection, Below Knee Amputation is the best approach.
A clean post-BKA stump.
- Above-Knee-Amputation (AKA)
- AKA is offered when the gangrenous and infection has spread up till the midshin with weak/no popliteal pulse and blood investigation and patient’s condition suggestive of severe infection.
What’s next?
I’ve seen a lot of families breaking down and crying when doctors advise that amputation was the best approach as a resolution. It is completely understandable. Losing something that you have had as long as you live equates to the same level of sadness when you lose someone you love. However, as a silver lining, amputation has good prognosis. I have seen numerous patients feeling better after the procedure and the improvements of their blood investigation post-amputation.
Although there are still complications post amputation like ‘phantom pain’ and ‘creeping amputation’, the prognosis of it is still quite good. In fact, with a well control of the blood sugar and diligence in cleaning the wound and attending physio regularly, a post-amputation patient is able to have a prosthetic limb. It may be pricey, but imagine having a stronger and more solid leg than before. These patients understand and are enjoying the benefits of amputation.
Amputation may seem like the end of the world or possibly not the answer you are seeking for to sustain a better well-being, but with the right attitude, it can actually be a new chapter in your life.
If you would like to make an appointment with an orthopaedic surgeon:
Find an orthopaedic surgeon in Malaysia, on GetDoc
Find an orthopaedic surgeon in Singapore, on GetDoc
References:
https://www.orthobullets.com/foot-and-ankle/7046/diabetic-foot-ulcers
https://www.orthobullets.com/trauma/12311/below-knee-amputation
https://emedicine.medscape.com/article/1829931-overview
http://www.aofas.org/footcaremd/treatments/Pages/Below-Knee-Amputation.aspx
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by Azim Nasaruddin
A junior doctor, currently 'slaving' in a Hospital in Johor Bahru, determined to increase health awareness to the Malaysian public through his love and passion in medicine and writing. "“For he who has health has hope; and he who has hope, has everything.” – Owen Arthur View all articles by Azim Nasaruddin.
