Management of Diabetic Foot

The amputation is necessitated by a condition called gangrene, in which a wound or injury in the leg of a person with diabetes causes an infection that worsens with time, leading to the death of the tissue. While the ulcer starts in the skin, the infection can spread to nearby muscles, tissues, and bone, necessitating amputation. To understand why this happens or how to minimize the risk of amputation, it is important to understand the health complications of diabetes.

Long-term complications from Diabetes

If diabetes is detected late, not managed well, or is severe, there can be complications such as:

• Cardiovascular problems: High blood sugar damages blood vessels and nerves in the heart, increasing the risk of heart attack, atherosclerosis (narrowing of arteries), and angina (chest pain).
• Nerve damage: High blood sugar can cause neuropathy or damage to nerves in the different parts of the body, such as the eye (retinopathy) and kidneys (nephropathy).
• Skin conditions such as bacterial and fungal infections are more common in people with diabetes.
• Hearing loss: Again, people with diabetes are more prone to hearing loss than non-diabetics, all other conditions being the same.
• Mental health issues: Diabetics are more vulnerable to depression and Alzheimer’s disease.

The first complication – vascular issues are not restricted to the heart alone and can occur in any part of the body. When they occur in the extremities of the hands or legs, the condition is called Peripheral Arterial Disease (PAD) or, a more recent name – Lower Extremity Artery Disease (LEAD). For this article, we will use the term LEAD. LEAD can happen to anybody, and one of the risk factors is diabetes. When a person has both diabetes and PAD, the risk of diabetes foot disease increases. As many as 50% of all diabetic foot disease patients have LEAD. That is why it’s important to know more about LEAD.

Lower Extremity Artery Disease (LEAD)

Arteries are blood vessels that carry blood rich in oxygen and nutrients from the heart to different parts of the body. These hollow tubes with a smooth lining prevent blockages and ensure a steady flow. In some people, especially those whose blood has a high cholesterol content, some of the cholesterol starts depositing on the walls of the arteries. The condition is called atherosclerosis. As a result, the artery becomes narrower, thereby reducing the blood flow, a condition called stenosis. The deposit soon hardens and is now called plaque. As plaque starts building up, the exterior of the blood vessel becomes hard and can develop a tear. Platelets in the blood rush to the incision site to repair the damage, thereby creating a clot.

The clot acts as a blockage in an artery that is already showing reduced blood flow. This means the limb supplied blood by this artery is getting lesser and lesser oxygen or nutrient-rich blood over time. As a result, the tissues start dying out slowly, and the condition is called gangrene. If there is an injury to the leg of such a person, the healing doesn’t happen quickly as enough oxygen-rich blood is not available now.

As a result, an infection sets in, which develops into an ulcer. The infection can spread to nearby tissues which are already showing gangrene—combining the two causes rapid decay or rotting of the tissues, which eventually necessitates an amputation. Gangrene can worsen with time without an injury or ulcer, leading to an amputation (an ulcer accelerates the degeneration).

Risk Factors for LEAD

• The number one risk factor is using tobacco products in any form (cigarette/beedi/cigar/chewing tobacco/hookah/gutka products) is the number 1 risk factor. Tar and nicotine deposits in the lungs cause less and less oxygen-rich blood to be pumped by the heart over time.
• Having diabetes. As explained above.
• Being age 50 and older. Aging induces a slow and natural thickening of arteries, which could be the reason.
• Having a personal or family history of vascular or heart conditions
• Hypertension or high blood pressure
• Hyperlipidemia or high blood-cholesterol
• Abdominal obesity
• Having any blood-clotting disorder
• Acute or chronic kidney disease, which is both a risk factor and a consequence of LEAD

Symptoms

 Early symptoms: The only early sign is claudication. That is, pain in the legs caused by walking, although the exact distance was covered earlier with no pain. The pain eases when the person rests for a while. After exertion, the leg muscles feel weak, heavy, numb, and tired. Once rested, the pain goes away, and the person can walk till the pain resumes. This is called intermittent claudication. If the condition is ignored or a doctor is not consulted, the same pain starts in the calf muscles, thighs, and hips.

Advanced symptoms

The aching pain in the feet and toes while walking turns into a burning pain while resting, especially at night and lying flat.

• The skin on the feet feels cool.
• There is redness or changes in the colour of the skin.
• Infections get cured but keep recurring.
• Sores on the feet and toes that do not heal for long.

Consequences

 If LEAD is not diagnosed or treated in time, it can lead to:

• Heart attack: Reducing blood supply to the heart gradually causes permanent damage to the heart muscle, triggering an attack.
• Stroke: When the above condition happens in the brain, it causes a stroke.
• Transient ischemic attack (TIA): A temporary interruption in blood supply to the brain.
• Renal artery disease or stenosis: A narrowing or blockage in the artery that supplies blood to the kidney(s).
• Amputation: Of one or more toes, or part of the foot, or even leg. More familiar with people with diabetes than non-diabetics.

Diagnosing LEAD

• Ankle Brachial Index: These measures blood pressure in the lower limbs compared to the upper arms. Blood pressure cuffs are placed on both the arms and legs and then inflated. The blood flow in both of them is monitored or ‘heard’ using a Doppler ultrasound. The more the disparity in BP between the arms and legs, the higher the likelihood of LEAD.
• Pulse Volume Recording: This measures the blood-volume changes in the legs. A blood pressure cuff is placed on either arm, and multiple cuffs are placed on both legs. The person is made to lie down, and the cuffs inflated. As blood flows or pulses through the legs, the volume of air increases or decreases within the cuff. These ups and downs are plotted as a waveform using an instrument. The deeper the waveform, the healthier blood flow is and, hence, a lesser likelihood of LEAD, while a flatter waveform can indicate LEAD. This test also shows where exactly the blockage is.
• Doppler Ultrasound: A small device called a transducer is placed on the leg, precisely above the artery suspected of having a blockage. The device emits sound waves that bounce off the artery, which are recorded with a pattern displayed on the monitor. This helps understand if LEAD is present and exactly where the blocks are.

Treating LEAD

Medications

• Medicines for diabetes: the patient will already be using them. But the dosage and drugs may be changed now.
• Medicines for high BP: Also called anti-hypertensives
• Medicines for high cholesterol: For example – statin medications
• Anti-platelet drugs such as aspirin and clopidogrel. These reduce the risk of clots, hence heart attack and stroke.
• Others: Drugs such as cilostazol reduce claudication pain and improve walking distance

Lifestyle changes

• Quitting smoking or the use of tobacco products completely.
• Eating a balanced diet high in fiber and low in fat, cholesterol and salt.
• Regular exercise: Walking regularly and exercises like running, swimming, and yoga.
• Constantly monitoring and keeping in check – BP, diabetes and cholesterol.
• Stress Management: Exercise, yoga, and meditation help keep stress levels low.
• Good foot-care by wearing proper-fitting socks and footwear.

Surgical Interventions

• Balloon angioplasty: A tiny balloon is inserted into the blocked artery using a catheter and then inflated. The balloon pushes against the plaque and relieves the blockage.
• Stents: In addition to balloon angioplasty, the doctors may insert a stent. This small metal coil sits inside the artery, pressing gently against its walls, thereby preventing a new blockage.
• Peripheral artery bypass surgery: Similar to the heart bypass. A section of a healthy vein from the patient’s body, or a synthetic replacement, is used to create a bypass around the blocked area in the leg artery, thereby restoring blood flow.
• Atherectomy: A catheter with a blade fitted at its end is inserted into the artery, and the plaque build-up is shaved out.

 

Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai, Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.

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