EVERY DAY, more than one major limb amputation is done in T&T.
Diabetic Foot Disease accounts for over 85% of lower limb amputations in Trinidad & Tobago. Sadly, the number of amputations has increased significantly, doubling from about 250 to 500 over the last 40 years.
Apart from the morbidity and disability of limb loss, about 15% of these patients die on admission to hospital (usually from acute sepsis). Another 20-25% die within one year. Thus, diabetic foot disease is both a limb-threatening and life-threatening condition.
The cost to the patient and family is significant. There is often loss of income/employment for the patient, while, for the family, they may have to hire caregivers for the patient. There are also additional costs for transport, medication, prosthesis, rehabilitation, and physical care.
The cost to our healthcare system is enormous. Of all common surgical conditions, the diabetic foot is responsible for the longest hospital stay. The average surgical patient is hospitalized for 4 days, while the diabetic foot spends 23 days. In addition, they have more dressings, more antibiotics, more blood tests, more consultations, more complications and more operations than the average surgical case. It has been estimated that diabetic foot hospital care costs about 600 million dollars annually in T&T.
How can Diabetes affect my feet?
The 3 commonest reasons for foot complications in diabetes are nerve damage (neuropathy), blocked blood vessels (vasculopathy), and immune compromise. The commonest precipitating factor in diabetic foot hospitalization and limb loss is foot trauma, accounting for 60% of cases in T&T, and 80% in Barbados. About 25% have impaired blood flow. Thus, foot care – prevention of foot trauma – is an extremely important preventative measure to decrease amputation rates. The other important measure is recognition and correction of blood flow problems in diabetic feet. Because of nerve damage, the foot has impaired sensation resulting in the patient not recognizing the injury when it occurs. It is often after several days that the patient or relative notices infection of the foot swelling, fever, redness but usually, no pain.
In the neuropathic foot, infection spreads rapidly and tissue destruction is extensive. Rapid spread of infection from the toe or foot up the leg, is a very common reason for amputation. Thus, early recognition and prompt treatment can be quite effective in limb salvage. The pattern of spread and corrective techniques are well known to those performing surgery on the diabetic foot.
When the blood supply is impaired, clinical, non-invasive tests and various forms of angiography can provide an unequivocal diagnosis. In about 90% of cases, we find lesions that can be corrected, thus improving blood flow to the foot and preventing amputation.
Red Flags to note
Any of these problems are warning signs that must be heeded and treated:
• Changes in skin colour or skin temperature
• Swelling in the foot or ankle
• Pain in the legs
• Open sores on the feet that are slow to heal or are oozing
• Ingrown toenails or toenails infected with fungus
• Corns or calluses
• Dry cracks in the skin, especially around the heel
• Foot odour that is unusual or won’t go away
Preventative Measures can save your feet
The good news is that in T&T, we now have techniques endovascular – (angioplasty, stenting), and vascular reconstructive procedures involving leg and foot vessels, that can salvage about 90% of the limb-threatened feet. Some of the limiting factors for these interventions are cost and availability of these facilities. While those may appear prohibitive, the cost of the limb loss to the patient and the family is immeasurable. The psychological effects are often as debilitating and enduring as the physical effects. We have had cases of severe depression, and suicide following amputation.
In all this apparent gloom, the good news is that we estimate that as much as 90% of the limbs we now lose can be salvaged by well-directed preventative measures, early diagnosis, prompt and appropriate treatment of septic, neuropathic, and osteoarthropathic feet.
Also, focused vascular reconstruction and endovascular procedures can now effectively deal with impaired circulation and these techniques are also available in Trinidad.
Recently, some innovative bony reconstructive procedures have been utilized in Trinidad, with good results for feet previously regarded as unsalvageable. Orthopaedic reconstruction of bony deformity is emerging as a new and progressive specialty in T&T.
Thus, a combination of general, vascular and orthopaedic surgery, along with meticulous medical care, good rehabilitation and appropriate public health measures can improve our limb salvage rate. Although we have had increasing diabetes and limb amputations, T&T is well poised to decrease the foot complications of diabetes and minimize amputation rates.