Pro­fes­sor Vi­jay Narayns­ingh

Pro­fes­sor Emer­i­tus of Surgery, UWI

Con­sul­tant Sur­geon,

Med­ical As­so­ciates Hos­pi­tal

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.

Re­con­struc­tive Pro­ce­dures

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.