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Diabetes and Amputation:
Protecting Your Feet and Limbs

~ by Jo Jordan

Amputation is a truly frightening prospect. And as unexpected as it may seem, diabetes and lower-limb amputation are closely connected. So much so that every year in the United States, between 80,000 and 84,000 non-traumatic lower-limb amputations are carried out as a result of diabetes complications.1

Diabetes-related amputations account for more than sixty percent of all non-traumatic lower-limb amputations in the United States.2

Partial foot amputation is successful in about seventy-five percent of diabetes-related amputations; however, twenty-five percent fail, requiring amputation of the leg from below the knee.3

While it has been estimated that five percent of adults who have diabetes will eventually require toe or foot amputation,4 foot care programs including regular examinations and patient education may prevent up to eighty-five percent of diabetes-related amputations.5 So if you’ve got diabetes, it’s crucial to arm yourself with the how’s and why’s in order to prevent future amputation.


How Are Diabetes and Limb Amputation Connected?

Diabetics are unable to produce or properly use insulin – a hormone produced by the pancreas that unlocks the cells of the body, enabling glucose to enter and fuel them – so glucose accumulates in the blood. High glucose levels can damage the nerves of the feet, and impair the body's ability to effectively fight infection.

Reduced sensation resulting from nerve damage (known as diabetic or peripheral neuropathy) can interfere with the body’s ability to detect pain. Diabetes can damage blood vessels, leading to poor circulation in the extremities. Tiny abrasions, blisters, and cuts may become infected before they’re even noticed, and poor blood flow can hamper the body's ability to heal.

Left untreated, a minor foot injury could turn into a serious infection, possibly leading to gangrene (tissue death). If an infection turns into an ulcer that won’t respond to treatment, the toe or foot – or a portion of it – may eventually need to be amputated. An infection can sometimes persist post-surgery, necessitating the removal of the leg from below the knee to try to halt the progression of infection.


Symptoms of Peripheral Neuropathy (Nerve Damage)

Symptoms of nerve damage may include,

  • Constipation or diarrhea
  • Dizziness or faintness
  • Erectile dysfunction in men
  • Indigestion, nausea, or vomiting
  • Numbness, pain, or tingling in the toes, feet, legs, hands, arms, and fingers
  • Urination difficulties
  • Vaginal dryness in women
  • Wasting of feet and/or hand muscles
  • Weakness
Depression and weight loss often accompany peripheral neuropathy.



Preventing Limb Amputation: Risk Factors and Preventive Care

People with diabetes are more prone to infections than the rest of the population and, once infection develops, they have more difficulty overcoming it. This is especially true when blood glucose is not kept within a healthy range. While keeping control of blood glucose levels will not prevent an infection, being within a healthy range will assist your body in overcoming an infection if one sets in.


Other Risk Factors Associated with Amputation:

  • Being elderly (amputation rates increase with age)
  • Being male
  • Being single
  • Clinical signs of peripheral arterial disease (PAD)
  • Foot deformity
  • Having elevated hemoglobin A1c (HbA1c)
  • Higher resting pulse rates
  • Inadequate footwear
  • Infection
  • Insulin use
  • Length of diabetes
  • Lower systolic blood pressure
  • Peripheral neuropathy
  • Previous history of foot ulcerations or infections
  • Vascular disease


Preventive Care

The most common reason for hospitalization for those with diabetes is foot-related issues. In fact, nearly half of all amputations are caused by neuropathy and circulatory problems that could have been prevented6. But by implementing a simple, preventive, daily foot care regimen, many hospital visits are entirely avoidable.


Caring for Your Feet

  • Wash feet daily with mild soap in lukewarm water; avoid soaking feet, and dry gently with a soft towel, paying careful attention to between the toes; sprinkle talcum powder or cornstarch in between toes.

  • Moisturize tops and bottoms of feet (but not between the toes) to keep skin soft.

  • Inspect feet daily. Use a hand mirror on foot bottoms to watch for blisters, bruises, calluses, corns, cracks/breaks in skin, cuts, dry skin, discoloration, hot and/or cold spots, ingrown and/or sharp toenails, redness, soggy skin, sores, and/or swelling in only one foot or leg. Be alert for anything abnormal, or for symptoms that were not there yesterday.

  • Trim toenails carefully, straight across, and then file edges with an emery board. Seek professional nail trimming if necessary.

  • File corns and calluses gently with a pumice stone after bathing or showering.

  • Never go barefoot. Wear slippers or comfortable, soft, seamless socks and proper footwear to prevent foot ulcerations.

  • Wear properly fitting shoes that allow toes to move.

  • Break in new shoes gradually, initially wearing them for only an hour at a time.

  • Check shoes carefully before putting on, feeling the insides to ensure they have no tears, sharp edges, or objects inside them that might injure feet.

  • Learn about specific products for the diabetic foot. It may be necessary to wear an orthowedge: a special shoe designed to alleviate pressure on the front of the foot.

  • Be aware of cracking from dry skin; it can become ulcerated over time.

  • Schedule regular foot checkups to inspect for early signs of nerve damage, poor circulation, or other foot problems.

  • Take foot injuries seriously. If a sore or other foot problem doesn't begin to heal within a few days, contact your health care provider.


General Preventive Care

  • Ask your health care provider to inspect your feet and hands during each visit.

  • Be aware that heating pads and electric blankets can burn skin, especially when neuropathy is present.

  • Care for small cuts, blisters, and/or abrasions immediately; seek professional help at the first sign of a foot problem.

  • Eat a healthy, balanced diet; consider a multi-vitamin to ensure adequate vitamin, mineral, and nutrient intake.

  • Exercise regularly to increase blood flow and insulin sensitivity.

  • Maintain a healthy body weight.

  • Quit smoking; it can cause and/or aggravate circulatory problems.
Always remember to examine your feet regularly, and check blood glucose often; maintaining healthy glucose levels goes a long way toward preventing future amputation.



A Word About Charcot’s Arthropathy

Charcot’s arthropathy is a progressive musculoskeletal condition characterized by joint dislocation, fractures, and deformities. Progressive destruction of the bone and soft tissue of – most commonly – the foot and ankle result.

A severe complication of diabetic neuropathy that affects sufferers of both types 1 and 2 diabetes, Charcot’s arthropathy is difficult to detect at first as its only symptom is swelling. While both feet can become diseased, in most cases only one is affected.

Onset occurs when diabetic neuropathy goes unnoticed. Usually, the foot becomes warm and extremely swollen, yet the sufferer has experienced no trauma (i.e. a twisted ankle); there is a disproportionate amount of pain compared to the degree of swelling, which refuses to subside.

Pressure within the foot causes a weakening of the bones, but the patient feels little pain as a result of the neuropathy, and continues to walk on the foot. This leads to severe deformities and irreversible ulceration. In the worst cases, the condition necessitates amputation.

Early diagnosis at a stage where treatment can minimize deformities and prevent the need for amputation is crucial.



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Notes:
1. Sandor Joffe, MD, “Hemochromatosis,” eMedicine Radiology, March 11, 2005, http://emedicine.medscape.com/article/369012-overview (accessed March 27, 2009).
2. National Digestive Diseases Information (NDDIC), a service of the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, “Hemochromatosis,” http://digestive.niddk.nih.gov/ddiseases/pubs/hemochromatosis/index.htm (accessed February 13, 2009).
3. Mayo Foundation for Medical Education and Research (MFMER), “Hemochromatosis,” http://www.mayoclinic.com/health/hemochromatosis/DS00455 (accessed February 13, 2009).
4. American Liver Foundation, “Hemochromatosis,” http://www.liverfoundation.org/education/info/hemochromatosis/ (accessed February 13, 2009).
5. Mayo Foundation for Medical Education and Research (MFMER), “Hemochromatosis,” http://www.mayoclinic.com/health/hemochromatosis/DS00455 (accessed February 13, 2009).


 
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