The Partners Blog

Special Teams Fight Diabetic Amputations

By LAURAN NEERGARD, AP
Mon Oct 1, 2:58 PM EDT

WASHINGTON —

A stubbed toe can lead to having your foot amputated? It can if you’re a longtime diabetic. And it can happen fast.

“Tuesday in the office, they’re fine. Friday, they’re in the emergency room with gangrene in a toe,” says Dr. Peter Sheehan, diabetes chief at New York’s Cabrini Medical Center.

It’s a little-known statistic: Foot problems _ wounds that won’t heal, infections, warping bones _ are the most common reason diabetics are hospitalized.

And many of the 80,000-plus amputations of toes, feet and lower legs that Americans diabetics undergo each year are preventable, say specialists who brought more than 900 health providers to a meeting last week to figure out how to do just that.

One recommendation: For hospitals to create diabetes limb-salvage teams.

It sounds simple. But it involves pairing specialists who seldom work side-by-side _ like podiatrists and vascular surgeons _ to shave weeks off the time it can take to get proper care for a festering foot.

“It gets them everything they need right away, without months of waiting (between doctor appointments) while the wound is going downhill,” says Dr. John Steinberg, a podiatrist with Georgetown University Hospital’s limb-salvage team.

Some 21 million Americans have diabetes, meaning their bodies cannot properly regulate blood sugar, or glucose. Over years, high glucose levels seriously damage blood vessels and nerves, eventually leading to kidney failure, heart disease and other complications.

Among them is a vicious trio: Foot ulcers that strike about 600,000 diabetics annually; loss of sensation in the feet called neuropathy that makes sufferers slow to notice they have a wound; and poor blood flow in the lower legs that makes the ulcers slow to heal.

Amputation may end the grueling cycle of unhealing wounds and infection on one limb. But those patients still face grim odds. About half will develop ulcers and infections in the remaining foot, and undergo more amputations. And within five years, more than 40 percent are dead.

Infection is the chief reason for amputating. But there are no firm guidelines on when a limb is beyond salvaging _ and a 2001 study of Medicare-covered diabetics found large differences in amputation rates in different parts of the country.

Until recently, most research into diabetic wounds has focused on methods to clean them out and spur new skin growth.

The newer message: Check blood pressure in a diabetic’s ankle before rushing to foot surgery. One in three diabetics over age 50 has a condition called peripheral arterial disease or PAD, where leg arteries become too clogged to get enough blood to the feet.

That’s one reason that last week’s meeting urged a team approach to saving diabetics’ limbs: Whatever foot surgeons apply to heal a nasty ulcer won’t work unless a vascular surgeon has first cleared clogged leg arteries.

“We are hostage to the blood flow,” is how Dr. David G. Armstrong, a podiatrist at Chicago’s Rosalind Franklin University of Medicine and Science, puts it.

Minimally invasive leg-clearing therapy _ propping open clogged arteries with balloons and stents, or rooting out the sludge with tiny razors and lasers _ is on the rise. But Dr. Richard Neville, Georgetown’s vascular surgery chief, says many diabetics have such severe blockages that they need blood rerouted, using one of their own clog-free veins or artificial blood vessels.

Then can come what Armstrong calls the variety of “goops and gadgets” to apply straight to the ulcer.

What works best? Studies are under way to try to determine that, but Armstrong and Steinberg recommend old-fashioned debridement _ scraping away dead tissue every few days _ and a vacuum-sealing device that helps keep the wound moist. Certain dressings can provide a scaffolding for healthy cell growth from the inside-out.

Between those vascular and ulcer-patching surgeries, patients see a lot of other doctors. Endocrinologists get blood sugar controlled enough to allow surgery. Infectious disease specialists find the right antibiotic cocktail. Orthotists design casts and special shoes to keep pressure off the foot’s weak spots.

Treating a simple diabetic foot ulcer can cost $8,000; an infected one, $17,000.

The main message for the average diabetic: Take off your socks and shoes at every visit to the doctor and ask that he or she examine your feet. Many doctors follow this government guideline, but almost half of diabetics don’t get a simple foot check that could spot brewing problems in time to avoid a limb-threatening ulcer.

And ask about the ankle blood pressure test, called an ankle brachial index. New York’s Sheehan says the simple test is a leading predictor of which diabetics will be hospitalized for foot ulcers, and the American Diabetes Association recommends that every diabetic over 50 get checked.

-Dr. Hinkes

According to Dr. Sherry Scovell, the director of endovascular surgery at Beth Israel Deaconess Medical Center in Boston, “The single best treatment method for peripheral vascular disease is prevention. Patients can imporve their outcomes via risk factor modification.” According to Dr. Scovell, “approximatley, 20% of patients with diabetes will develop either a foot infection, ulcer or rest pain and will require hospitalization.”

If you are concerned about your circulation and the possibilites of limb loss here are a few things you can do for yourself to keep your legs.

1. Stop Smoking! This alone will significantly reduce your risk of atherosclerosis.

2. Meticulous Foot Hygiene. Even if there are no symptoms, you should practice good foot hygiene. Your feet should be inspected daily. Look for dry or cracked skin, corns and callouses or thick and discolored nails. Consider professional foot care for these problems.

3. Moisturize skin to prevent cracking and an opportunity for infection.

4. Wear shoes that fit properly. Improperly fitted shoes can cause pressure points on the foot triggering an ulcer and infection.

5. Pain in your legs when you walk (intermittant claudication) or at night (rest pain) can be an indicator of vascular disease. Excercise, such as walking or riding a bicycle can help increase circulation.

6. High blood pressure and high blood lipids also can contribute to vascular disease.

If you develop an ulcer on your foot is is CRITICAL that you have an evaluation by a vascular surgeon. These specialists in circulation have 21st Century tools like ankle-brachial index, a non invasive test to evaluate your circulation, and arteriogram, a definative exam to identify problems with your circulation. Once identifed, a vascular problem can often be corrected with an endovacscular surgical procedure.

According to David Allie, MD., a noted endovascular surgeon, 90 % of limbs with circulatory problems can be re-vascularized, thus preventing amputation. Amputation as a 1st treatment is WRONG, legs can be salvaged. But why even let yourslef get to the stage where you need to consider amputation?

Practice prevention for vascular disease and live a full and healthy life without worrying about losing your legs.

-Dr. Hinkes

Fish oil is primarily known for lowering the risk of sudden cardiac death, and it could potentially lower patients’ risk of stroke, non fatal heart attack, heart failure, atrial fibrillation and dementia, says Dariush Mozaffarian, MD, an assistant professor of medicine and epidemiology at Harvard Medical School in Boston. There’s no doubt, however, says Mozaffarian, that “for cardiovascular health, the most important single food in the food supply is fish or omega-3 and high doses are not required.”

This is good advice for patients with diabetes who should be vigilant about their vascular health. Remember, problems with circulation disproportionately affect the patient with diabetes.

You might have a few questions, so lets’ proceed.

Right about now you are probably asking yourself, , “OK, what kind of fish should I be eating?”

The doctor recommends eating seafood once or twice a week and likes the oilier fish such as salmon, herring, anchovies, and tuna. If you don’t like fish or feel you might not be getting enough Omega-3 acids, a low dose supplement is then recommended. The over the counter version of Omega-3 is known as Omacor, a soft gel capsule. Four grams/day is recommended for patients with triglyceride levels of 500 or greater.

Yes, “OK, how can I know if I need supplements?”

A risk profile is created using the results of your lipids , glycated hemoglobin, (A1C), and inflammatory markers and body mass index (BMI) and blood pressure.

Coincidentally these, and other measures are ALSO evaluated in the amputation prevention evaluation. With the vascular system being extremely vulnerable to plaque build up the result is critical limb ischemia. Prevention in cardiovascular health plays a significant role in amputation prevention.

A 5-year trial begun in 2004 named Outcome Reduction with an Initial Glargine Intervention (ORIGIN) will evaluate cardiovascular events in 10,000 early type 2 and pre-diabetic patients in 600 sites in 35 countries.

-Dr. Hinkes

P.S. Don’t take fish oil or Omega-3 if you are allergic to fish………….

Most of us at one time or another have stubbed our toe or even dropped something on our toe resulting in a discoloration under the nail or a black spot. In almost all cases the black spot is the result of the trauma resulting from bleeding under the toenail. Sometimes the entire nail seems to be affected and the bleeding can cause pressure and pain. After the injury some people are unable to wear shoes due to the pain and will need medical help with their problem. If the wound to the toe is acute, the blood can be evacuated painlessly by opening a small hole in the nail by electrocautery or after anesthetizing the toe removing the entire nail.

But wait, not all black spots under the nail are dried blood. Sometimes a black spot under the nail can indicate a different and more sinister problem, melanoma. The American Cancer Society estimates 60,000 cases of melanoma will be diagnosed in the United States this year, and 8000 people are expected to die from the disease.

Melanoma can be found anywhere on our body, even in places “where the sun don’t shine,” and that includes the soles of the feet, between the toes and around or under the toenails. Half of the people who learn they have melanoma of the foot die within five years because the cancer had already spread throughout their body by the time it was diagnosed.

How can we decide if that black spot under your nail is dried blood or a melanoma? One easy way is to mark the nail and watch to see if the black spot moves along with the nail as it grows out. If the spot moves as the nail grows, chances are that the problem is dried blood. However, if the spot does not move with the nail as it grows it may be a melanoma. At this point a biopsy should be done to send a piece of the affected tissue to the pathologist for microscopic diagnosis.

If you are diabetic you should not be walking barefooted even in your home. But if you notice a mole, freckle or spot that starts to change over the course of a month and becomes asymmetrical or changes its border, color diameter or elevation, see a doctor immediately. It could be more than dried blood. Early recognition and treatment of melanoma can save your life.

-Dr. Hinkes

The miracles of modern medicine were on display in New Orleans at the New Cardiovascular Horizons Meeting and it was quite a show… Hundreds of medical specialists from a variety of disciplines including primary care, surgeons, podiatrists, nurses, physician assistants and technologists were in attendance to learn the latest about endovascular surgery and amputation prevention. The real significance of this meeting was not so much the display of the latest technology but the interdisciplinary nature of the gathering. Just as patients with diabetes need their posse of specialists each who treats a specific part of the problem, the educational experience here was also interdisciplinary.

Sitting in dark rooms with endless PowerPoint presentations is the norm at most meetings, but not this one. After the second speaker finished his presentation we were switched “live,” just like on NBC to an operating room to see an endovascular surgeon using the specialized tools of his trade on a real patient through the magic of the internet/cable TV.

Endovascular surgery involves using long pieces of fiber optic wires thinner than a piece of your hair that are threaded through a small incision that opens into the femoral artery, in the patient’s groin (no identifiable parts of the patient were seen). The goal of today’s procedure was to open a blocked artery in the patient’s leg to return circulation to the foot. The entire process was done via the surgeon watching a TV monitor that showed real time images from inside the body that were taken with a “C” Arm machine much like a fluoroscope.

I watched in total amazement on a TV monitor and saw the whole show. I saw the guide wire snake through an imaginary road map of unseen arteries, leading the way for the excimer cold laser that would be used to destroy any calcification or plaque in the artery. Before inserting the laser, the “Polar Catheter” was put into action to freeze the artery to -10 degrees Centigrade. Seems that modern science has figured out that if we freeze the artery BEFORE we laser it, the procedure works better and that is the job of the Polar Catheter. After preparing the artery with the freezing procedure the surgeon carefully inserted the laser through the tiny incision on the leg and then rolled the wire containing the excimer laser between his thumb and index finger. The laser could be seen on the TV monitor rotating and silently destroying the calcified clot. Right in front of my eyes this tiny laser vaporized calcified blockages in the artery of the unknown star patient.

As often happens, things didn’t go exactly right. But, credit the surgeon who had years of training and experience who was able to figure out the problem and what it would take to fix it, again, right before our eyes. “OK, I see the stent is fractured and that is going to cause us a problem,” he said. “We are going to fix this by placing a balloon catheter INSIDE the stent.” And without saying another word his trusty surgical assistant ripped open the package containing the right size stent and carefully threaded it into the catheter.

I watched the TV monitor, holding my breath, as the balloon catheter moved closer to the fractured stent and was inflated. Done. Problem solved, just that quick.

Now, for the moment of truth, 10 cc’s of a dye used for imaging the results of the procedure was sent swirling into the catheter and I watched the TV screen to see, if indeed, the artery was open. Then, in real time, on TV, I saw it, where there had been no previous indication of any circulation in the artery, there was indeed robust circulation..all the way down to the foot. The leg had been saved from amputation.

Why am I so excited about this technology?

It is because now patient’s with CLI or Critical Limb Ischemia no longer will need to have their legs filleted open from their groin to their ankle, risking infection and a lengthly recovery and recuperation and can have the circulation restored through an incision on their leg of less than 1 inch in length! An added benefit of this procedure is that the patient will not need to have the other leg filleted to harvest the vein for the by-pass graft to be performed. Some patients are just not healthy enough to tolerate the load of trauma of opening both legs, one to provide the donor graft and the other to receive the graft.

Oh and the Silver Hawk., well this little device is used to literally scrape out the plaque from within an artery like you would use a cheese knife to slice cheese. A slice at a time the Silver Hawk moves up and down the artery and literally cuts out the plaque that is then brought out thru the catheter and removed from the artery. And for cleaning out arteries in the foot that are too small for the silver hawk there is the mini hawk. A smaller version of the silver hawk that fits into the tiny arteries in the foot!

Every patient that is facing an amputation should have the benefit of a consultation with a surgeon trained in these 21st century limb saving techniques.

No longer should amputation be the 1st treatment or treatment of choice for patients with critical limb ischemia, there is an alternative that really works!

-Dr.Hinkes