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Diabetic Foot and Ankle Complications and Limb Salvage

Diabetes Mellitus: What is this disease and What does it have to do with your feet?
Over 15-20 million Americans suffer from diabetes mellitus. It is a disease associated with a decrease in insulin production from the pancreas. When the pancreas does not produce adequate amounts of insulin, the body's regulation of sugar, starch and other carbohydrates become defective. Hyperglycemia (increased sugar in the blood) is the laboratory diagnosis. Some of the symptoms that diabetic patients have include increased thirst, weight loss, increased urination, and blurry vision. But what does this have to do with your feet? The purpose of this article is to help educate the diabetic patient on some of the foot problems caused by hyperglycemia and to help prevent them.

Infection
All diabetic patients are more prone to infection. When the blood sugar is higher than normal, white blood cells which normally fight infection do not work properly. As a result, bacteria and other organisms may invade tissues at a rapid rate causing inflammation, and abscess formation. Because the feet are frequently exposed to trauma, infection in the feet can be quite common. Once the skin is broken, bacteria may cause an ingrown toenail, cellulitis (skin infection) or osteomyelitis (bone infection). All diabetic patients can decrease their susceptibility to infection by good control of blood sugar with proper diet, insulin, and exercises.

Neuropathy - What is this?
When there is an increased in blood sugar for a long time, the nerve in the leg and feet become damaged resulting in altered sensations of numbness, and tingling. This altered sensation is called neuropathy. A diabetic patient could walk on a needle or a pebble for days and not know it. If a person without neuropathy walked on such a hard object, that person would have pain. Because the diabetic patient with neuropathy cannot feel the foreign object, he/she will continue to ambulate, causing tissue breakdown and eventually bacterial infection. This may lead to an amputation. Also, nerve damage will cause weakness in the small muscles in the foot and leg creating imbalance. When muscle imbalance occur, the foot may be prone to develop hammertoes, bunionsand other deformities, all of which may cause friction, breakdown and infection.

How does a diabetic patient know whether or not he/she has neuropathy? We have special instruments which help in the diagnosis of neuropathy. We also test to see if reflexes of the leg and feet are present as well as for other sensations. These are all decreased in a diabetic patient with neuropathy. This may result in having a Diabetic Charcot Foot.


Peripheral Vascular Disease
Diabetes is an important cause of hardening of the arteries. Other important causes include hypertension, high cholesterol and cigarette smoking. The hardening of the arteries result in poor blood flow to the extremities thus, decreasing nutrients and oxygen to vital tissues. This causes pain in the affected areas and that is why there is pain in the back of the calf during ambulation. And when one is at rest, the pain subsides because there is now adequate nutrients to the tissue. When the circulation becomes very poor, there will be pain all the time and at rest. The lack of nutrients will also result in poor hair growth on the toes, the nail may become deformed and the feet will be bright red when a person sits with the legs dangling over . This poor circulation can be diagnosed by checking for pulses in the feet and with a Doppler Ultrasound. Poor circulation may improve dramatically if one discontinues smoking cigarettes, and exercises.


What is a Diabetic Foot Ulcer?
When an opening in the skin of a diabetic patient occurs, it may form a hole and that is known as an ulcer. This ulcer may be due to poor blood flow or altered sensation. When we feel pain by stepping on a stone or wearing tight shoes, we usually feel pain and take appropriate actions to reduce it. But if you cannot feel pain, you will continue to walk and this could break the skin. Bacteria and other organisms may invade the hole resulting in an infected ulcer. This may infect the bone and cause osteomyelitis. IV antibiotics for 6 wks and or amputation may be required to treat this problem. The ulcers may occur on the toe, middle of the foot, as well as on the heel and ankle.


What is the role of Achilles tendon in diabetic foot ulcer and can surgery help?
 Diabetic patients frustrated by hard-to-heal, infection-prone ulcers on their feet could benefit from a common, minimally invasive surgical procedure to relieve tightness in their Achilles tendons.
 
The Achilles is the largest tendon in the human body, connecting the calf muscles to the heel bone.  As we age, the tendon naturally tightens.  However, diabetes exacerbates the process as increased blood sugar levels deposit glucose in the collagen of the tendon, greatly reducing its elasticity and making stretching almost impossible. 
A tight Achilles inhibits ankle movement, forcing diabetic patients to place excessive pressure on the front of the foot.  Pressure normally absorbed by the ankle has to go somewhere else and the forefoot gets most of it, heightening the risk for ulcer development underneath the toe joints. 

Foot sores or ulcers are a common complication of diabetes.  They result from sensation loss or neuropathy, which deprives diabetes patients of their ability to feel pressure or pain in the lower extremities.  Therefore even the slightest cut, blister or wound can develop into a diabetic foot ulcer.  Such wounds can cause tissue and bone infections and can result in loss of a toe, a foot, a leg or even a life.  Published research has shown that surgery to lengthen the Achilles tendon in a diabetes patient can help prevent ulcer recurrence.  My goal is to close the wound as quickly as possible, to avoid infection, and The Achilles is the largest tendon in the human body, connecting the calf muscles to the heel bone.  As we age, the tendon naturally tightens.  However, diabetes exacerbates the process as increased blood sugar levels deposit glucose in the collagen of the tendon, greatly reducing its elasticity and making stretching almost impossible.
 
A tight Achilles inhibits ankle movement, forcing diabetic patients to place excessive pressure on the front of the foot.  Pressure normally absorbed by the ankle has to go somewhere else and the forefoot gets most of it, heightening the risk for ulcer development underneath the toe joints. 

Foot sores or ulcers are a common complication of diabetes.  They result from sensation loss or neuropathy, which deprives diabetes patients of their ability to feel pressure or pain in the lower extremities.  Therefore even the slightest cut, blister or wound can develop into a diabetic foot ulcer.  Such wounds can cause tissue and bone infections and can result in loss of a toe, a foot, a leg or even a life. 

Published research has shown that surgery to lengthen the Achilles tendon in a diabetes patient can help prevent ulcer recurrence.  My goal is to close the wound as quickly as possible, to avoid infection, and to prevent the ulcer from recurring in patients with advanced diabetes.  This is best achieved by a minimally invasive procedure to lengthen a tight Achilles tendon.

Lengthening occurs by making three small, pinpoint incisions to loosen and stretch the tendon.  This helps restore ankle flexibility and relieves forefoot pressure.  The procedure allows diabetic patients who keep their blood sugar under control to walk more normally and may lower their risk for redeveloping foot ulcers. 

I have seen many diabetic patients whose foot ulcers heal, yet continue to recur because the untreated Achilles tendon problem is the root cause.  Thus, I advise diabetic patients who have developed foot ulcers to schedule an appointment with my office to determine if Achilles tendons surgery is appropriate for them. 

What is a Diabetic Gangrene?
This is a complication of a lack of blood flow to the foot and is a severe complication of diabetes. It occurs when the tissue does not have any oxygen and nutrients for several hours. Thus the tissue dies and turns black. Then infection occurs with or without pus. When this occurs, the patient will probably loose the affected area.



How are Foot Ulcers and Gangrene Treated?
Diabetic foot ulcers may be treated conservatively with the use of bed rest and antibiotics. We also help improve reduction in ulcers by the use of foot supports to help redistribute the pressure causing the tissue breakdown. If osteomyelitis or gangrene is present and neglected, amputation will become eminent. This may include single or multiple toes, the entire foot below the knee and in severe cases, the entire leg including the knee. Although amputation may appear disabling, many patients can return to useful and productive lives.


What Can You Do TO Prevent Amputation?

Exercise:
Many of the complication associated with diabetes can be avoided with exercise. Walking is still the best form of activity and it will improve the circulation. Try to walk as far as you can without having to stop. You can start out slowly and then try to walk 3-4 miles per day.

Other types of exercise include raising the heels, knee bending with your back straight, moving the leg up and down while sitting and walking up the stairs. All of these will help give motion to your legs and will increase circulation. Also, yoga, as well as other stretching forms of exercise will help loosen up the muscles and thus improve circulation.


How can you avoid foot ulcers?
Avoid injuries to the foot.
Inspect your feet for cuts, redness, swelling or sores.
Have a friend or family member look at the foot for any lesions.
Never walk barefoot
Avoid hot and cold areas. Stay away from electric blankets and hot-water bottles.
Get rid of Garters or elastic bands
Avoid cutting your own corns or calluses or using strong chemicals from the drug stores.
Custom molded shoes, orthosis and other devices may be used to help offload pressure producing areas.
Obtain regular foot examinations.


The following are foot care tips.
Keep feet clean, warm and dry.
Inspect feet daily
Do not forget to dry between the toes. Ulcers may form from maceration if not dried properly.
Use Eucerin cream or other lotion to keep the feet from cracking.
Cut the toenails after bathing when they are soft. Those with poor vision, unsteady hands, lack of sensations or poor blood flow and thus those that have a foot at risk should consult a Podiatrist. In general, if you have diabetes, you should see a Podiatrist routinely.
If your feet feel cold at night, wear socks at bed rather than using an electric blanket. The electric blanket may cause a burn in a neuropathic patient.
If you see a cut in the foot, go see a doctor immediately. Infection can occur anytime.
Powder the feet and shoes after bathing.
Wear comfortable and wide shoes. Buy shoes at night when your feet are the most swollen. This will prevent you from buying tight shoes.
You may call us at any time if you develop sores or wounds on the feet, ingrown nails, numbness or pain in the feet or legs, hammertoes, bunions, gangrene or other foot infection.

The following are some diabetic foot complications that may occur at any time.  These complications are limb threatening.

Case # 1: Diabetic Foot Ulcers unresponsive to conservative treatment, healed well after meticulous plastic rotation of the skin and limb salvage.

Case # 2

This patient is also a diabetic who had a heel (calcaneal ) fracture which then formed into a severe ulcer. She was told to have a below the knee amputation by many surgeons. By performing meticulous surgery and rotation of skin tissue, the ulcer healed and now she is ambulating with both legs.

Case # 3

Severe diabetic foot infection. This patient was told by many that nothing could be done for him and that a below the amputation is needed. With meticulous surgery, including plastic rotational skin flaps, skin graft, and proper wound care, this severe diabetic foot complication healed.

Case # 4

Diabetic great toe ulcer and infection. This patient was told to have the great toe amputated. The ulcer was due to jamming of the great toe and lack of motion at the great toe joint. By performing a strategically placed surgical incision and bony correction allowing for more motion at the great toe, the ulcer healed.

Case # 5

Diabetic with gangrene at the heel. She was also told to have the leg amputated. With surgical debridement of the dead tissue and application of a special skin graft, the foot was saved.

Case # 6

The following is a patient who has severe diabetes with gangrene and bone infection at the foot. He was told to have a below the knee amputation.

After the toe and part of the midfoot was amputated, a specialized plastic surgical technique was performed to allow for healing.

Several months later, the affected area healed quite well. He still has his foot and leg and is ambulating.