Additional Diabetes Information:
The treatment starts at home which includes taking meticulous care of the diabetic feet, much before ulcers develop. To avoid direct heat by hot water bottles of fire places. In case of cold feet, use warm socks or gauge the temperature of the hot water bottles which have normal sensation, before using it. Avoid injury to your feet while cutting nails.
According to Dr. Chopra, causing injury to one's feet while cutting nails is a very common cause of infection followed by gangrene and foot lose. Should you injure your feet, do consult a vascular surgeon immediately.
“If ulcers or gangrene of the feet develops one should get admitted at the hospital as it is the safest way to save your feet from amputation,” he says.
Hospitalization is necessary due to the following reasons:- Lack of pain makes you neglect them. Many Diabetics have poor vision due to retinopathy and therefore can't do a good job. Many Diabetics suffer from heart failure with oedema which needs correction as it worsens ulcers. This can be done in the hospital only. Once in hospital the doctor will closely examine the ulcer, paying particular attention to its base as the infection is tracking deeper than anticipated and may be involving the bone
Diabetic Ulcer is caused due to many factors, and it can be of three types:-
(a) Involving Arteries
(b) Involving nerves
(c) Involving both arteries and nerves.
According to Dr. Chopra, should the Ulcers be superficial involving the skin and subcutaneous tissue, sparing the deep tissue, the treatment is to avoid weight bearing and take care of the ulcer by regular dressings.
If the ulcers are deep, they need to be dealt with in the operation theatre by removing all the dead tissue and the involved portion of the underlying bone.
“It is pleasing for the patient and doctor to see a healed ulcer. But by no means is the treatment over. The management is life long,” he says, adding once the ulcer is healed, special shoes are ordered to avoid overload on the area of ulcer. If there is infection or discharging wound or non-healed ulcer, avoid wearing shoes.
Dr. Jaisom Chopra warns that the pus in the foot could be dangerous as it can quietly creep into the blood, marking one very sick, though the patient remain unaware that his or her life is in danger because of Sepsis (bacteria in the blood). Along with this may be present uncontrolled diabetes (blood sugars in 400s) and heart failure.
In such circumstances, one should not resist hospital admission. The treatment available is urgent ICU admission, where Intra-venous antibiotics +vigorous control of your diabetes+ control of your heart failure are done on a war footing.
In majority is cases, cleaning of the foot would suffice. Regular dressings will be needed in hospital till there is no infection. The last resort available is Skin Grafting done to close the wound Dr. chopra However, cautions that “one should always remember that other foot of the affected person is not safe. Statistics show that 46% develop ulcers in the other foot within 2-3 years and 20% land up with amputation of both legs”.
Another presentation in diabetics is non-infective, dry gangrene of the foot, which does not bother the patient, which the patient tends to ignore, bur Dr Chopra warns patients and says that the patient should consult a vascular surgeon at the earliest.
“Do not say no, to amputation of toes is the doctor so, as in no time this harmless looking gangrenous toe or foot will get infected and in such cases the patient will not only be in danger of losing his leg but his life too may be at risk” , he says.
Diabetic foot and smoking is the worst combination and are partners in crome. “If you do not give up smoking the chances of your losing your foot increase manifold”, Says Dr. Chopra.
So the Golden Rules for those suffering from the Diabetic Foot are do not neglect if ever. If the vascular surgeon says so, get admitted to the hospital. Do not resist surgery as that may be only chance to salvage your limb.
However, for those who end up with and amputation, Dr Chopra has words of hope. With advanced prosthesis, your mobility will hardly be affected and your social life will remain the same, he says.
Most of us experience pain in the legs while walking and also while resting, but a majority of us ignore the pain or at the most take some pain killers and get momentary relief. Bur such repeated occurrence of leg pain is not to be ignored as it could be due to an underlying Vascular problem.
The Vascular disease is caused due to the blockage of artery to the leg. It is due to the deposition of fat within the artery wall narrowing it and thus leading to reduced blood supply to the leg and causing pain and other problem. Diabetics and heavy smokers have to be extra careful.
The following are the symptoms of Vascular disease.
- Pain on walking relieved by rest
- Pain preventing your from sleeping at night(Rest Pain)
- Pain in the legs, hips, buttock, while walking relieved by rest,
- Pain when laying down (or when legs are elevated ) relieved by dangling or lowering legs
- Changes in colour appearance of legs and feet.
- Thin shiny skin on the legs.
- Thickened brittle toe nails.
- No hair on toes, legs and calves.
- Feet turn dark when down, turn pale when up.
- Blue or purple toes.
- Wound (Ulcers) on the lower legs found between toes or on the tip of the toe, outside of the ankles anywhere your shoes rub.
According to Dr. Jaisom Chopra Vascular Surgeon with Batra Hospital New Delhi
If the pain prevents you from sleeping at night, one may be in danger if losing his leg and has to be brought immediately under the notice of a vascular surgeon?.
Dr Chopra further says not everybody needs hospitalization if the pain is not interfering with your life style then exercise and complete abstinence from smoking a required.
The patient suffering from the above symptoms has to undergo certain tests before it is diagnosed as Vascular. Firstly colour Doppler Or Ultrasound of the leg arteries to show the site of narrowing or blockage and seeing if collaterals will be capable of taking the increased blood flow post? operatively.
The second test is Angiogram before the surgery. It is a slightly painful invasive technique showing the inner lining of deceased arteries along with the extra channels (collaterals) making the legs survive so long.
As mentioned earlier, if the patient has pain only while walking and that is not interfering with his life style, then probably exercise and complete abstinence from smoking will help. In other cases two kinds of surgeries are performed depending on the intensity of the problems.
In the case of Minimal Invasive Surgery, a patient needs hospitalization for 1-2 days. This technique is basically ballooning of the arteries (Angioplasty). It is dependent on the site and length of the blockage. A wire is passed from the groin or the arm to the site of mischief. A Balloon is passed over this wire to dilate the narrowing or blockage once achieved then a stainless steel stent is put into the area to prevent narrowing again. If possible, this is an excellent option with good result and long patency rate, says Dr Chopra.
The second type is Bypass Surgery where the patient needs hospitalization for 7-10 days. It is similar to the heart bypass except here the leg artery is being bypassed using your own vein or synthetic graft. In high flow system like the Aorta these last well over 20 years, while those below the groin last anywhere from 10-15 years, Good collaterals develop in the time and give enough blood to the leg.
The last and final option of not performing a surgery is possible in a critically? Ischaemic leg?, then Intra-venous strong vasodilator drugs may be given over 5 days to try and dilate your vessels by drugs.
Dr Chopra further says that less than 2% land up with major amputation if timely advise is taken from the vascular surgeon. Life would become much better if not absolutely normal.
In US, 10% of the people over 70 years have blocked arteries and those in the age group of 40-69 have 3 to 4% blocked arteries. The statistics for India are not available but presume that they are higher than US.