Mind That Diabetic Foot

2010 Dr SC Misra Oration Award [Listen to audio podcast] was conferred upon Dr Ajith Kumar Varma at the 55th Foundation Day of Department of Surgery (General), Chhatrapati Shahuji Maharaj Medical University (upgraded King George's Medical College - KGMC). Dr Varma is an assistant Professor in the Department of Endocrinology at Amrita Institute of Medical Sciences in Kochi, Kerala. After serving the army for 15 years, he is doing excellent work in the field of podiatric surgery, related to the diabetic foot. I had the opportunity to meet him when he was recently in Lucknow to attend the 55th Foundation Day Celebration of Department of General Surgery, CSM Medical University, where he charmed everyone with his suave manners and modesty, as well as his passionate zeal for improving the quality of life of those living with diabetes. Read more

This article is based on an exclusive interview given by him to Citizen News Service (CNS). The concept of reconstructive and corrective surgery for the diabetic foot has evolved very recently, as a means to correct foot deformities. This latest technique is presently being practised in very few countries of the world. There are a few selected centres in the US, UK, Germany, Russia, Spain and Australia, with USA, which has 7 podiatric schools performing such operations, topping the list. In India, Amrita Institute of Medical Sciences, situated in Kochi, is the only institute doing this type of reconstructive surgery in high risk patients of totally deformed diabetic foot, thus obviating the traumatic need for amputations.

There is an entity called 'Charcot' in diabetic foot problems. In prolonged diabetic foot problems there is an increased blood flow to the lower limbs, due to autonomic neuropathy, which causes demineralisation of the bones. It is a tsunami like effect, just washing away the minerals of the bones. Moreover, it stimulates certain cells which simply eat up the bones. All this weakens the bones, and makes them soft and pudgy. This results in the collapse of the foot and ankle bones, making it impossible for the patient to walk. Moreover, multiple increased pressure points are developed on the soles of the affected feet, where ulcers and calluses develop. These act as portals for entry of bacteria. As the cellular immunity of the patient is suppressed, even the slightest bacterial infection can cause a serious life threatening problem, so much so that if the patient is not given proper treatment within 24 to 48 hours of the infection setting in, it may result in amputations or even death.

Worldwide, 50% of all leg amputations happen to people living with diabetes. In India, an estimated 50,000 amputations are carried out every year due to diabetes related foot problems. By employing reconstructive and corrective surgical techniques, to correct the shape of the deformed feet and remove the high pressure points, a large number of such amputations can be prevented. Thus the patient can lead a near normal life, free from complications.

After having trained in the US, two years ago, Dr Varma has been performing different types of foot and ankle corrective surgeries, at the Amrita Institute, to normalise the shape and function of the grossly deformed diabetic feet. Last year, more than 25 such surgeries were performed. The best, amongst the 8 to 10 types of surgical techniques currently available, is the Triple Arthodesis Surgery, which costs around Rs 30,000. The costs of implants, titanium screws and suture fibre wires are additional. This, according to Dr Varma, is quite reasonable, especially when compared to the exorbitant fees charged in the USA for a similar operation.

Not only this, Dr Varma and his team have developed a new 'Amrita Sling Technique' for foot stabilisation, which is one of its kinds in the entire world. This obviates many complications which routinely occur after the reconstructive surgery.

In normal corrective surgery of 'Charcot's Foot' (as is being done in the US and elsewhere), the patient has to take rest for 4 to 5 months before s/he can start walking, as the bones need time to reconsolidate gradually. Moreover, during this period, an external fixture called 'Illazarov Frame' has to be fixed on the foot with screws and pins, which penetrate the bones and flesh. When the patient starts walking, it is very likely for infection to set in, paving the way for amputation.

But the Amrita Sling Technique, when applied once the reconstruction is done, results in quick normalisation of the gait bio-mechanics and ambulation of the patient. This reduces the long recuperation period, and also minimises the post operative complications. It has been successfully tested on 10 patients at the institute who are now leading a normal life.

Apart from doing pioneering work in the field of podiatric surgery, the Amrita Institute happens to be the only one in Asia, offering three specialised courses under one roof, informed Dr Varma. It conducts a one year post doctoral fellowship programme in podiatric surgery with a view to train more doctors in this field. Another 4 year course in diabetes and diabetic foot surgery exists for MBBS students, as also a course for training paramedical staff for management of diabetic foot.

Dr Varma stressed upon the importance of proper and timely foot care and foot wear advice to patients, to prevent limb and life threatening infections. From the day the patient is diagnosed with diabetes, proper foot care and foot wear advice must be instituted to prevent further complications. As far as a good foot wear prescription is concerned, it has to be given with utmost care. Diabetic foot wear are not off-the-counter purchases. They are made of specific material, like micro cellular rubber, micro cellular polymer, or ethyl vinyl acetate, which distribute pressure evenly on the surface, and prevent build up of pressure points, to avoid formation of calluses which are entry points for bacterial infection. Proper footwear should ideally be prescribed only after doing a pedopodogram, in which plantar pressure at each point of the under surface of the feet is measured. This is as necessary as testing the blood sugar levels of a patient before prescribing insulin or other oral medication.

With India earning the dubious distinction of being the diabetic capital of the world, Dr Varma rightly stressed upon the need for awareness about the complications of the disease in the public, in the patients, and, above all, in the primary care physicians, working in rural areas. In his words 'Pick up the lesion at the earliest', so that the problem can be resolved without amputation. In developing countries, as in India, the amputation rate is over 45%, whereas in the USA, and also in patients at Amrita Institute, it is a mere 8.5%, thanks to the novel surgical techniques available. Not only this, as diabetes is a disease of the blood vessels, all the organs get affected, especially the heart, which is strained over 15%. Even with the best of processes in place, there is 85% mortality, within 5 years of the amputation, due to cardiac arrest. Hence it is imperative to salvage the limb. Only then can we improve the quality, as well as quantity of life of patients, many of whom may be bread winners of their families.

Through good healthcare and informed self-care, it is possible to prevent diabetes-related amputations in the majority of cases. Prevention is always better than cure, more so in the case of diabetes.

Shobha Shukla
(The author is the Editor of Citizen News Service (CNS), has worked earlier with State Planning Institute, UP, and teaches Physics at India's prestigious Loreto Convent. Email: shobha@citizen-news.org, website: www.citizen-news.org)

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