Salvaging the foot in people with diabetes

With over 200,000 diabetic foot related amputations in India every year, it is  critically important to do all that is warranted to salvage, and to care for, the feet of the people living with diabetes. Dr Robert Frykberg, Chief of the Podiatry Section, Carl T Hayden VA Medical Center, Phoenix, Arizona, USA, said to Citizen News Service (CNS) at the Amrita Endocrine, Diabetes and Diabetic Foot Conference (AEDFC 2012): "Rate of amputations is probably higher in India with 200,000 amputations per year in India [than in USA]. About 15-20% patients of diabetic foot might end up with amputations."

Incidence of diabetic foot varies from study to study, explained Dr Frykberg. "According to one  study, about 9% of the patients with diabetes might develop diabetic foot. But incidence of those with diabetic foot developing a foot ulcer that leads to osteomyletis (bone infection) is very high (up to 20%). In US, about 70,000 – 80,000 patients per year undergo amputations related to diabetic foot. Most of these amputations are due to non-healing foot ulcers. The problem is much worse in India because India has many more patients with diabetes presenting much later and all doctors are probably not aware of all modern techniques and principles of care for a diabetic foot. Proper debridement, proper offloading, better care of the disease and paying better attention to nutrition in diabetes care are important in salvaging and taking care of the foot of people with diabetes", said Dr Frykberg.

"If the wound is not clinically infected it is not necessary to treat with antibiotics or do cultures and we should rather pay attention to the basics: debridement, offloading, good diabetes care and good nutrition, said Dr Frykberg. It is a misconception is that all ulcers need antibiotics-- they don’t. Most diabetes specialists probably know that antibiotics are  not the cure-- it is the offloading, and assessment for vascular disease which helps," said Dr Frykberg.

Speaking about the Charcot Foot, Dr Frykberg said it is a growing problem. "It is early diagnosis, early offloading, and catching it early that will minimise the problems. If we wait, if it is left undiagnosed and if the patient keeps walking, then it is very limb threatening as ulcers get infection. So everything is dependent upon high degree of clinical suspicion, early diagnosis and early offloading" said Dr Frykberg.

Charcot foot is a condition causing weakening of the bones in the foot that can occur in people who have significant nerve damage (neuropathy). The bones get weakened enough to fracture, and with continued walking the foot eventually changes shape. As the disorder progresses, the joints collapse and the foot takes on an abnormal shape, such as a rocker-bottom appearance. Charcot foot is a very serious condition that can lead to severe deformity, disability, and even amputation. Because of its seriousness, it is important that patients with diabetes—a disease often associated with neuropathy—take preventive measures and seek immediate care if signs or symptoms appear.

"The diabetes situation in the US is similar to that in India, except that probably more people have access to care in US because more people have health insurance-- either private or government. There is more emphasis on early interventions of prevention although not exclusively. Diabetes and diabetic foot are very common in the US too. I think we no longer see the severity of cases as you do in India because of the monetary or financial barrier that people tend to have here. It seems that in India most people don’t have health insurance  and they pay from their pocket for healthcare. The irony is that early prevention and treatment is the most cost-effective way and we should start teaching our patients about how to take care of their diabetic foot. The importance of early care results in dramatic reduction in severity of cases we are talking about" said Dr Frykberg.

Bobby Ramakant - CNS