IOH Diabetes Information About Neuropathy Complications and Amputation

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IOH Diabetes Information About Neuropathy Complications and Amputation
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Amputation
Prevention, Causes, Procedures, Statistics

Taking Care of Your Feet
See our section on Foot Care Tips
If you have diabetes you need to pay special attention to your feet. Certain complications with diabetes may cause loss of sensation from nerve damage (neuropathy) and circulation throughout the body, including the feet. Reduced sensation can interfere with the body’s injury warning system: pain. Even small cuts, blisters, and abrasions can go unnoticed (because they don't hurt) and can become infected due to poor circulation.

Diabetics in general, have a tendency towards easier infection, and infections with diabetes are slower and harder to overcome – especially when blood glucose is not under tight control. Hyperglycemia (high blood glucose levels) reduce the body's ability to fight infection normally. Keeping your blood glucose in range will not only help prevent damage and infection, but will help your body overcome an infection.

Infections can ulcerate, fail to respond to treatment, and eventually all, or a portion of the foot, may need to be surgically removed (amputated). If the infection persists even after amputation, it may even be necessary to remove part of the leg from below the knee in order to halt the deadly progression, which unaddressed, can lead to death.

(Diabetes Care, November 2004;27:2636-2641) reported alarming statistics for the rate of amputation among the diabetic population in Barbados. However, from the data, we are reminded that an ounce of prevention is worth a pound of cure. For example, the study indicated that simply not wearing shoes tripled the risk of diabetes-related, lower-extremity amputation among Barbados residents and risk of amputation was quadrupled in the same population for those wearing “fashion” footwear, as well as for female walkers wearing sneakers into town. It would seem obvious that good footwear plays an important role in preventing foot ulcerations which can lead to further complications including amputation.

Other risk factors for amputation (indicated in the report) include the following:

* Single persons and men
* Length of diabetes, those on insulin, those with an elevated HbA1c
* Higher resting pulse rates and lower systolic blood pressure
* Previous history of foot ulcerations or infections
* Sensorimotor neuropathy
* Clinical signs of peripheral arterial disease (PAD)
* Inadequate footwear.

For those who examined their feet daily, a remarkable 80% risk reduction was reported.

Diabetes-Related Amputation Statistics
* Each year, approximately 80,000-84,000 nontraumatic, lower-limb amputations are performed due to complications from diabetes (United States).
* Diabetes-related amputations account for more than 60% of all nontraumatic lower-limb amputations (United States).
* Partial foot amputation is successful in about 75% of diabetes-related amputations; 25% fail and require amputation of the leg from below the knee (United States).

A predictor of those who undergo surgery (partial amputation) and will not require further amputation is how well blood glucose is controlled prior to surgery. Those with A1c levels at 7 or below stand a far greater chance for successful outcome. Post surgery target-range blood glucose levels are critical to avoid further amputation.

How Problems Can Occur
Chronic high blood glucose levels can restrict blood flow and diminish circulation to the lower limbs, especially the feet. The problem is worse for older a persons and those who have had diabetes longer periods of time (true for both type 1 or type 2 diabetes). Perhaps one of the most important prediction variables, and one that can be avoided with proper daily attention to blood glucose levels, is whether or not the person has been managing their diabetes effectively.

Poor circulation makes it harder to treat infections and ulcers, made harder still when blood glucose levels are high. Neuropathy, (damage to nerves) can make it hard to detect problems early due to diminished, or even the total loss of sensation. Persons with neuropathy can lose all feeling in an area and suffer severe damage to tissue and never even feel it. (One physician stated “neuropathy can leave feet and lower legs so numb patients could walk around with a nail under their foot for a day and not realize it."

Early detection and treatment is crucial to saving limbs but unfortunately, by the time most patients seek treatment there is already gangrenous tissue surrounding ulcerations and the limb cannot be saved.

Amputation Procedures and Rate of Success
Below-the-knee surgical amputation of the damaged leg used to be standard procedure. In the past ten years a new procedure called transmetatarsal amputation (TMA) is more commonly performed. In this procedure only part of the front of the foot is removed. TMA is not successful in all patients and further, more aggressive amputation (below the knee) is still required. In the United States, many doctors are still inclined to perform the older, more invasive surgery. If you are facing amputation, be sure to ask if you are a candidate for TMA.

Studies show that success depends, in large part, on the following:

* TMA performed on persons with HbA1c blood glucose levels above 10% are almost certain to be unsuccessful.
* Success rate of surgical TMA for persons with HbA1c blood glucose levels of 7% or lower is highly successful.

Preventive Care for Diabetes Foot-Related Complications

Since most problems for diabetics begin with small sores on the skin like scrapes and blisters it is important to visually inspect your feet every single day. Other steps you can take to ensure healthy feet include lifestyle changes and observation:

* Quit smoking, which can cause or aggravate circulatory problems
* Check blood glucose often, and stay in target range as much as possible
* Eat a healthy, balanced diet
* Exercise regularly (exercise increases blood flow and insulin sensitivity)
* Maintain a healthy body weight
* Check your feet DAILY and immediately care for small cuts or blisters
* Have your doctor inspect your feet and hands at every visit
* See your doctor at the first sign of any foot problems
* Be aware that heating pads or electric blankets can burn skin, especially when neuropathy is present.

The most frequent reason for hospitalization in persons with diabetes is due to problems with their feet. But many of these problems, including amputation and hospitalization, could be prevented through simple preventive foot care.

Depression
The rate of depression among diabetics with ulcerations parallels that of those who have already undergone amputation. Part of the reason may be that ulceration often is an impending sign of the need for amputation. Counseling for both those with ulcerations showing signs of depression, and for those having undergone amputation is often advised.