Sole mates: Caring for your feet with Diabetes Put Feet First ,prevent amputation

Globally and in India the prevalence of Diabetes Mellitus(DM) is increasing, nearly 212 million population affected. It is not only affecting the affluent society also the poor socioeconomic groups, not only elderly individuals also the younger generations and not only in the urban area also in the rurals. It implies a huge financial burden, not only for the individual and the family but also for society and the health system, something a country like India can ill afford.

The life time risk of developing Diabetic foot ulcer(DFU) is 15-25% of Diabetic population. The risk of amputation is 25%, out of four one will require amputation. Risk of amputation is 15 times more in patients having Peripheral Arterial Disease(PAD) with DM. The risk increases by 1% per year. Normally it starts as small ulcer following a trivial injury, if You neglect it You may land up in amputation. Any DFU, We need to rule out PAD by consulting a Vascular surgeon on time. Because 85% of amputation can be prevented by early detection and treatment for Vascular Diseases.

PAD is often under diagnosed, under estimated, and vascular pain (claudication) in the legs, any foot  injury pain are being masked by neuropathy in Diabetic patients. Where they may not be able to appreciate the pain due to sensation

loss(neuropathy). Abnormal deformed foot due to intrinsic muscle weakness can pose foot at risk for developing ulcer. PAD can be micro or macrovascular disease. The development of PAD begins with atherosclerosis(athero means fat, sclerosis is thickening, hardening), ultimately impacting the dynamics of blood flow.

Predictors of amputation: poor blood sugar control, smoking, long duration of diabetes may have neuropathy, absent pulses due to PAD. No operation to be performed on diabetic foot without checking the limb pulse status and ruling out PAD.
Effects of amputation: Dependent, reduced quality of life,  loss of self confidence, mental and emotional stress, Job risk, extra burden to the family, most importantly high risk of losing another toe if one toe amputated or even another limb if one limb is amputated.

Why to consult a Vascular  Surgeon?

Any patients with PAD and diabetic foot ulcer, there is high morbidity and mortality. If We don’t treat on time, it may cause infection and sepsis, may even cause risk to life. Without revascularisation,  ischemic ulcers do not heal. The facts are, Only one fourth of patients will get relieved of critical limb ischemia(CLI) by vascular intervention, one fourth will continue to live with CLI, one fourth undergo amputation and remaining one fourth may lose their life. Every 10 seconds two new cases of diabetes detected and one dies. Every 30 seconds one person loses limb in Diabetes.

Small Diabetic foot ulcer(DFU) is a warning signal to consult Vascular Surgeon, before it leads to limb loss or even life if present late. Presenting early to Vascular Surgeon, reduce the hospital stay, cost effective, may not need ICU care or strong antibiotics. Delay in presentation with large infected wound with critical ischemia, may need multidisciplinary care from other specialists( Diabetologist, plastic surgeon, critical care, infectious disease,  cardiologist, nephrologist, rehabilitation and physical medicine), long hospital stay,  ICU care and multiple surgeries as well. Initial treatment would be wound care by surgical debridement and strong broad spectrum antibiotics controlling infection. Then assessing the severity of PAD by an angiogram CT/MR, and subsequently planned for Vascular surgical procedures depends on the level of arterial blockage either by endovascular (balloon angioplasty/stenting) or open bypass or both as Hybrid procedures according to the nature of PAD. Most of the time they are multisegmental PAD, not only peripheral they are also polyvascular involving other vascular territories like heart, brain, kidney, intestinal blood vessels, etc.,

How to evaluate them?

All patients complete clinical examination and checked for peripheral pulses, Hand Doppler flow signals, Ankle brachial Index(ABI),Toe brachial index (TBI), Duplex scan study and CT/MR angiogram study to know the level of blockage, nature and number of blockages. They also will be screened for any other systemic illness like hypertension, stroke, high cholesterol, cardiac disease, respiratory, renal illnesses, etc., Because PAD is marker of systemic atherosclerosis. According to the risk category and severity of PAD, patients will be chosen for open or endovascular interventions or both.

Prevention of PAD: PAD is a progressive disease. Life style modifications is very important in preventing PAD progression by doing  Regular Exercise, eating Balanced Diet. Good glycemic control is very essential to reduce the progression and to bring HbA1C < 7% according to the individual condition. Cessation of smoking is important to reduce worsening of PAD and cardiovascular events. Dyslipidemia is closely associated with PAD, to be treated with lipid lowering agents. Adequate management of blood pressure to 130/80 to reduce progression. Daily self foot examination and care is very essential to look for any cracks, ulcers, is crucial in preventing infection and foot loss. Early Vascular intervention in DFU and Annual Vascular Consultation is recommended to prevent major limb loss.

Let's Unite for a Healthier Tomorrow

By working together, we can take control of PAD and promote healthy Life . Our goal is to empower individuals with knowledge, encouraging them to prioritize their vascular well-being. Through awareness and education, we can reduce the burden of this condition and improve overall health outcomes. So as part of Vascular Society of India who is spreding awareness about Vascular health between 3^rd August – 9^th August  by celebrating Vascular Awareness week my request to all of you to spread the knowledge. 

Dr Rajarajan Venkatesan

Senior Consultant, Vascular and Endovascular Surgeon, Apollo Hospitals, greams road, Chennai