An article was recently published which found, in part, that diabetic patients feared an amputation more than they feared death. I agree that an amputation is distasteful, a horrible complication, and definitely something that we would all prefer to do without; but I also know that if faced with that situation you should choose life. I want you to read this article, and realize that you can live through an amputation. I’m going to describe some of the surgical process and how a surgeon looks at an infection. I will discuss how to handle surgery and an amputation. I’m also going to give you some tips and recommendations that will help you avoid the next amputation.
Increased Amputations with Diabetes
Why do diabetics suffer amputations? The general population (without diabetes) is at minimal risk of non-traumatic amputation. However, every 30 seconds a patient with diabetes loses a limb worldwide. In diabetes as the blood glucose level increases it jams the immune system. The body communicates internally with molecules, but these signals can be interrupted by the high glucose levels. This is especially apparent with immune signalling. So the diabetic patient has trouble fighting off infection* (More here, advanced article). Infection once established is very painful, but those with poorly controlled diabetes may also have peripheral neuropathy, or a loss of sensation. So by the time they can feel the infection it is already a serious problem, and has sometimes already extended to bone.
Bone Infection
Osteomyelitis is a five-dollar word for bone infection. Once bacteria reaches the bone it will begin eating the bone, and the body attempts to form new bone over the top of it. This leaves the bacteria living between layers of living and dead bone. Some bacteria are also prone to forming biofilms, which are protective shells. Biofilms limit the ability of antibiotics to penetrate, and this
preserves the bacteria. What this means is that even strong IV antibiotics may not be able to treat an infection. This will lead to a decision of living with a chronic wound; an ulcer which may constantly be draining, necessitating weekly visits to the podiatrist or wound care center, and which will occasionally flare up requiring antibiotics and possibly hospitalization. The other option would be surgical debridement, or an amputation.
Shock of Worsening Infection
Watching as some part of your body becomes infected, turns red, starts smelling strange then horrible must not be very comforting. Watching the process, and realizing that a course of treatment is not working can be very disheartening. Hearing from your physician that you need an amputation, or that you need to be taken to the operating room can be quite a shock.
Surgery
You will not be able to eat for at least eight hours before your surgery. Already my favorite way to start a day. Then add diabetes, and stress on top of that. Then there is the family member that you are trying to shepherd through the entire process. The doctors and nurses come and go, all seeming to ask the same questions. Don’t they talk to each other, you might be wondering. Kind of, each person involved has their own information that they need to document, and for each person it’s a little different. Finally you are wheeled back to a large room with bright lights. The surgeon will be there, also the anesthesiologist and several nurses. We’re all wearing masks so it can sometimes be difficult to tell who is who. A few minutes after entering the room you will usually be placed under anesthesia, which usually means you are sleeping on in a dream-state for the rest of the surgery. There is a lot that goes into anesthesia, that’s why it is its own specialty. If you have questions or concerns about this, write them down and talk to anesthesia before the surgery.
Surgical Evaluation
But what is the surgeon doing? An incision is placed in the affected area, revealing the soft tissues lying beneath the skin. If we are performing an incision and drainage there will usually be an abscess which is filled with pus. Once located the abscess will be drained, removing all of the purulent fluid (pus). The space that the abscess occupied will then be evaluated and inspected. Was the pus touching bony structures? Is the pus coming from anywhere else? Is the pus following tendons deeper into the body? If yes to any of the above, then further evaluation and exploration will be performed.
In the case of an amputation or bone debridement, the soft tissues will be cut or reflected away from the bone. The bone is then inspected. The bone should be quite firm on the outside (the cortex) and should be intact. There should be no fracture, and no holes in the bone. If there are holes in the bone, it is likely that infection has created them, and this bone needs to be cut away. Some surgeons prefer to cut or scrape the infected bone, and then leave everything else. Some prefer to cut behind the infected bone, trying to remove all of the infection in one fell swoop. In the foot, for example when the tip of a toe is infected, it is sometimes possible to only remove the one infected bone and leave the remaining bones. In adults bone infection will usually not cross a joint, in kids infection can cross a joint. So if you remove a bone at the joint (knuckle in the finger/or toe), the remaining bone has a higher chance of being clear of infection. After the infected tissue is removed, the surgical site is irrigated (washed). Then we take another close look at all the tissues which are exposed. Does everything else look clean? Are the remaining bones firm? Is there any necrotic tissue? Is anything still draining? If all looks ok then the surgeon will suture, staple or tape the area closed.
When It’s Worse Than Expected
Sometimes once the incision is placed, and the abscess is evacuated, the infection is noted to be much worse than we realized beforehand. In the foot, for example, we may have been planning on just an incision and drainage, and end up needing to take a piece of bone, or an entire toe. Tissue that is clearly infected or dead needs to be debrided (removed) while we have access to those areas. This is why during the preoperative exam, we sometimes don’t know the extent of the procedure that will be performed. When a surgeon says, ‘I’ll have to see what it looks like when I get in there,’ it really means we have to evaluate the surgical site visually and by touching these structures. Even then, we take tissue that is clearly infected, dead or non-viable, but we attempt to leave as much as we can. If we have to take so much that the structure (ie. the toe, etc.) is non-functional, then we look at taking that structure off or out. It is not possible to wake the patient up once surgery has started and consult again about taking more tissue, that’s why we try to discuss it in the preoperative exam.
Healing After Surgery
Most patients will be discharged home after surgery, unless they were already an inpatient, are very sick, or had a larger amputation. Whether going home, staying in the hospital, or going to a rehab facility, you now begin the recovery and healing process. Any surgery for infection that is performed is done, in part, to reduce the bacterial load (number of bacteria) so that the immune system can come in and clean up the little pieces. Surgery is like the heavy lifting, but any remaining bacteria have to be cleaned up by your white blood cells in conjunction with antibiotics. Even with all the advances in surgery and medicine, the doctors help stabilize the body so that the body can take back over and correct and repair things at the cellular level. If the patient is in too poor health to do this work, all the medical team can do is try to support the patient until he/she is strong enough to conduct these repairs. This is why control of your blood glucose, and staying in a good state of overall health is critical.
In the case of foot and leg, if an amputation has been performed you may need a special shoe, a special insert, or a prosthesis. You may also need physical or occupational therapy to accommodate for the missing part. In the case of the big toe, you can expect to lose some balance, for the smaller toes you will not usually realize that the toe is missing unless you are looking at it. In the case of amputation of part or all of the foot, you will need a specialized insert and a special shoe. Often these are diabetic shoes, and they now come in many styles from athletic shoes to work-style boots.
Tips on Prevention
First I’d like to thank you for reading this far. This is probably the most important part of the article, how to avoid this situation in the first place. As you may know, I’m a high-risk podiatrist, meaning I treat conditions of the foot, ankle and lower leg for the high-risk population.
Get A Podiatrist
So my first tip is if you have diabetes, peripheral vascular disease, charcot, or foot deformity, get in to see a podiatrist. I believe that the appropriate time for referral to a podiatrist is at the time of diagnosis of diabetes. Have you heard this joke? When did Noah build the Ark? Before the flood. It’s better to have a good podiatrist, and be established in his or her care, before you really NEED a good podiatrist. Type podiatrist into this site to find one located near you.
Check Your Feet Daily
You already have a podiatrist? Great. Next I want you to begin checking your feet every day. If you’re the type of person that likes to bathe daily then a good time to perform this check is after getting out of the shower/bath. If you don’t bathe daily, then check your feet before you get into bed. I list these times because I believe that most of you will not be wearing shoes during those times. To check your feet, begin by looking at your ankle. Then scan down towards your toes. Look between the toes. Then look at the bottom of the toes, the ball of the foot, the arch and the heel. Then look at the back of the heel and the ankle. Now switch to your other foot and perform the same check. (Here is a video by Dr Desmond Bell which describes using a smart-phone and a selfie stick).
Why Check My Feet Daily?
What are you looking for? Non or slow-healing cuts or scrapes, heavy calluses, parts of the foot that are darker than other areas, ingrown nails, thickened nails, or ulcers (non-healing sores). Or anything else that looks strange, the great thing with a foot check is most of you have two feet so just compare with the other side. If you see something you don’t like, call and make an appointment with your podiatrist (see step one above).
Control Your Sugar (Hyperglycemia)
My final tip for you today is to watch and control your blood glucose. You want to work with you PCP (Primary Care Physician) on this one (More about diabetic team members). But remember that you only see your PCP every once in a while, might be 6 weeks, or 6 months before your next visit. If you notice that your blood glucose is poorly controlled, or out of the range that your PCP recommended to you, then call the office and let them know. If you know that you are struggling to not eat carbs or to maintain a healthy balanced diet, ask for a nutrition consult. If your blood glucose goes high and stays high, you have a much higher chance of having diabetic complications. The magic number here is 7, if your A1C increases above this number you are much more likely to have a diabetic complication – blindness, foot infection or ulceration, kidney failure, etc.
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*This statement is an oversimplification. The interaction between diabetes, the immune system and the many molecules involved in healing is very complex. More reading here, and here.
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