DIABETIC AMPUTATION

Save Your Remaining Leg – Be Alert to “Triggers”

by Dr. Mark Hinkes, DPM

Ÿ FACT: Diabetes is the cause of about 80% of the 120,000 non-traumatic amputations performed annually in the United States.

Ÿ FACT: Every 30 seconds, a limb is lost due to diabetes.

Ÿ FACT: After a person with diabetes has a major amputation, there is a 50% chance that he or she will have the other limb amputated within two years.

If you have had an amputation of one foot or leg, you are at higher risk of losing the other foot or leg. Worse yet, half of those who lose a leg will not survive five years.

If you have lost protective sensation for pain, have poor vision, or don’t inspect your feet, you may not be aware of a problem until there is pus or blood on your socks, and, by then, it is usually too late.

The good news is that you don’t have to be one of those statistics. But, you do have to commit to being extra vigilant in detecting problems early and taking appropriate action. A very small issue – a scratch, a misstep, a tight shoe – could be the “trigger,” the minor event, that starts you on the road to major problems. Just like a gun, a simple trigger click can lead to an uncontrolled explosion, with dreadful consequences.

If one of the following “trigger” events happens to you, take recommended actions and see your foot care specialist immediately. A visit to the doctor is a small expense when weighed against the financial, emotional and psychological cost of a second foot or leg amputation.

Toenail Issues

Toenail problems are very common and can cause pain or functional disabilities for people with diabetes. If you’ve already had an amputation, your foot care professional should cut the toenails on the remaining foot.

If you hit your nail against an object like a doorframe or chair leg, or drop something on it, your nail will suffer blunt force trauma. You may suffer a hematoma (blood under the nail) that may need to be evacuated to relieve your pain. Other treatment may include debriding (cleaning) or reducing the thickness of the nail. In some cases, the nail is permanently removed.

An ingrown toenail can be dangerous for people with diabetes. If a piece of your nail gets imbedded in the soft tissue adjacent to the nail, don’t attempt to solve this problem on your own. A podiatrist can remove a portion of the side of the nail in a painless procedure under local anesthesia. You will need to wear a surgical shoe until the site heals.

If you get a toenail fungus, mold or yeast infection, your nail may thicken and change color. A deformed toenail can scrape the adjacent toe and cause an ulcer or cause a collection of pus (abscess) to develop under the toenail as a result of pressure from the shoe against the nail. A soft tissue infection that goes unattended may turn into a bone infection.

Common Foot Problems

Inspect your feet daily, and contact a professional if you detect an unexplained foot odor, redness, warmth, pus, tenderness, pain, swelling, abnormal positioning, or if you have trouble putting weight on your foot. Fever, chills and high blood pressure combined with elevated blood sugars may mean an infection has spread; go to an Emergency Room immediately.  

Pain

Pain is a red flag; if you have any of the following foot health issues, seek medical attention.

  • Heel pain may be inflamed soft tissue but can also result from a broken bone, a tight Achilles tendon, a pinched nerve, arthritis or other problems.
  • Ankle sprains, if left untreated, increase your risk of repeated sprains and chronic ankle instability.
  • ŸBig toe stiffness and pain usually develops over time as the cartilage in the big toe joint wears down and eventually leads to arthritis. The sooner a doctor diagnoses it, the easier it is to treat.
  • ŸAchilles tendonitis causes pain and tenderness at the back of the foot or heel, usually from a sudden increase in physical activity.
  • ŸPinched nerves, neuritis and neuromas are nerve problems that can affect the front of the foot, heel and/or ankle. The most common nerve problem in people with diabetes is a burning, shooting, tingling or numbing feeling in the area of the toes and just behind the toes on the bottom of the foot.

Testing is available to identify each of the possible reasons for your pain, so there is no need to suffer when it can be diagnosed and treated.

Wounds

If you have diabetes, you have a greater risk for complications from wounds. Because diabetes decreases your blood flow and alters the function of your immune system, your injuries are slower to heal than those in someone who does not have the disease. If you also have peripheral sensory neuropathy (the loss of protective sensation of pain in your feet), you won’t necessarily notice an injury right away.

There’s no such thing as a “minor” wound to the foot when you have diabetes; even a small foot sore can turn into an ulcer that, if not properly treated, can lead to amputation.

Any wound that doesn’t heal in four weeks is cause for concern, as it may result in a worse outcome, including amputation.

If you have a wound:

  • ŸClean it with warm soapy water and dry it well.
  • ŸPut an antibiotic cream on it immediately.
  • ŸCover it with light gauze and keep pressure off of it.
  • ŸDon’t wear closed shoes.

See your foot care specialist or a local wound center within seven days at most if the wound hasn’t responded to treatment.

Foot Ulcers

A foot ulcer is an open sore, wound or hole somewhere on your foot – a crater-shaped break in the skin. These ulcers often occur in high-pressure areas – under or around a corn or callus. The break may appear to be small, but a larger ulcer may be hidden under the skin growth or keratosis. Up to 82% of foot ulcers are related to pressure from narrow or otherwise inadequate or improperly fitted footwear. Foot ulcers can be caused by painless or silent trauma from mechanical, chemical or thermal origin.

Most ulcers that lead to amputation can be prevented through daily foot inspection and care, regular visits to your physician and podiatrist, foot-care education, wearing proper shoes, and early recognition and treatment of any suspected trouble areas. A special infrared thermometer can be used to check your foot temperature once a day; a four-degree difference between one region of the foot compared to the other foot requires professional attention.

Infections

Foot infections in people with diabetes become more severe and take longer to cure than the same infections in people without diabetes. They account for the largest number of diabetes-related hospital admissions and are the most common non-traumatic cause of amputations. If left untreated, infections can threaten life and limb.

If you have a bacterial infection, it means that bacteria have penetrated your skin – the protective envelope that covers your body. Most infections start off as mild infections but also have the potential to become serious. Foot infections often start out small and are relatively easy to treat. A doctor can best determine the cause and appropriate treatment. By identifying the specific bacteria causing the problem, the most-effective antibiotic and method of delivery (oral, topical, intravenous, injection) can be prescribed.

A bone infection, or osteomyelitis, for example, is the most-feared foot complication for a person with diabetes. Bone infections most often occur when bacteria gain access to the bone from a nearby soft tissue infection or foot ulcer. Early detection can limit the destruction of the bone and may resolve the infection with antibiotics rather than surgery. Osteomyelitis in the diabetic foot can lead to limb loss and life-threatening complications, such as blood poisoning, known as septicemia.

The dark, moist and warm environment inside your shoe is the perfect place for mold, yeast and fungus to prosper. Infections caused by these troublemakers may occur on your nails, between your toes, or on the sides or bottom of your foot. They are usually responsible for superficial skin infections on your foot, often referred to as tinea pedis, or “athlete’s foot.”

If you notice whitish, inflamed, itchy and peeling skin on the foot, you may think you just have dry skin, but you may have a mold, yeast or fungal infection. Do not scratch this itch because the infection can spread to other parts of your body via your hands.

Practice Preventive Foot Health

If you practice preventive foot-health behaviors, the chances of developing a problem will be minimal. You will identify problems early and resolve them promptly.

Inspecting your feet every day is the most cost-effective way to prevent foot issues and reduce your healthcare costs. Exercise, proper nutrition and smoking cessation, which are important in diabetes care in general, are also important in preventing amputations.

For more information and to learn about Dr. Hinkes’ book Keep the Legs You Stand On, please visit www.amputationprevention.com.

This information is provided for general educational purposes only and is not intended to replace the specific advice of your doctor or other healthcare professional. Contact your doctor or other healthcare professional immediately if you have an emergency.

 

Author Notes

Dr. Mark HinkesDr. Mark Hinkes is chief of podiatry and director of podiatric medical education at the Veterans Affairs Medical Center/Tennessee Valley Healthcare System in Nashville, Tennessee, and author of Keep the Legs You Stand On, the first book on foot health for people with diabetes that focuses on amputation prevention.

He was chairman of the Preservation Amputation Care and Treatment (PACT) Program for a decade. He is certified by the American Board of Podiatric Surgery and the American Professional Wound Care Association and is a diplomat of the American College of Foot and Ankle Surgeons. He is a member of the American Podiatric Medical Association, the Federal Services Podiatric Medical Association, and the American Diabetes Association.

Dr. Hinkes earned a B.S. in Psychology from Loyola University of Chicago, Illinois, in 1973 and graduated from the Ohio College of Podiatric Medicine in 1976. He trained at Westchester General Hospital in Miami, Florida, and opened a private medical practice there with privileges at Westchester, South Miami and Baptist Hospitals and Kendall Regional Medical Center. In Florida, he taught podiatric medicine to undergraduates at Barry University, was president of the Dade County Podiatric Medical Association, and became bilingual in English and Spanish.

In 1998, he left South Florida to join the Veterans Affairs Medical Center in Salem, Virginia, as chief of their podiatric service. He served as the VA’s national field advisor for quality assurance in podiatric medicine. 

During his 30+ year career, Dr. Hinkes has also served as a consultant, clinical instructor, a lecturer and an author of peer-reviewed journal articles. In his leisure time, he enjoys gardening, traveling, and creating stained glass art.

Dr. Hinkes recently became a member of the AmputeeNews.com editorial board.

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Institute of Medicine (IOM) Report Calls for Transformation of Attitudes Toward Pain and Its Prevention and Management

pain and compassionEvery year, at least 116 million adult Americans experience chronic pain, a condition that costs the nation between $560 billion and $635 billion annually, says a new report from the Institute of Medicine titled Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research . Much of this pain is preventable or could be better managed, added the committee that wrote the report.

The committee called for coordinated, national efforts of public and private organizations to create a cultural transformation in how the nation understands and approaches pain management and prevention. Some of the recommended changes can be implemented by the end of 2012 while others should be in place by 2015 and maintained as ongoing efforts.

“Given the large number of people who experience pain and the enormous cost in terms of both dollars and the suffering experienced by individuals and their families, it is clear that pain is a major public health problem in America,” said committee chair Philip Pizzo, dean, Carl and Elizabeth Naumann Professor of Pediatrics, and professor of microbiology and immunology, Stanford University School of Medicine, Stanford, Calif. “All too often, prevention and treatment of pain are delayed, inaccessible, or inadequate. Patients, healthcare providers, and our society need to overcome misperceptions and biases about pain. We have effective tools and services to tackle the many factors that influence pain and we need to apply them expeditiously through an integrated approach tailored to each patient.”

A new analysis undertaken as part of the study finds that the medical costs of pain care and the economic costs related to disability days and lost wages and productivity amount to at least $560 billion to $635 billion annually. Because the range does not include costs associated with pain in children or military personnel, it is a conservative estimate.

Healthcare providers, insurers and the public need to understand that although pain is universal, it is experienced uniquely by each person and care – which often requires a combination of therapies and coping techniques — must be tailored, the report says. Pain is more than a physical symptom and is not always resolved by curing the underlying condition.  Persistent pain can cause changes in the nervous system and become a distinct chronic disease. Moreover, people’s experience of pain can be influenced by genes, cultural attitudes toward hardships, stress, depression, ability to understand health information, and other behavioral, cultural and emotional factors.

Successful treatment, management and prevention of pain requires an integrated approach that responds to all the factors that influence pain, the committee concluded. The majority of care and management should take place through primary care providers and patient self-management with specialty care services reserved for more complex cases. Healthcare organizations should take the lead in developing innovative approaches and materials to coach and empower patients in self-management.

Training programs for dentists, nurses, physicians, psychologists and other health professionals should include pain education in their curricula and promote interdisciplinary learning, the report says. Many healthcare professionals are not adequately prepared to provide the full range of pain care or to guide patients in self-managing chronic pain. For example, a recent study found that only five of the nation’s 133 medical schools have required courses on pain and just 17 offer elective courses. Licensing and certification exams should include assessment of pain-related knowledge and capabilities. Programs that train specialists or offer training in advanced pain care need to be expanded.

The report calls on Medicare, Medicaid, workers’ compensation programs, and private health plans to find ways to cover interdisciplinary pain care. Individualized care requires adequate time to counsel patients and families, consultation with multiple providers, and often more than one form of therapy, but current reimbursement systems are not designed to efficiently pay for this kind of approach and healthcare organizations are not set up for integrated patient management.

Due to its significant toll on individuals and society, pain warrants a higher level of attention and resources within the National Institutes of Health. The report recommends that NIH designate a lead institute to move pain research forward and increase the scope and resources of its existing Pain Consortium. NIH, academic researchers, and other public organizations should collaborate with private firms to advance research and development of new and improved therapies.

The study was mandated by Congress and sponsored by the National Institutes of Health. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies.

To read Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research online or to acquire a copy, visit http://www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research/Press-Release.aspx

Johns Hopkins Evidence-based Practice Center Awarded $475,000 Project to Identify Wound Care Best Practices

An estimated $25 billion is spent annually on treating chronic wounds on patients in the United States. These chronic wounds deeply affect the quality of life of more than 6 million people who have them and can lead to amputation. The most common types of chronic skin wounds and skin ulcers are related to venous disease (conditions related to or caused by veins that become diseased or abnormal). Many treatment options are available, but the quality of evidence showing which treatments work better than others is often lacking. It is hard to prove which treatments are effective and should be the standards of care.

red cross The Agency for Healthcare Research and Quality (AHRQ) awarded the Johns Hopkins Evidence-based Practice Center a $475,000 project to carry out an extensive research review and create a scientific report to inform healthcare providers about effective state-of-the-art wound care. Through this project, the Johns Hopkins Wound Center and the Johns Hopkins Evidence-based Practice Center are conducting an evidence-based review of wound care to determine what is known and unknown about it, and to establish strategies of care that are proved to work.

Gerald Lazarus, MD, founder of the Johns Hopkins Wound Center and professor of dermatology and medicine at Johns Hopkins Bayview Medical Center, and Jonathan Zenilman, MD, newly named director of the Wound Center and professor of medicine and chief of the Division of Infectious Diseases at Johns Hopkins Bayview, are co-principal investigators of this study. Working with Eric Bass, MD, MPH, director of the Johns Hopkins Evidence-based Practice Center, a team of recognized experts are trying to find important clinical answers to help treat patients with chronic wounds.

“This research is a unique and important study that underscores the scientific credibility and intellectual honesty of the Wound Center,” says Dr. Lazarus. “It’s a great example of how translational research affects everyday lives. The information we gather and present will help countless clinicians and patients to make better, more educated decisions about the best course of treatment to heal wounds.”

This type of study, known as comparative effectiveness research, is done to inform healthcare decision makers by providing evidence on the effectiveness, benefits and risks of various treatment options. Johns Hopkins researchers will compile and analyze all of the evidence available from existing clinical trials, clinical studies, literature and research about chronic wound care. This research will determine the value of therapeutic interventions -such as medications, antibiotics, dressings and surgery – for healing chronic wounds.

A report will show healthcare providers, patients and others which treatments work best under certain conditions. The report will be designed as an important tool to understand the facts about different wound treatments. Its goal is to provide the best possible information about wound treatment choices that is easily usable so that healthcare providers can work with patients to make informed decisions about the right treatment plan for each wound.

Chronic wounds are a worldwide problem. Their prevalence and cost are increasing because of the aging population and more cases of obesity and diabetes worldwide. Chronic wounds often are associated with underlying conditions, such as diabetes, clogging of the arteries, diseases of the veins, neurological problems, consequences of rheumatological illnesses, inflammation of vessels and other medical difficulties. Wounds that will not heal are frequently signs of larger and more complicated health problems. Nonhealing wounds can take a toll on patients far beyond the pain and discomfort of the wound. They can cause patients to lose their mobility, which may lead to a decline in general health and emotional well-being. Patients can become disabled, unable to work and depend on care from others.

“The topic of chronic venous ulcer treatments was nominated to AHRQ’s Effective Health Care Program by a consumer and will be further developed by the Johns Hopkins Evidence-based Practice Center,” said Christine Chang, MD, MPH, medical officer of the Center for Outcomes and Evidence at the Agency for Healthcare Research and Quality. “The Johns Hopkins Evidence-based Practice Center is one of 14 centers in AHRQ’s Evidence-based Practice Center Program and has a core team with both clinical and systematic review expertise. It has assembled an excellent research team for this topic and included individuals with extensive experience in the treatment and management of patients with chronic venous ulcers, as well as those skilled in systematic review methodology.”

Dr. Chang adds, “While we do not formulate clinical practice guidelines, our hope is that this evidence report will provide patients and providers with the best information available to make well-informed decisions about care. The evidence report may also indicate areas of ongoing uncertainty, which will also be important as they consider various treatment options. We expect that clinician and consumer guides, as well as other translational materials, will be developed by our program, based upon the findings of the evidence report.”

The Johns Hopkins Wound Center is located at Johns Hopkins Bayview Medical Center and specializes in diagnosing and treating chronic wounds, preventing wound recurrence and preserving limbs. The Wound Center’s team prides itself on having the most advanced clinical knowledge of wound practices and compassionately applying those practices to treat patients who are suffering from chronic wounds and their underlying conditions.