Mr.
Mitchell was hospitalized and given intravenous antibiotics to ward
off infection, but a sore between his fourth and fifth toes was filled
with pus. Dr. George F. Wallace, director of podiatry services at University
Hospital, told him that he might lose those two toes, and ultimately,
that was the case. Mr. Mitchell, who now wears specially designed shoes,
is back to work and relieved that his loss wasn't more severe. "I'm
grateful that the infection was caught when it was, and that I didn't
lose the foot," he says. "It could have been much worse." That's
true. Foot wounds are a major source of concern for people with diabetes.
According to the American Diabetes Association (ADA), 15 percent of
diabetics will develop a foot ulcer (an open sore on the foot), and
between 14 percent and 24 percent of that group will require some type
of amputation. In the most severe cases, infection leads to gangrene,
and the patient could lose a foot or a leg. The decision to amputate
never is taken lightly, and as little is removed as possible. Diabetes
is a chronic disease in which a person's body doesn't produce enough
insulin or properly use it. Now it is recognized as a public health
concern of epic proportions that's expected to increase even more. "In
2000, about 11 million people had been diagnosed with diabetes, with
another 6 million people unaware they had the disease," says Dr.
Wallace. "It's estimated that by 2050, 29 million people will have
diabetes-an increase of 165 percent." Type
II, or adult onset, diabetes accounts for most cases of the disease.
People who are overweight, have a family history of diabetes, are over
age 45, were gestational diabetics (women who had high blood sugar levels
during pregnancy), or are African American, Latin American, Native American,
or Asian and Pacific Islanders, have a higher risk of developing diabetes
than others. Symptoms of Type II diabetes include extreme thirst, excessive
urination, unexplained weight loss, blurred vision, and tingling or
numbness in the hands or feet. However, some people never experience
any signs of the disease. Diabetes
affects many areas of the body, especially the kidneys, eyes, and feet.
"Uncontrolled diabetes can lead to poor circulation. The feet contain
tiny blood vessels that are far away from the heart, which adds to the
circulatory problem," explains Dr. Wallace. "The nervous system
is also affected, causing what is known as diabetic neuropathy. This
nerve damage reduces or completely eliminates the patient's ability
to feel pain in the feet. If he or she is not daily checking their feet
for changes in the skin, they could develop an infection and not even
be aware of it." Among diabetics, those most at risk to develop
these sores are people who have had the disease for more than 10 years
and those who have poorly controlled diabetes or other diabetic complications.
If the patient has peripheral vascular disease, for example, a wound
can take longer to heal. The
sole, or plantar surface, of the foot is the most common location for
an ulcer. Problems can begin with something as seemingly innocuous as
a bunion or a hammertoe and a poorly fitting shoe that rubs against
these deformities. The pressure breaks down tissue, and an ulcer can
very quickly develop. That's a critical time for medical intervention.
"Not all ulcers are infected, and there are excellent treatments
that can be used to keep them that way," says Dr. Wallace, who
is board certified in podiatric foot and ankle surgery and podiatric
orthopaedics. One method is to "off load" pressure from the
affected foot with the use of special orthotics, sandals, shoes, padding,
or walking casts. If
an ulcer is infected, the goal is to prevent spread into the bone and/or
tissue death, or gangrene. The patient may be hospitalized, and a two-prong
approach begins: oral or intravenous antibiotic therapy and an incision
and drainage surgery to clean up the site. Three to five days after
the first surgery, a second procedure is done to close the wound. Often,
timely intervention is effective enough that amputation can be avoided
or, as in Mr. Mitchell's case, be minimal. "People are often afraid
to seek treatment when they have a foot ulcer. They assume that there's
a need for amputation, or that if they lose one toe, they lose their
sense of balance, which isn't true," says Dr. Wallace. "The
fact is, the sooner they come in, the more we are able to help them."
It's
important for patients to remain vigilant after treatment. Research
indicates that among people who have had foot wounds, more than half
develop another within two to five years. Regular visits to a podiatrist
and wearing shoes with diabetic inserts designed to redistribute pressure
along the foot can be helpful in preventing recurrence. In
the most severe scenarios, a foot or a leg is amputated to save the
patient's life. In all, an estimated 67,000 diabetes-related lower-extremity
amputations are performed each year in America. Dr. Wallace is among
those healthcare professionals who believe that number can be reduced
if people with diabetes practice preventive foot care, keep their blood
sugar levels well controlled, and stop smoking. Team
Players in Diabetic Foot Care
It
takes a comprehensive, team approach to address the many facets of diabetes,
and podiatrists--foot and ankle specialists--play a key role. Doctors
of podiatry, like their medical doctor counterparts, complete four years
of post-graduate education; however, they attend podiatric medical colleges.
Their course work includes anatomy, histology, physical diagnosis, pharmacology,
radiology, and surgery, as well as clinical rotations at affiliated
hospitals. Afterward, podiatrists
typically complete a two- to three-year residency, rotating in areas
from orthopaedics to sports medicine. They can also become board certified in certain
specialties. In
addition to treating the "every day" foot complaints--hammertoes,
heel spurs, and corns--podiatrists are well versed in keeping diabetic
feet healthy. Along with its
staff podiatrists, University Hospital has a certified diabetes educator
available to answer questions during the diabetic foot clinic held every
Friday. "ADA
guidelines call for the primary care physician to examine a diabetic
patient's feet--with socks and shoes removed--at every visit,"
says Dr. Wallace, "but that doesn't replace the need for regular
podiatric care." A newly diagnosed patient typically is referred
to a podiatrist for a complete foot exam, which provides a "baseline"
for the specialist to refer to in future visits and the opportunity
to address any concerns, such as thickened toenails that need trimming.
The patient receives comprehensive instruction in daily foot care, from
keeping feet clean to recognizing changes in the skin. After
the initial visit, says Dr. Wallace, the patient might be asked to return
in a year, six months, or three months for another exam--it all depends
on the condition of the patient's feet. But he says patients with diabetes
should take a careful look at their feet every day. "The
most important part of preventive diabetic foot care is daily inspections,"
he says. "People with diabetes need to check their feet every day,
or have someone in their household look for them. Unfortunately, because
of diabetic neuropathy, these patients can't rely on how their feet
feel. The best time to check is after a shower or bath while drying
the feet." "Above
all, patients shouldn't panic or procrastinate. Early treatment can
be beneficial and possibly eliminate any need of amputation. That, for
us, is how we define 'success.'" To
make an appointment with University Hospital's Podiatry Services, call
(973) 972- 2500.
Dr.
George F. Wallace
Director of Podiatry Services at University Hospital
