“Save a limb, save a life”
Thousands of people with diabetes are having limbs amputated in surgeries that could have been prevented. Life expectancy plummets following these surgeries – so why aren’t we working harder to stop them from being necessary? In this episode Gemma speaks to two podiatry experts from the University of Malta, associate professor Cynthia Formosa and senior lecturer Dr Alfred Gatt. They explain how a united front from healthcare professionals across the world is needed to combat the issue. Discover how improved screening procedures, earlier diagnosis and better patient awareness are vital components in saving people from amputation, and how podiatrists need to be seen as the key person in the life of someone living with diabetes.
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For my inaugural podcast, I spoke to Professor Cynthia Formosa and senior lecturer Dr Alfred Gatt of the University of Malta, both specialists in the treatment of diseases of the foot. I wanted to know why there was an amputation crisis among diabetic patients, and what could be done by scientists, clinicians and the industry to address that crisis and reduce the incidence of the most drastic intervention, the surgical removal of a limb.
We began with the reasons why diabetes and its complications can lead so inexorably towards amputation. The circulatory system which takes blood around the lower limbs, supplies cells with blood and takes away waste; if this system becomes impaired in any way, then problems can arise very quickly. One of the symptoms of diabetes is arteriosclerosis, the narrowing of the arteries which carry the blood, so, inevitably, as the feet are furthest away from the heart, they therefore suffer most severely from a reduced blood supply. This can lead to peripheral arterial disease, which is a surefire recipe for the degradation of the condition of the feet.
Another problem associated with diabetes is neuropathy, which involves damage to the nerves. This can be hugely dangerous: if you have nerve damage, you can’t feel pain properly, so it’s easy to cause damage to your extremities without even realising it. Damage can lead to tissue problems and poor healing; this can be the beginning of a journey which sadly, ends in amputation.
Amputation in diabetic patients is very prevalent, and there is a huge gender imbalance. Men are three times more likely than women to undergo an amputation. And that’s not the end of the journey, either. Amputation dramatically reduces quality of life, it can lead to further amputations, and the mortality rates of amputees are much higher than those who haven’t undergone such procedures. It’s genuinely a life-and-death scenario. Save a limb, save a life.
How do we reduce the rates of amputation? One obvious route is through more frequent and better testing. It’s usually fairly clear when someone is at a very high risk of requiring amputation, or, conversely, at a very low risk. The difficult judgements come in the middle, when the symptoms might just be developing. That’s where thorough assessment by a competent and experienced podiatrist is so vital.
What needs to be tested? Vascular function can be checked with a Doppler ultrasound which measures blood flow and will reveal any impairments. Neuropathy can be monitored using an instrument called a monofilament (usually gauged to a force of 10 grammes), which tests the sensitivity of the foot. It can alert physicians to decreasing nerve function and therefore indicate that problems are already developing. Early diagnosis is absolutely key to reducing the numbers of amputations. And many of these issues are preventable.
Experts have estimated that four out of five amputations are preventable: but how do we do this? There are several things we can do. It’s important to make sure that blood sugars are controlled. To achieve this, prescribed medication must be taken regularly and as instructed. Clinicians also need to be aware of the possible impact of cultural differences on the treatment of lower limb conditions; for example, in hot countries, patients do not always wear appropriate footwear, which can lead to their conditions deteriorating unnecessarily; and it is absolutely vital, overall, that clinicians and patients work together to ensure that diabetes and its side effects are managed properly.
Cynthia and Alfred agreed with me that, in an ideal world, people would visit their local podiatrist as regularly and as casually as they went to the dentist, to ensure consistent and ongoing and reactive care. Diabetic patients need to be monitored on an at-least-yearly basis, possibly more frequently, depending on their risk stratification. Why don’t they? Podiatry is not a uniform discipline. It comes in all shapes and sizes, varying widely across Europe, for example. In some cases, it is carried out by people who don’t have adequate training. It also doesn’t receive the media coverage or the funding for research which other specialisms do: we all know about the importance of oncology and screening for cancers, for example, yet the incidence of diabetes, with all its potentially devastating consequences, is much higher than that of cancer.
In conclusion, we need more effective guidelines on screening and treatment of diabetic limbs. We must have better coordination of research, so that scientists are working together, not pulling against each other. Can we reach a stage of zero amputations arising from diabetes? That’s the ideal scenario, of course, but the burden lies with clinicians, scientists, patients and equipment manufacturers. We are all in this together.
By Gemma Bailey
Director, Bailey Instruments