People at risk of diabetic foot need to check their feet daily, as infection can lead to amputation, writes CLAIRE O'CONNELL
IF YOU had a stone in your shoe or you stepped on a thumbtack, you’d deal with the situation pretty quickly. But for some people with diabetes, damage to nerves can mean no warning signals of foot pain. And if left untreated, such injuries may worsen to the point where amputation is needed.
But identifying patients who are at risk of developing diabetic foot means they can benefit from early interventions, and that should help reduce the risk.
“Complications of diabetes come on in stages, whether it’s the eyes, the kidneys or the feet; and amputation is really the end stage of the foot being involved in diabetes,” says Dr Ronan Canavan, a consultant endocrinologist at St Vincent’s University Hospital and St Columcille’s Hospital. Diabetes can result in nerve damage and poor circulation, putting the person at risk, he notes.
“The problem with the diabetic foot is lack of pain means they keep walking on a prominent part of their foot or a stone in their shoe or a nail and they don’t know about it,” he says.
“This may go on for hours and may give rise to an ulcer on the foot and this can become infected. It’s still possible for it to heal up after it is infected, but if it fails to heal up then you are at risk of having an amputation.”
However, such serious complications are not inevitable, and screening patients can help identify a patient’s level of risk for diabetic foot, according to Canavan. “Unfortunately screening of the diabetic patient is one area where Ireland is at least 20 years behind the rest of Europe and America,” he says.
“It happens to patients if they attend hospital, but as their follow-up appointments get longer and longer because of waiting lists, they are not necessarily getting it every year. And there are still a lot of diabetic patients who don’t attend hospital.”
Canavan is part of a multi-disciplinary team at St Vincent’s to identify and help patients who are at risk of diabetic foot and work to avoid amputations. “If patients get up to the high risk, when they have [nerve damage] or vascular disease, there is a risk of something happening in the following months in terms of ulcer or amputation.
“But if they can be seen by the surgeons, the podiatrist, the tissue viability nurse and by myself, then we can make sure we have looked at the foot and done things to help protect it. And when a screen is negative, you can reassure that the risk of an ulcer or an amputation happening over the next year or 18 months is very low.”
Podiatrists play a key role in such teams, and Canavan describes as “a good start” that the HSE is looking to recruit 16 new podiatry posts for the national diabetes footcare programme.
Awareness of the condition is growing, according to Edel Kellegher, a senior podiatrist at St Vincent’s and part of the multi-disciplinary team – but delay in getting treatment can still be a big issue. “A lot of problems would come about because people aren’t aware of the injuries and there’s a delayed response,” she says. “And by the time they seek help the problem has escalated.”
She encourages the patients she sees to check their feet daily for cuts, sores, swelling or red spots, and if there’s a foot deformity such as a bunion or clawed toes that could push up the risk, proper footwear can help.
If the skin or bone has become infected, antibiotics may be of use – but ultimately prevention is best, she says.
In some severe cases, limbs could be saved by improving blood flow through narrowed or blocked arteries, and Enniscorthy-based company Clearstream Technologies has developed catheters to facilitate angioplasty below the knee. This involves a clinician inserting a guide-wire and catheter down into the arteries of the leg, then inflating a balloon to clear blockages and allow blood to flow through.
“In diabetic patients, the area below the knee can be severely diseased,” says Karl Hoffman, product manager with Clearstream, which was recently purchased by multinational company C R Bard.
“The area below the knee is technically challenging because of the small calibre of the tortuous vessels and the fact that there is a longer distance for the wires and catheters to pass,” he says.
“The Clearstream catheters are very low profile and flexible and they pass easily along the wire and through these narrowed and blocked arteries.”
