How to avoid amputation with diabetic foot syndrome?

Lower limb amputation is something that many patients with diabetes fear and, unfortunately, this threat is quite real. Even abroad, up to 15-20% of all cases of diabetic foot syndrome (which include foot ulcers, non-healing wounds, gangrene, etc.) require amputation.

But the saddest thing is that amputation in most cases can be prevented with proper and timely treatment.

Prevention of the formation of trophic ulcers

Шаг 1: Профилактика образования трофических язв:

There are special measures to reduce the risk of wounds and ulcers of the lower extremities in diabetes mellitus.

Step 2: If foot injury does occur:

These problems are curable in the vast majority of cases, but treatment must be correct and started in a timely manner. Seeing a doctor too late, only after a seemingly small wound has not healed for 1-2 months, is fraught with the development of complications of a trophic ulcer, the spread of a purulent-necrotic process to deep structures (bones, ligaments, joints), which is why damage to a toe or foot may become permanent. The sooner qualified treatment is started, the higher the chances of success!

Еще одна серьезная проблема состоит в том, что лечение ран (да и многих заболеваний) при сахарном диабете таит в себе много «подводных камней». Из-за них лечение в хирургических кабинетах и отделениях общего профиля часто менее эффективно, чем в кабинетах и отделениях «Диабетическая стопа» . Узнайте у Вашего эндокринолога, в какой кабинет «Диабетическая стопа» Вы можете экстренно обратиться в случае возникновения проблем.

Step 3: Current Treatments for High-Risk Amputation Situations:

К таким ситуациям относятся остеомиелит и язва на фоне критической ишемии конечности.

Osteomelitis

Osteomyelitis is a purulent lesion of the bone. There are various forms of this disease (it occurs not only in diabetes mellitus). But in diabetic ulcers, osteomyelitis is not a rare complication.

Unfortunately, once a diagnosis of osteomyelitis is made (and confirmed radiographically), there are only two main treatment options, each of which is quite difficult for the patient and has not only advantages, but also disadvantages:

1. Amputation of a toe or part of the foot (followed by treatment of the wound in the Diabetic Foot office to maximize healing and minimize the risk of problems along the way). If wound healing is not complicated by wound infection and other problems, this type of treatment allows you to quickly “get back to work,” but the operated foot no longer fully performs its functions; congested areas appear on it, in which the likelihood of new trophic ulcers is increased. In addition, a post-amputation wound on the foot may not heal in the case of impaired arterial blood flow, and if it cannot be restored (see below), the outcome of treatment may be a high amputation (at the level of the leg or thigh).
2. Another method of treatment is a long and fairly strict (combination of drugs, high doses) course of antibiotics, lasting at least 1.5-2 months. According to modern international (and Russian) recommendations, the non-surgical treatment option is absolutely equal to the surgical one, but its effectiveness is approximately 70-80%, and in case of failure, you still have to contact a surgeon. The disadvantage of this method is the risk of side effects of a long course of antibiotics, however, there are methods to minimize them (prevention of dysbacteriosis, antifungal agents, etc.). Due to the numerous disadvantages of the surgical treatment method, the non-surgical approach is becoming increasingly popular around the world. It is also used in the “Diabetic Foot” room of our clinic.

Critical limb ischemia

Критической ишемией конечности называют выраженное нарушение притока крови к стопе по артериальным сосудам. Это состояние может причинять страдания само по себе, вызывая сильные боли (характерный признак – ночные боли, требующие опускания ноги), но на его фоне очень высок риск того, что любое мелкое повреждение кожи (трещина, ссадина, потертость, врастание ногтя) будет не заживать, а неуклонно разрастаться, превращаясь в болезненную язву – зону некроза кожи.

A reliable assessment of the patency of the arteries is provided by ultrasound methods of vascular examination (Doppler ultrasound (USDG) or duplex (triplex) scanning – determining by what percentage the artery is narrowed) or angiography (X-ray examination of the arteries with the introduction of contrast, performed only in a hospital). Recently, angiography has been used using a special computed tomograph (so-called multislice CT).

Diabetic ulcers of this type (which are called ischemic or neuro-ischemic (as opposed to neuropathic – occurring against the background of preserved blood flow)) heal extremely poorly. Even with complete and actively carried out complex treatment of a diabetic ulcer, the probability of response to treatment and complete healing is only 20-30%.

Despite the abundance of various so-called “vascular” drugs, the vast majority of them do not affect the likelihood of healing. Only a few drugs have provided tentative (and not very strong) evidence of benefit in this condition. These are intravenously administered prostaglandin preparations (vasaprostan and alprostan), and recently certain hopes have been placed on low-molecular-weight heparins (Clexan, Fragmin, Fraxiparin in the form of subcutaneous injections) and intravenous injections of urokinase. But the question of the benefits of these drugs has not been finally resolved.

But the situation changes radically when using the most effective method of restoring blood flow – “semi-surgical” (balloon angioplasty) or surgical (vascular bypass). And, if previously these methods were not available to patients with diabetes mellitus, today in Moscow several hospitals are already successfully performing restoration of arterial patency in diabetes mellitus. The situation is also changing in other Russian cities.

Thus, if in the treatment of a diabetic ulcer the successful prevention of amputation depends on the doctor at the “Diabetic Foot” office, then in the case of critical limb ischemia it depends on a vascular surgeon or (more often) on a specialist in intravascular treatment methods.