Amputation risk in Diabates

Dr. Jitendra Singh

The commonest non-traumatic cause of foot amputations or lower limb  amputations in this country continues to be Diabetes Mellitus. It is  strange that while enormous funds are being pumped in by international  agencies including the World Health Organisation (WHO) to set up artificial limb centres and rehabilitation centres in under-developed or developing  countries including India, little attention is paid to the preventive  aspects of this incapacitating handicap which could be avoided with timely  care and awareness.
George Bernard Shaw once wrote, a surgeon gets paid more for amputating a  limb than for saving a limb. The current focus on preventive aspects of  Diabetes has brought to light the risk of diabetes related lower limb  amputation getting doubled or even tripled because of improper foot care.
Vulnerability Factors
The risk of amputation obviously increases with the duration of Diabetes  and the extent to which Diabetes has been kept under control. Certain  laboratory parameters like glycosylated hemoglobin (Hb AIC) serve as an  indicator of how well the Blood Sugar levels have been under control over a  period of time and thus could also predict the underlying vulnerability of  a Diabetic to develop various complications including diabetic foot that  often precedes an amputation.
Available data reveals that amputations are more likely in those  Diabetics who have a previous history of foot ulcers or limb infections,  neuropathy accompanied with dimunition of sensation in the extremeties and  peripheral vascular disease involving narrowing of arteries resulting in  impaired blood circulation in the limbs.
Fashion Shoes not always Safe
In the current era of consumerism with a penchant for marketing products  which are unusual, innovative and somewhat exclusive, the use of fashion  shoes has also come under a question mark. A report published in one of the  world’s most reputed medical journals “Diabetes Care” states that wearing  fashion shoes may be associated with as much as fourfold increased risk of  amputation in Diabetics.
Figures gathered from surveys among diabetic population make some  interesting revelations. The lower limb amputation risk was found to be  nearly tripled by going barefoot in men, doubled by wearing sneakers  regularly to work in women, increased fourfold by wearing sneakers to town and doubled by wearing rubber thong sandals. In other words, high-risk  footwear seems independently associated with 2 to 4 fold increased risk of  minor or major amputation.
Needless to reiterate, the feet of a Diabetes affected individual are  susceptiple because of diminished sensation unable to perceive minor trauma  or pressure effect due to inadequate footwear. Peripheral Vascular Disease  leading to reduced blood circulation increases the chances of a noticed or  an unnoticed sore getting complicated and uncontrolled Blood Sugar levels  contribute to unrelenting infection at the site. It is with this  consideration that Diabetics should be reminded to conduct a careful daily  self-inspection/examination of their feet and particularly look for any pressure areas, scratches, injury marks etc. Significantly, some of the  studies claim that daily self-examination of feet is associated with as  much as 80% reduced risk of amputation.
In a nutshell, a health strategy that aims to improve footwear particularly in those who already have diabetic foot disease and that seeks  better diabetes education with emphasis on preventive self-care coupled  with early medical help-seeking behavior can certainly help reduce the  burden of lower limb amputation among Asian Indians.