vascular medicine , surgery and wound care

Diabetic foot complications are predictable, therefore preventable

Diabetes foot care is grossly neglected.Over sixty percent of amputations occur in diabetics.Eighty-five percent usably begin as trivial injuries or ulcers. If it is predicable it is preventable. Amputation rates in diabetes can be reduced with a proactive evidence based approach.This has already been shown by the LEAP study in the USA as well as the St Vincent Declaration in Britain! The reader is invited to look at a detailed review in the Powerpoint section under Strategies in the management of the diabetic foot

Smoking + Diabetes = Amputation
Evidence based approach for neuropathy, arterial disease, and deformity

Do not underestimate the importance of bony deformity
Do not forget to offload as part of the foot care prescription
Was this predictable and was it preventable ? Yes, No, Maybe??
This is a 53 insulin dependant diabetic male with a previous history of a right below amputation and amputation of his 2/3 digits on the left foot. He had been lost to follow up after his below knee amputation. He smoked 40+ cigarettes/day and drank alcohol regularly. He lived in a remote area of Northern Ontario and did not seek medical attention regularly.

According to his significant other he was complaining about his foot for over three months but would never let her look at his foot until the day he showed up on our emergency department. His wounds were foul smelling even after he was cleaned up. His leg was not deemed salvageable and he was given the benefit of a below knee amputation that same day. Post op he developed an acute MI and died one week later.

Looking at the above photo carousel, a narrative can be developed:

These wounds are not acute

His personal cleanliness is suspect

He demonstrated evidence of both peripheral neuropathy and peripheral vascular disease and foot deformity and therefore considered a high risk for limb loss

He has not been wearing proper footwear or off-loading foot support

He walked around his house barefoot

There is an animal in the house

He had not seen a doctor or proper foot care provider

There are staggering statistics regarding diabetes and its complications. More than 2 million Canadians have diabetes with Northern Ontario disproportionally high relative to our brothers and sisters in the South. Over 60% of all non traumatic amputations occur in diabetics. In amputated diabetics, 50% develop ulcers on the contralateral limb within 2 years. 50% have a contralateral amputation within 5 years and the 3 year mortality after the first amputation is 50%.

There is significant variability in foot care assessment and risk potentially leading to inappropriate care. Overall, the complication rate in diabetes is not well monitored and specifically Canadians with diabetes are not well monitored for foot conditions. Globally, there is no standardization of primary foot care in people with diabetes.

Foot related issues are the the most common complication needing admission to hospital in people with diabetes.

World wide, there are over a million amputations in the diabetic population each year. We know that at least 15% of all people with diabetes will develop a foot ulcer and that 85% of all amputations in diabetics are preceded by an ulcer. Every year in Canada , 1 in every 250 Canadians have some part of their limb removed.

Both the USA and Great Britain are starting to report a decrease in the number of limb amputations despite the increased prevalence. The reason for this is the development of an evidence based proactive approach with standardization of care.

Diabetic foot problems are a threat to each and every Canadian.We need a standardized approach, a change in both patient and health care provider education and a proactive mindset. There should be more emphasis on the utilization of knowledge translation methodology for implementation of things that work. High risk patients should be seen every 6-8 weeks.The low risk, once yearly.

Not all diabetics need special orthotics or off loading boots.They all need proper footwear. Proper footwear is individualized but must be assessed by a competent provider and SHOULD BE AVAILABLE to all Canadians as part of a Federal/Provincial initiative.

This man's outcome might have been different. It was predictable but was it preventable? There are many social determinants of health (SDOH) in Canada. Outcomes vary for many reasons which are beyond our control. This presentation was predicable but was it really preventable?