Neglect of diabetic foot treatment may lead to leg amputation

Shardul Nautiyal - Mumbai

Diagnosing diabetic foot has come of age from the days of detection by a tuning fork to today’s cutting edge vibration perception threshold sensitometer, heat and cold sensitometer. However, the technological advancement has failed to translate into teatment, with around one per cent of diabetics in India living under the threat of leg amputation.

The treatment of diabetic foot is marred by dearth of diabetic foot specialists, expensive treatment, lack of training centres and an unregulated market for diabetic footwear. The magnitude of the problem can also be gauged from the fact that of over three crore diabetic population in the country, 15 per cent suffer from diabetic foot problems.

A diabetic foot implies peripheral vascular disorder, peripheral neuropathy and autonomic neuropathy or a combination of these. Diabetic foot conditions develop from a combination of causes, including poor blood circulation and neuropathy.

Says Dr Jessy Thomas, diabetic foot specialist, Hiranandani Hospital, “Diabetic with a foot complication spends 53 per cent more on the treatment other than cardiac and nephrology related complications.” The treatment for diabetic foot depends upon the grade of diabetic foot, the level of intervention like oral or (intravenous) antibiotic, offloading techniques, IPD/OPD(care), surgical intervention, vascular intervention, infrastructure of the hospital and expertise. While an intermediate surgery costs around Rs 8000 to Rs 10, 000, major surgeries are as high as Rs 20,000 to Rs 25,000. The cost can soar higher in case of vascular block, where the angiography of the legs and revascularisation with angioplasty or bypass is required. Additionally, antibiotics cost Rs 3,000 to Rs 4,000 per day. “Repeated surgeries coupled with long hospital stay is also a major contributor to the expense of the treatment of diabetic foot,” informs an expert from Hiranandani Hospital.

Shortage of specialists and expensive treatment have led to leg amputations, which could have been avoided. People with diabetes are upto 40 times more likely to undergo a lower leg amputation. Herein, the role of a diabetic foot expert comes in to salvage the limb. The amputation rate can be brought to as low as three per cent if timely diabetic foot treatment is available to patients.

Says Dr T K Sahi, honorary surgeon, J J Hospital and professor, surgery, Grant Medical College, who has pioneered the treatment and management of salvaging of limbs in the end-stages of peripheral circulatory disease with or without diabetes, “Amputations can be avoided and limbs can be saved, even in the end stages of peripheral circulatory disease through surgical techniques like ‘Revascularisation by Omental Transfer’ and ‘Bilateral Simultaneous Revascularisation’.

Recognition of her work in salvaging limbs came when she was awarded the young researcher best paper award at the World Congress 2000 of the International College of Surgeons, which concluded in Suntec City at Singapore in October, 2000.

“Diabetic foot management is a highly specialised work requiring exceptional dedication as one has to deal with several issues like injury, infection, diabetes, non-healing ulcers, circulatory deficiencies and neuropathies,” adds Dr Sahi.

Why such an acute shortage of diabetic foot specialists? Dr Arun Bal, diabetic foot surgeon, Raheja Hospital, attributes the shortage to the absence of courses in podiatry in the medical curriculum at graduate or post graduate level. “Increase in diabetic foot patients is due to the lack of diabetic foot specialists at primary healthcare centres,” remarks Dr Bal.

The unavailability of diabetic foot specialists delays the diagnosis of diabetic peripheral neuropathy or diabetic foot and hence late referral to the specialty centres leads to an escalation in the cost of the treatment, point out experts. Diabetic foot experts, who are doing dedicated work are mostly self-trained. “The existing orthotists in the country, who make artificial limbs, orthopaedic shoes and belts, are not fully equipped to make the diabetic foot wear as their training is incomplete in various aspects of diabetic foot problems,” informs Dr Bal.

Amrita Institute of Medical Sciences, (AIMS), Cochin is the only institute in India offering one-year course in diabetic foot management for nurses, one-year diabetic foot surgery for surgeons and a two-year diabetic educators Course.

	Simple patient education and cost-effective footwear would prevent 85 per cent of amputation. If this is not done in the future, the country will face tremendous economic loss
Dr Arun Bal

To iron out the hurdles, Dr Bal suggests simple patient education and cost-effective footwear, which would prevent 85 per cent of amputations. “If this is not done in the future, the country will face tremendous economic loss,” cautions Dr Bal. To make the treatment more affordable, there is a need to have indigenous instruments. While the cost of an indigenous sensitometer is Rs 22,000, the cost of an imported one is Rs 85,000. “Dhansai Lab, which manufacturers these equipment has been able to sell 500 to 1000 indigenous sensitometers with the support of DFSI, across the country in a year’s time,” informs Dr Bal. Even indigenous foot scanners should be made available at all the centres across the country.

According to Dr Harish Kumar, consultant endocrinologist, AIMS, Cochin, “The specialty can get a boost if manufacturing of diabetic foot wear and equipment for testing is regulated.” Diabetic Foot Society of India (DFSI) has set up a sub committee to standardise diabetic foot care in India and bring about guidelines for diabetic footwear. DFSI is also working to educate the doctors and nurses. World Diabetes Federation (WDF) is conducting a pilot project for training teams of doctors and paramedics on diabetic foot management at primary level across the country.“The solution to the problem lies in changing medical nursing, orthotist and physiotherapy curriculum. Nursing and orthotic curriculum should also incorporate chapters on diabetic foot management,” suggests Dr Bal.

Experts say that the government and private organisations should come forward in starting training courses at various levels for prevention and treatment of diabetic foot for doctors and paramedics.

Good manufacturing practices should be applied to make simple, cost effective and scientific foot wear. “Government should recognise the huge gap in therapy and academics, thus, starting a certified course in podiatry, setting up a foot clinic in all public hospitals and increasing the awareness through exhibitions, electronic and print media,” says Dr Rajiv Kovil, consultant diabetologist, Kovil Diabetes Centre.

Some of the problems of diabetic foot peculiar to our subcontinent is because people tend to walk barefoot. 

“Not only do we not use footwear indoors, but a large section of our population do not use it even outdoors. Patients with severe neuropathy do not have any sensation and are unable to feel pain on injuring their feet. These injuries like cuts from sharp objects and burns from hot surfaces are likely to occur both indoor and outdoor. So once a patient has poor sensation and poor blood supply in the feet, i.e., a “high risk foot”, it is necessary to educate the patient and use appropriate footwear to prevent injuries and ulcers in the feet,” informs Dr Kovil.

shardul@expresshealthcaremgmt.com