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Saving Limbs by Healing Chronic Diabetic Foot and Leg Wounds


Aug 10, 2009

Dramatic technological improvements in the treatment of foot and limb wounds have reduced the need for amputation.

A 43-year-old Iraq war veteran with diabetes is living in Texas with his wife and four young children when he is told that he must prepare for the amputation of one of his legs.  The spreading, non-healing wounds and their complications make the amputation necessary to save not just his limb, but his life, his doctors tell him.  But he refuses to proceed with the amputation surgery.

Instead, he searches the Web until he finds a research study on limb preservation and wound healing advances. The study is led by a former military doctor now at Boston Medical Center, a podiatrist and podiatric surgeon by the name of Dr. Vicki Driver. The man gets in his truck and drives 1,500 miles to see her. She agrees to work with him, enlisting the help of a team of vascular, cardiac, and other specialists, and in the end, she saves his leg. Later, when he develops wound ulcers in the other leg, she and her team of specialists manage to heal and save that one, too. 

The good news for people with diabetes is that this story, although perhaps more dramatic than most, is not at all unusual.  Until rather recently, however, the man from Texas would probably have lost both his legs.  Dr. Steven Kavros, a respected podiatric surgeon and researcher at the famed Mayo Clinic in Rochester, Minnesota, says that when lower limbs are amputated in people with diabetes, 40 to 50 percent of those patients lose another limb within three to five years.  He adds that if a person with diabetes has a non-traumatic limb loss, there is a 50 per cent chance that he or she will die from cardiovascular complications in three to five years.

Estimates are that 15 percent of people with diabetes will develop foot ulcers, often without recognizing it until too late, due to poor foot circulation and neuropathy that masks pain. How significant a problem are non-healing wounds in lower extremities for people with diabetes?  Consider this finding from Dr. William J. Ennis of University of Illinois in Chicago:  "People with diabetes account for 60 percent of all amputations performed in the United States annually."

Self-Management Is Crucial
For this story, we interviewed three of the world's leading podiatric physicians and surgeons who specialize in diabetic wound healing and limb preservation. Although they all lauded the remarkable progress that new treatments and systems have made possible, they also repeated the counsel that people with diabetes have heard from their doctors many times: The most important factor in preventing lower limb wounds and amputations is dedicated self-management of the disease, including constant attention to the feet and lower extremities as well as A1c levels and vision changes.

In his practice as a doctor of podiatric medicine and surgery at Georgetown University Hospital in Washington, D.C., Dr. John Steinberg specializes in the diagnosis and treatment of complex lower extremity wounds. The 80 patients that he typically sees during a week are a varied group.  "We may have a U.S. senator or ambassador in one examining room and a homeless person in the other," he says. 

Dr. Steinberg notes that his biggest challenge is finding the cause of the wound. Diabetes, he says, is not the cause. "Diabetes does not cause foot ulcers and recalcitrant wounds," he emphasizes.  What does cause these ulcers and wounds in the feet and lower limbs of people with diabetes, he explains, is pressure on the feet and legs caused by ischemia, poor circulation, neurological problems, and infection-all complicating and attending factors of the disease. To heal the wound, the solution is to relieve the pressure, which Dr. Steinberg calls "the mechanics."  Sometimes those mechanics may involve surgery to correct a bone or foot deformity, coupled with getting the patient into special shoes.

Many of the patients who come to Dr. Steinberg and his podiatric colleagues at the Georgetown Hospital have already been to one or two other physicians who've not been able to offer the solution they seek.  "These patients then ask us if we can help," he says, "and our answer is usually ‘yes.'"

New Technology Is a Formidable Treatment Tool
New technology is another reason that Dr. Steinberg and other cutting-edge podiatric specialists are able to treat severe lower limb wounds before the bones become infected.  Dr. Steinberg says that he has witnessed a "dramatic improvement" in wound healing technology in the 10 years since he finished his fellowship in diabetic limb salvage at the University of Texas Health Science Center in San Antonio. Non-healing, or recalcitrant, wounds are being healed and closed, infections are being eradicated, and even the elasticity of connective tissue in limbs is often being recovered.

A significant challenge with non-healing wounds is that they often have deep wound beds where bacteria colonize and produce flourishing infections, says the Mayo Clinic's Dr. Kavros. The bacteria develop into a biofilm, which he describes as looking like a cookie. In fact, the bacteria create a sugar-laden form over the wound that obstructs the application of antibiotics and treatment. 

However, new technologies are available to remediate this high degree of colonization and the biofilms that block the healing process. Hyperbaric chambers are sometimes used to literally bombard the wound area with pure oxygen, boosting blood flow and encouraging healing. Another therapy treats the wound with a device that combines painless ultrasonic sound with a fine saline mist. The sound energy and saline stimulate cellular activity and accelerate healing.  Known as "MIST Therapy," it's been found to be remarkably effective, economical, and quick.

MIST Therapy, which was approved by the FDA in October 2004, was developed by a Minnesota company named Celleration. Treatments are done 5 centimeters from the wound.  Typically, wounds are treated three times a week, and each treatment is about four minutes long. 

In one study done by Dr. Kavros and his co-investigators, size-of-wound reduction in patients using the system was achieved 72 percent of the time, versus a 46 percent reduction in the patients using normal wound therapy. Total wound closure for patients using the system was 70 percent, compared to 21 percent for the patients receiving normal care. 

"I first heard about this system in 1999, and I was very skeptical," Dr. Kavros says. "Now, every day, we see more and more evidence of its effectiveness.  We often see changes in a week and a half." The net result, he says, is that with this new system, he can "handle more cases, with better results, in less time and for less cost."  He likes to tell the story of a 62-year-old patient who was so grateful for his recovery with the treatment that he purchased a MIST Therapy system and donated it to the clinic.


Categories: A1c Test, Amputations & Amputee, Diabetes, Diabetes, Research, Type 1 Issues, Type 2 Issues, Wound Care



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Comments

Posted by Anonymous on 13 August 2009

As someone raising a diabetic, I so appreciate understaning this complex issue and having something I can share with my boy's MD. THANK YOU for making this issue understandable--- to both the professional community and the layperson.

Posted by Anonymous on 13 August 2009

It's so painful to be involved with a diabetic and watch issues like this come and go. I am genuinely grateful to have something I can share with John's vary caring--- but not particularly dully informed--- MD, that can get his attention on this issue.

Posted by Anonymous on 19 August 2009

I am a Wound Nurse Specialist (CWOCN) working in a formal Diabetes Foot Amputation Prevention Program for LSU. We learned early on from research produced in preventing amputation with Hansen's Disease (Leprosy) patients, that the vast majority of lower extremity amputations (50-90%) could be prevented by addressing the neuropathy problems most commonly experienced by diabetes patients. Patients who have PAD (poor arterial blood flow) should be evaluated by a Vascular surgeon to re-establish blood flow. Patients with neuropathy commonly have loss of a pain warning system, have foot deformities, and/or have gait disturbances. What is MOST essential is removing the biomechanical (pressure) from the wounded foot and offloading sites of high pressure commonly noted with common foot deformities such as claw toes and prominent bones on the bottom of the foot. MIST therapy is an expensive modality that is not the "Magic Bullet" in this care. It has benefits that can promote ingrowth of healthy wound tissue, but is just another adjunctive modality. A listing on informaiton that may be of informational value to readers is located at our website: www.medschool.lsuhsc.edu/dfp.

Posted by Anonymous on 19 August 2009

Diabetes is such a tough disease to manage ... one day's sugar readings vary from the last depending on exercise, food, stress and more. As a type one diabetic (w/o complications for 33 years)it's best to take it one day at a time and motivate yourself to overall try your best and pay attention. Even still, it's a battle. Prevention of complications are self induced, to a point. You still carry a disease that effects so much of your body and taxes the mind in management. There is no day off in management. Be strong and never give up! The pay off is amazing!:-)

Posted by Anonymous on 20 August 2009

Unfortunately, the CMS and medicare are making it tougher and tougher for the real Foot & Shoe Experts: Certified Pedorthists; to supply appropriate preventative footwear for the millions of diabetics who should be fitted under the Therapeutic Shoe Bill. They are now requiring us to have Certified facilities and Perfomance Bonds that cost too much for the average Specialty footwear store to afford!! That means less well fitted feet and more un-necessary or avoidable foot ulcers!!! Remember, less than 10% of Podiatrist have anything more than 2-3 hours of footwear and Accomodative Inlay trainig in podiatry school..

Posted by Anonymous on 7 June 2011

Avron Daniller, MD, FACS, FRCS (Los Angeles, California) and his colleagues have had tremendous success in reversing symptoms of peripheral neuropathy and preventing lower limb amputations in a very high percentage of diabetic and non-diabetic patients with peripheral neuropathy. The procedure is realitively simple, and usually takes about 90 minutes. I am a type 1 diabetic of 45 years, and am a trained molecular biologist / medical researcher and I have seen miraculous results when I was working on a separate project in his office for several months, several years ago. I think he is still practicing at Providence Health Tarzana Hospital and Long Beach Memorial Hospital (Wound Care/Prevention Clinic) in California. This procedure is now also being performed at Johns Hopkins and various other University Medical Centers around the country.


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