Dr. Colin Michie, Paediatrician, with Steve Hyer, Physician and Endocrinologist
Amputation of the lower leg is being performed more frequently in the Caribbean. The most frequent cause is damage from diabetes, because the numbers living with this condition is rising. Trauma following road traffic or agricultural accidents, combat, unexploded ordinance or cancer can also lead to amputation. However, the majority of these life-saving procedures in people with diabetes are avoidable.
A friend recently told me just how rapidly his amputation took place. Relaxing into early retirement, he felt well. He did not think his diabetes was serious – he enjoyed chocolate and cigarettes, he avoided blood checks. He thought his body would cope. A small painless sore on his right foot enlarged steadily over three months, but he never mentioned it to anyone and began to use his father’s stick to assist his walking. A nurse taking his blood pressure noticed that both his feet were in poor shape. Treatments for his diabetes did not progress – he found the nurse bossy! Two months later, he collapsed with sepsis – in Hospital, a below-knee amputation was planned that month. After surgery, he started to attend to his diabetes, and his other foot, with great care. He has stopped smoking and is preparing for prosthesis with a therapist. He cherishes an independent life, but finds his lack of balance and his missing foot demoralising. For the first time in his life, my friend is anxious, sometimes depressed. He is afflicted too by persistent, sharp pains and itching where his big toe used to be: Phantom pains.
In 1676, a Dutch anatomist, Filip Verhuyen, had a lower leg amputation as a young man when sepsis developed after a minor injury. He kept and dissected his amputated leg. He named the Achilles sinew (now tendon) as a result. However, he spent the rest of his career puzzling over why he suffered pains from a toe joint that was pickled in the jar of preservative on his desk. He could see no cause for pain in his own carefully dissected toes. Phantom limb pains torment almost all amputees; many hide them for fear of the stigma of a mental health diagnosis. Their cause is still not known. Brain scans show that amputation does not change subconscious cortical maps of the body, even in children. It is likely that the lack of visual or touch signals from an amputated limb has something to do with pain perceptions, perhaps through the thalamus, an area of brain that can cause pain after spinal injury.
Phantom limb pains may persist for many years. They may develop following the removal of internal organs, such as a kidney! Pain can be managed with opiates or anti-seizure medications such as gabapentin. However, mirror therapies are effective and have fewer side-effects: A patient is coached in moving the remaining limb while watching in a mirror, or using a VR headset.
The long nerves and blood vessels reaching down to the feet need careful protection. High levels of glucose contribute to reduced blood flow, loss of sensation and damaged immune defences in the feet. Diabetic foot pathologies in most countries are the most common reason to admit people with diabetes onto a Hospital ward. Amputation rates vary, though, from two or three per 100,000 Spaniards in Madrid to approximately 49 per 100,000 Trinidadians. Most are below-knee amputations. This large difference emphasises different access to multidisciplinary diabetes care.
Diabetic care teams require a dietician, regular blood tests and mandatory annual foot checks. People with diabetes need well-fitting footwear and should avoid walking bare feet if they have any problems with sensation. Family members or a podiatrist can help with safe toenail cutting. Concerns relating to foot ulcers or injuries need rapid assessment by a care team. Devices such as hand-held dopplers measure foot circulation at home and skin devices can continuously monitor glucose – both allow patients to identify healthy choices and activities. A physician’s guidance highlights available treatments, medical and physical, that improve glucose control, nerves performance, vascular functions and foot health. Avoiding amputation that causes these dramatic changes to body integrity, mental state, mobility and lifestyle is a priority.
The Trinidadian study of amputations showed fewer than 20% of their foot amputees had a prosthesis fitted. Those with prostheses face challenges of finding one that is comfortable and practical. Considerable support and practise are vital to develop a normal gait. Virtual reality glasses may help some, wearable robotics are being researched. Cell therapies are being trialled to treat inflammation, rebuilding small blood vessels in the feet.
Globally a leg is amputated every 30 seconds. Prevention of this nasty complication is possible. We can all support diabetic relatives, or those with diabetes in our community.
Dr. Colin Michie specializes in paediatrics, nutrition, and immunology. Michie has worked in the UK, southern Africa and Gaza as a paediatrician and educator and was the associate Academic Dean for the American University of the Caribbean Medical School in Sint Maarten a few years ago.
Useful resources: woundscanada.ca/dhfy-doc-man/public/3208-lpj-spring-2024-v5n1-pg6-10-in-the-news/file ~ cdc.gov/diabetes/diabetes-complications/preventing-diabetes-related-amputations.html
