Here is a terrific article from the Daily Mail from our friend and colleague Prof. Mike Edmonds’ world-class unit at King’s College Hospital, London.
Thousands of diabetics could be saved from needless amputation, claims ‘one-stop shop’ specialist
By DAVID HURST
One of the great worries for diabetics is complications.
Nearly 800,000 are at risk of blindness, heart disease and kidney failure because their blood sugar levels are not under control, it was reported last weekend.
Every week 100 people lose a foot or limb through diabetes.
The amount of amputations through diabetes could be reduced if patients were seen at a specialist centre, a specialist has claimed
But according to a leading specialist, much more could be done to reduce the numbers who have an amputation – if only patients were seen at a specialist centre.
Retired nurse Valerie Robinson was destined to be another of the unlucky ones.
Last year, an ulcer on her left ankle became so badly infected that doctors told her it was highly likely to become gangrenous. The leg would have to be amputated or she would die. ‘I was absolutely devastated,’ she recalls. ‘I’d never thought it would come to this. It was very depressing.’
Foot ulcers – the result of nerve damage and poor blood flow – are a common problem for diabetics. The nerves control blood pressure. Damage to them causes reduced blood flow to the extremities, leading to a loss of sensation.
Poor blood flow means the skin does not regenerate as quickly and becomes thin and easily damaged. The feet are particularly vulnerable. Even something as apparently benign as a shoe that rubs can cause problems, as no pain is felt.
Left untreated, a sore can develop.
The lack of blood flow means the skin takes longer to heal and doesn’t heal as well – often resulting in an ulcer and infection. Up to 15 per cent of patients with foot ulcers end up needing amputation.
As well as great personal misery, this costs the NHS £252 million a year.
Diabetic Valerie Robinson was saved from having her leg amputated after seeing Dr Edmonds
But Valerie was spared drastic surgery thanks to the pioneering approach taken by Dr Mike Edmonds, a diabetes consultant at King’s College Hospital in London. He runs what could be described as a one-stop shop for diabetics.
Unlike most hospitals, Dr Edmonds has a large team of experts, including orthopaedic surgeons, vascular surgeons, specialist nurses and chiropodists.
He believes that more than half of diabetic amputations could be avoided if all a patient’s diabetic complications, from blocked arteries to bone problems, were treated, rather than just their feet.
‘We’re mainly a diabetic foot clinic, but we can also treat other damage caused by diabetes, such as kidney or heart failure,’ he says.
‘Our approach is different from most hospitals. The key is to ensure patients get speedy, aggressive treatment, provided by experts across a range of disciplines. As a result, we’ve managed to save the limbs of patients who were destined for an amputation.’
Valerie is typical of the patients Dr Edmonds sees. The retired nurse from Hastings, East Sussex, was diagnosed with type 2 diabetes in 1986.
‘I knew, from being a nurse, how important it is for diabetics to look after their feet. I always wore shoes that fitted well. But two years ago I developed a condition called Charcot foot, where the bones in the feet soften and cause the foot to change shape.
‘My left foot started getting flatter, and my ankle started to turn over unnaturally.
‘Then, last year, I slipped and bruised my left foot, and just below my knee. I got the ulcer due to my bad circulation and the wound couldn’t heal. I knew ulcers were bad news, so I went to my then local hospital in East London.’
There, to her horror, doctors told her she was at very high risk of gangrene. If her lower leg was not amputated, the infection could spread and kill her.
Then Valerie struck lucky. First, her leg did not become immediately gangrenous and, a few months later, during a check-up, one of her doctors mentioned King’s College Hospital.
She asked to be sent there for a second opinion. Dr Edmonds and his team were confident her leg could be saved through a simple operation. ‘I cried with relief when they told me,’ she says.
The cause of Valerie’s problems was the bone deformity, which made her vulnerable to falls and therefore ulcers. These kinds of bone deformities are common in diabetics because nerve damage causes the joints to deteriorate.
The nerve damage also means patients have little or no sensation, so they’re less likely to notice when their feet are painful. It means they continue to walk and put pressure on the bones, making the injury worse.
Dr Edmonds explains: ‘We’re increasingly treating patients with “neuroischaemic feet” – that is, with both nerve damage and reduced blood supply.
‘The main treatment is to improve the blood supply, either by opening up the artery in the leg with a balloon or stent, or performing a bypass around the blocked artery.’
Fortunately, Valerie still had a good enough blood supply to the leg, so rather than opening up the arteries, the team’s orthopaedic surgeon corrected her misshapen foot to solve the problem for good. Valerie’s ankle was straightened by the insertion of a special nail into the bones of the foot.
‘Many hospitals think the sort of operation we did on Valerie is hazardous and doesn’t work,’ says Dr Edmonds.
‘Working with the smaller arteries below the knee, including the foot, requires complex procedures which are not readily available to diabetic patients in most hospitals.’
But having a team ready to take an ‘aggressive’ approach to diabetic disease means this kind of option is possible at King’s College Hospital.
clinic, which accepts referrals from around the country, sees between 20 to 35 patients every day and there are only about three amputations a year – ten times fewer than the national average.
‘One lady came to us with severe gangrene in her big toe and an infection in the surrounding bone. She had blocked arteries in her lower leg and she’d been warned she might lose her leg.
‘But the staff here performed an arterial bypass to her lower leg to save it. In the end, she lost only her toe.
‘What makes our approach so successful is that we take a holistic approach,’ says Dr Edmonds. ‘Patients with an ulcer need their whole body treating, not just their foot.’
There are only a handful of other UK hospitals, including Ipswich, Edinburgh and Exeter, with anything close to a similar service.
‘There should be teams such as our one at every hospital to help patients such as Valerie,’ says Dr Edmonds.
Valerie knows how lucky she’s been. ‘I can’t bend my ankle, and never will be able to – but my leg has been saved,’ she says.
‘I can stand and walk on my leg once again. Without the clinic, I’d be fitted with a prosthetic leg. It’s a fantastic service.’
• DIABETIC Foot Clinic, King’s College Hospital, 020 3299 3223. Diabetes UK, 020 7424 1000, http://www.diabetes.org.uk