Amputation Prevention Teams: Why aren’t there more like them all over the world?

Diabetics from amputation: Why aren’t there more like them ?

A wonderful article in the Daily Mail featuring our SALSAmigo and Olmos laureate, Prof. Mike Edmonds of King’s College.

The A-team: who can save diabetics from amputation: So why aren’t there more like them all over Britain? 

  • Steuart Robson, aged 63, first experienced pain in his left leg in 1994
  • The father-of-three had been diagnosed aged 23 with type 1 diabetes
  • By late 2009, Steuart’s doctors thought amputation was his only option
  • But his wife, Sally, found out about a multi‑disciplinary diabetic foot clinic
  • The clinic consists of a range of specialists including vascular surgeons

After years of worsening pain in his left leg, 63-year-old Steuart Robson was facing the last resort: amputation. 
He was on the verge of becoming one of the thousands of people who have a limb amputated every year due to ‘diabetic foot’.
The condition, which results in 100 foot amputations every week in the UK, occurs when blood vessels in the lower limbs are so badly clogged up and damaged that the feet are starved of blood. 
This can lead to infection and even gangrene, where loss of blood supply causes tissue to die.
Steuart first experienced pain in his left leg in 1994, after being diagnosed aged 23 with type 1 diabetes. 
With type 1 diabetes, the body doesn’t produce insulin, the hormone that mops up glucose from the bloodstream (type 2 is where patients don’t produce sufficient insulin).
As Steuart’s condition deteriorated, walking became a struggle and eventually he needed a wheelchair. 
Then, in 2006, a 3cm-wide weeping ulcer appeared on his left shin. 
Doctors tried treating it with antibiotics but it wouldn’t heal.
By late 2009, with blood supply to his lower leg practically non-existent, Steuart’s doctors thought amputation was his only option.
‘The pain was like a constant burning sensation,’ says Steuart, from Addlestone, Surrey, a father-of-three who is a warranty administrator with a car dealership.
‘I was on morphine-based painkillers to help try to numb it, but they were not strong enough. I would have said “yes” to amputation right there and then to stop the pain,’ he adds.
Diabetes can lead to a particularly aggressive form of atherosclerosis, the condition where arteries become clogged with fatty substances. 
High levels of glucose damage the lining of the blood vessels, as well as increasing the build-up of fatty deposits.

In diabetes, the smaller blood vessels below the knee and in the foot are particularly prone to this. 
As a result they narrow, becoming blocked and preventing blood — and oxygen — reaching the lower legs.
The nerves are also damaged. As these help control blood flow, this can worsen symptoms. And because these nerves also convey sensation, the feet can become numb.
Poor circulation can also lead to the skin on the feet becoming dry and breaking easily.
All of this means that the tiniest bump, or something as innocuous as a shoe rubbing against the skin, can cause a small cut, which can develop into an ulcer. 
The nerve damage and lack of sensation means patients often don’t know they have an ulcer until it has become established.
Poor blood flow exacerbates the problem — the lack of oxygen and molecules crucial for repair mean injuries are less likely to heal, if at all. 
Steuart is delighted he was able to access the specialist treatment at the diabetic foot clinic

Steuart is delighted he was able to access the specialist treatment at the diabetic foot clinic
Weeping wounds can easily become infected and, in the worst cases, this leads to gangrene. 
In severe cases, amputation is the only option to prevent sepsis. 
Even diabetics who successfully manage their condition for years can eventually fall victim to diabetic foot, as with age the arteries naturally begin to harden and narrow.
Taking aspirin and statins can help prevent diabetic atherosclerosis progressing but for diabetic foot there has been no ‘cure’, which is why there are so many amputations.
Steuart was fortunate to avoid this drastic option. 
In late 2009, after he’d been referred to a specialist amputation unit, his wife, Sally, came across a Daily Mail article about a multi‑disciplinary diabetic foot clinic at King’s College Hospital, London.
Patients facing amputation usually have many foot problems which require specialists to work together to save the foot.
These patients are having a ‘foot attack’ and need immediate co-ordinated care, in a similar way to heart attack and stroke patients. 
Although his GP had not heard about this foot clinic, he agreed to refer Steuart.
The clinic is run by Professor Mike Edmonds, a diabetes specialist, and the team consists of a range of specialists including vascular surgeons, orthopaedic surgeons, chiropodists, podiatrists and radiologists.
A key part of their approach is using interventional radiology (IR) to help unblock the damaged arteries and restore blood supply to the stricken limb.
Guided by imaging techniques such as X-ray, CT scans and ultrasound, specialists insert tiny wires through the blood vessels to the damaged arteries. 
A tiny balloon is then inserted into the artery and inflated, squashing the fatty deposits and clearing the blockage. 
The artery is then held open with a metal tube, or stent.
The technique, known as balloon angioplasty, is widely used for treating blocked arteries to the heart.
Figures from the Society for Vascular Surgery published in 2011 suggest the technique has a 96 per cent success rate — meaning the blood vessels in the leg remain open — in the first year.
The team discovered Steuart’s problems were caused by blockages in an artery in his left thigh and in arteries below his knee.
Within four weeks he was undergoing treatment. First, he had a balloon angioplasty performed by an interventional radiologist.
A vascular surgeon then performed a bypass of the blockage in the arteries in his calf. 
Again, in a technique more widely used for blocked arteries to the heart, the blood flow is redirected around an obstruction using a piece of vein taken from elsewhere, usually from the thigh.

Find out if you’re at risk of diabetes with the Four Ts test

‘Now I don’t even need crutches,' said Steuart (pictured with wife Sally)

‘Now I don’t even need crutches,’ said Steuart (pictured with wife Sally)
Steuart needed both procedures to increase the blood flow enough to help his lower leg heal. 
He also had a skin graft for his ulcer.
Finally, doctors decided it was necessary to amputate one of the toes on his left foot. 
‘There was such severe ulceration and infection that it would put the rest of my leg at risk — but this was a small price to pay if my leg could be saved,’ he said.
Most patients take three to 12 months to fully heal. Three months later, Steuart was pain-free: walking, driving and back at work. He has since been monitored regularly.
A couple of years later, the team found the blood flow in his leg had decreased again due to further narrowing of the artery — the continuing effects of diabetic atherosclerosis.
However, according to a study published in the journal Diabetes/Metabolism Research and Reviews, up to 80 per cent of patients don’t need any further interventions for five years. 
Another angioplasty tackled Steuart’s blockage. He still has regular ultrasound examinations to check his blood flow.
Professor Edmonds, who highlighted Steuart’s case at the recent Cardiovascular and Interventional Radiological Society of Europe conference in Glasgow, wants to see more specialist units across the country to reduce the alarming number of people who lose limbs to diabetic foot.
He believes that in the long run it will save the NHS millions of pounds. 
Latest estimates state that the cost of caring for patients with diabetic ulcers or diabetic amputees was up to £662 million per year in England alone.
Ulcer care alone is estimated to be £219 million each year, while amputation care is £55 million.
‘It is widely recognised that using vascular bypass and interventional radiology to combat diabetic foot is a much cheaper option than amputation,’ says Professor Edmonds.
‘Amputations should not happen because the problems are detectable and potentially treatable.’
He says teams similar to his own should be located at every hospital: ‘Clinical and economic studies indicate that multi-disciplinary foot clinics can improve patient outcomes and make savings that exceed the cost of the team.’

1 in 7 

The proportion of hospital beds occupied by a patient with diabetes 
His views are echoed by interventional radiologist Dr Trevor Cleveland, who works at the Sheffield Vascular Institute in the Northern General Hospital.
‘The majority of patients suffering from diabetic foot are elderly and unwell,’ he says.
‘Anything that means they avoid general surgery under general anaesthetic has got to be welcomed and that’s why the non-invasive methods we use in IR have a high success rate. 
‘Most patients have this done as a day procedure under local anaesthetic.’
Steuart is delighted he was able to access this specialist treatment. 
‘If I’d ended up with a prosthesis, I would have taken months to get mobile, which would have affected my work,’ he says.
‘Now I don’t even need crutches, and I’m back behind the wheel after being unable to drive for four years.
‘The difference between how I was and how I am now is like night and day.’

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