Advanced/ Modern Treatment

Advanced/ Modern Treatment

What are Advanced Diabetic Foot Treatments?

These are special advanced or modern treatments that are used in select diabetic foot patients when the situation demands. These modern treatments sometimes help to improve and accelerate the healing of the foot. They may improve the chances of saving the foot. But, treatment isn’t necessarily good just because it is new or technically advanced, or expensive. There are always advances going on in every field including those related to diabetic foot. But, one has to be careful in choosing any modern technique and weigh the pros and cons before taking any. By far, most diabetic feet are amputated because of not taking known standard treatments like offloading (and customized diabetic shoes and proper debridement(cleansing of the wound) in time.

Following topics are Covered here

• Suction therapy – NPWT/VAC (Negative pressure wound therapy/ Vacuum-assisted closure)
• Angiography and angioplasty
• Methods of wound cleaning like ultrasonic debrider, maggots.
• Growth factors for local wound dressing
• Plastic surgery and flaps
• Artificial limbs
• Footwear

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Suction therapy – NPWT/VAC (Negative pressure wound therapy/ Vacuum assisted closure)

What is it? A low suction is constantly applied on the wound to keep the wound clean. This avoids the need of regular dressing; instead a change can be done every 5 days. It improves the rate of healing and rate of success. It is also of a great help socially to patient as he needs to visit hospital just every 5-6 days.

Prerequisites

o Wet wound – Suction therapy (VAC/NPWT) helps more in wet kind or exudative type of wound where lot of pus or discharge is coming out.

o Debridement – Suction therapy (VAC/NPWT) can suck only liquid material and hence any solid dirt has to be cut out first surgically EVERYTIME the dressing is changed.

Procedure

o A special sponge is cut of the size of wound and applied using a waterproof and airproof dressing. A tube is taken out of the sponge into a small suction machine. Constantly dirty fluid is sucked out and collected into a plastic can in the machine, which is changed at the time of dressing (after 5-6 days). Suction pressure is adjusted. It runs on electricity and needs to be kept plugged in mostly, though its battery can run it for 1-2 hours

o The whole procedure may take approximately 45 minutes.

o The machine can be taken home and carried or disconnected easily at will, especially when patient needs to move from place to place. Most machines way between 1-2 kg.

o The whole procedure can be done as a day case in hospital OT or at home as wound improves.

o Some need anesthesia in initial stages, when some wounds are painful. Most patients though fare well without anesthesia because of the damaged nerves (neuropathy, a complication of diabetes)

o The procedure usually needs multiple repetitions depending upon the wound.

o Machines are available usually on rent, but the services and dressing is chargeable.

o Research shows that VAC/NPWT improves the rate of healing and helps avoid amputations.

o Please note, suction therapy (VAC/NPWT) helps in certain cases only, typically what is called wet wounds. Using them blindly to all wounds, especially dry wounds or wounds with poor blood flow is not appropriate and can do more harm in some cases. Also, all major dirt needs to be cut out surgically first before applying suction. The machine can’t suck any solid dirt but only infected liquid material.

Side effects

o Most patients don’t complain of any pain, except for some pulling sensation.

o Some patients are disturbed by the constant whirring sound of suction machine, especially in night.

o If a patient complains of pain, other reasons must be checked like untreated infection, poor blood supply, and plaster cuts.

It is better to call the technicians at the first doubt, rather than wait.

Advances

o Irrigation VAC – Here wound is kept intermittently moist by machine by pushing in saline at regular intervals. It is more useful in relatively dry wounds.

Angiography and Angioplasty

Most diabetics have some circulation problem, but in 10-15 % diabetics, it is very poor to endanger the foot. Active treatment is required to improve the blood flow. Without adequate blood flow, wounds don’t heal and leg may need to be cut higher and higher.

o Angiography of the leg (peripheral angiography)

What is it? – Literally it means visualization of blood flow in vessels. ‘Angio’ stands for blood vessels and ‘graphy’ stands for seeing. Angiography is a highly specialized test done to know the blood flowing into the leg and the foot. It is an invasive test, as an injection of some contrast is required to see blood vessels. It can be done by different methods like Digital subtraction angiography (DSA), CT angiography (CT scan of blood vessels) MR angiography (MRI scan of blood vessels), and CO2 angiography.

What is it? – Literally it means visualization of blood flow in vessels. ‘Angio’ stands for blood vessels and ‘graphy’ stands for seeing. Angiography is a highly specialized test done to know the blood flowing into the leg and the foot. It is an invasive test, as an injection of some contrast is required to see blood vessels. It can be done by different methods like Digital subtraction angiography (DSA), CT angiography (CT scan of blood vessels) MR angiography (MRI scan of blood vessels), and CO2 angiography.

Procedure – A contrast injection is injected in the body so that the blood flowing is ‘seen’ more clearly. It can be done as a day case. The contrast injection itself can cause serious allergic reaction or damage to kidneys.

Advances

Because of different methods available, one can just do angiography in the first setting, rather than decide of angioplasty on urgent basis. The decision can be taken later whether to do angioplasty (depending upon urgency of the situation).

Also the contrast material used now is less harmful for kidneys compared to older ones.

o Angioplasty – It means actually doing something to increase the blood flow, like widening the blood vessel or putting a stent in the blood vessel. Usually this is preceded by angiography. Angioplasty is expensive. Angioplasty though sounds like a simple procedure, is a serious one; it has its own pitfalls and complications. A lot of thought needs to be put in the decision of doing angioplasty. These are some of the important issues that need to be considered before doing angioplasty.

Advances

Modern techniques allow angioplasty to be done at a lower level of the leg or even in foot below ankle level, increasing the chances of foot survival. But results vary.

Notes o It doesn’t help all patients – In diabetes, by the time a person gets a foot problem, the diabetes has been there uncontrolled for many years. Hence the damage to the blood vessels has happened not just in one place, but all over the body, in multiple places and in all organs, including heart brain, kidney.

o Limitations of results – Even in the leg itself, there may be multiple blocks all the way up to the small blood vessels of the toes. Hence, removing a block at knee level may not always help if there are blocks further down in the foot.

o Technical difficulties – Blood vessels are likely to be hardened in diabetes and difficult to open up.

o Most doctors can do angioplasty only in the leg and not in the foot, because the blood vessels in foot are small. Hence it may not always work for foot problem.

o In a few selected cases, angioplasty/bypass surgery can help to save the foot.

o IMPORTANT – In diabetic patients, owing to uncontrolled diabetes for many years, there are multiple hardened calcified long blocks from head to toe in all blood vessels. Most people may not get benefitted even if circulation is opened in one place. This is because, even if one block is removed, there are likely to be many blocks beyond it. The procedure itself is costly and has complications. It definitely has a place in poor circulation but is useful in very select cases and it should be used wisely.

• Bypass surgery – Similar to the bypass in heart, it can be done even in legs and can help in much selected cases. Here again the blocked part of the blood vessel is bypassed. For the same reasons as above, it is done in very select cases. Nowadays it is done rarely.

Wound cleaning/Debridement methods

o Debridement or cleaning of wound to remove all dirt is the most necessary part of diabetic foot treatment

o Traditionally, sharp blades and scissors are used. They are still the method of choice

Advances

Different methods have been tries to remove dirty necrotic area

o Ultrasonic debrider (Mechanical) – It cleans the wound effectively without damaging the effective part. But results are similar to old methods

o Enzymes – Special creams are used on wound to slowly cleanse it if. They may contain enzymes like papain.

o Maggots (Biological) – Specific maggots are used to eat away the dirty portion. Though useful, most patients don’t like it and rarely ever used in India.

o Autolysis – Using body’s own mechanism of destroying dirty part by constantly providing moist dressing either by simple saline dressing or irrigation techniques by machine.

Growth factors and special dressing materials

o Growth factors increase the rate of healing. Specialized ointments containing platelet growth factor or epidermal growth factors are used

o Growth factors increase the rate of healing. Specialized ointments containing platelet growth factor or epidermal growth factors are used

Plastic surgery in diabetic foot

Advances

Thick skin or vascularized flaps can be taken from totally different areas of the body and stitched to the ulcer area using microscopic techniques. Results vary in diabetics as blood vessels are hardened.

Notes– o Natural skin of foot is the best option and every effort must be made to save every millimeter of the skin. The reason being, we walk on foot and the skin of sole of foot is thick and specialized to take weight. Any other replacement won’t be as good.

o Most complicated plastic surgeries are difficult as skin from other parts doesn’t stick easily because of blood flow problem.

o Not suturing wounds after surgery but letting them heal naturally saves a lot of skin.

o Common plastic surgeries

 Local flaps – Saving skin of the foot and using it to cover raw areas, is what is done most commonly.

 Skin graft – Partial thickness skin graft can be taken from patient’s own body, usually the opposite thigh. Skin grows there again. It is a relatively simpler procedure and has high success rate. Most general surgeons can do it without needing a plastic surgeon. But, the skin is thin and gets damaged easily. Hence, saving local skin is very important.

Anesthesia in Diabetic foot

Advances

Local blocks – Practically, most surgeries can be done under some local or regional block. Here, only the affected part of leg is anesthetized by selectively locating the nerves and numbing them. Popular blocks are – ring block for toe, ankle block for foot, popliteal or knee level block for major foot surgery, etc.

Machines like nerve stimulator or ultrasound are used to locate the specific nerves. These techniques have made anesthesia very safe in diabetic patients.

Notes

o Special anesthesia is necessary.

o Anesthetic fitness – A patient will always need some test to check the status of important organs like heart, kidney, liver, lungs. Usually a physician gives fitness or a ‘green’ signal for the surgery.

o High risk – All diabetic foot patients had diabetes for many years and that too uncontrolled. This has already damaged important organs especially the heart and kidney whether routine tests show it or not. So, when any chemical anesthetic is used, one has to take care of these important organs.

o No general anesthesia – It is risky and best avoided.

o Skilled anesthetist – Just like there are specialized doctors, there are specialized anesthetists. Anesthetist may use ultrasound or other methods to locate the exact nerve.

Artificial limbs

Even after a major amputation, below knee (BK) or above knee (AK) amputation, a person should be able to walk on his own feet taking help of modern prosthetics. Fit people can do running, cycling, dancing, and mountain climbing.

Jaipur foot is the popular rubber based Jaipur foot is available for a very cheap price and still does all the basic works of a good limb. It has helped millions of people to stand on their feet.

Advances

(1) Using silicon elastomer as an interface between the stump and socket has made artificial limb very comfortable to the patient.

(2) New limbs have dynamic, response facility. Plastic springs are used.

(3) There are shock absorbing mechanisms in artificial limbs

(4) There can be microprocessor controlled movement

Notes

How to choose?

 Read and acquire knowledge – Though a wide range of artificial limbs is available, choice should be made after understanding the concept and components of artificial leg. No one but yourself can tell you exactly what you are looking for. There is no short cut, but to know about it yourself.

 Most important part – By far the most important part of the artificial limb is the interface or the soft material used between your remaining leg (amputation stump) and the artificial limb. This material decides the comfort level, the safety and the health of the remaining limb. We don’t want ulcer in the remaining limb again. Usually a silicone elastomer is used. It should be soft and thick.

 Shop – Visit different suppliers. Understand what they have. Compare material and price. They will like to sell what they have and the most expensive thing from it whether you actually need it or not.

. Footwear

Probably, the most useful advances for diabetic foot have happened in the field of footwear for diabetic patients. This issue is so important and has radically changed the outlook toeards the future of diabetic foot that, we have covered it in a separate page “Footwear in Diabetic Feet”

Advances

CAD/CAM – Computerized technology has helped technicians (pedorthotists) to find the exact pressure dynamics and prepare footwear customized for that unique foot. This is called CAD/CAM technology (CAD (Computer assisted design. CAM – Computer assisted manufacture).

Note

Here again, the man behind the machine, the pedorthotist is more important than the machine itself. A good pedorthotist can prevent many more amputations than a good foot surgeon. Getting a customized and personalized service as per the needs of the patient has so far been difficult in India.

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 Your needs – Understand your needs. If your needs are walking from room to bathroom and to lift and car, you don’t need fancy prosthetic limbs. A simple one may serve the job. No need of limb with artificial intelligence or shock absorber or dynamic responses.

 Budget – With every technology, cost climbs high. So budget constraints need to be followed.

 Fitness of body and mind – You should be capable of walking otherwise. If there is a hip or back problem or weakness, and person can’t even stand using a walker or help and support, an artificial leg won’t help to walk. First make rest of the body capable of walking. Many people buy fancy artificial limbs owing to marketing skills of salesman and don’t use it.

REMEMBER…

Most legs are lost because of not taking enough care to prevent problems and not taking appropriate treatment in early stage. As it happens, most effective things that help to prevent amputation are either cheap or free, but need time and discipline and regular care. They are discussed in ‘How to prevent diabetic foot problems’