Dr. Mark Hinkes

Older adults in nursing homes and long-term care facilities often have multiple health problems. With medical advances in the treatment of diabetes, aging Americans are living longer with the disease. In fact, as many as one in four nursing home residents has diabetes.

Foot health and amputation prevention programs for geriatric patients with diabetes are crucial to allowing the elderly to remain functional and independent. Patients with healthy feet can continue to walk and exercise. With proper foot care, falls and fractures can often be prevented.

As chief of podiatry and director of podiatric medical education at the Veterans Affairs Medical Center, Tennessee Valley Healthcare System, and author of “Keep The Legs You Stand On,” it has been my personal and professional goal to reduce the rate of amputation for patients with diabetes.

That can be accomplished by identifying those who demonstrate high-level risk factors such as: decreased circulation, loss of protective sensation and pedal deformities. A thorough assessment and an individualized preventive care plan can prevent a triggering event of mechanical, thermal or chemical trauma that can lead to ulcers, infection, and ultimately, an amputation. A podiatrist can quickly identify those patients with foot deformities, vascular, neurological or pedal biomechanical problems and provide prompt and proper treatment, including prosthetic items, such as shoes, insoles braces and walking aids.

Geriatric and long-term care residents with diabetes have a greater risk for foot ulcers, infections and amputations due to diabetic neuropathy.  Usually first observed as a tingling sensation, diabetic neuropathy often results in loss of sensation in the feet. This makes residents especially vulnerable to silent or painless trauma. For example, the resident may not feel a stone in their shoe or something dropping on their foot. They might be insensitive to an over-the-counter product that contains salicylic acid that destroys tissue painlessly. Or, they might not feel exposure to extreme heat, putting their feet close to a fire or heater and not being aware of a burn to the skin.

Once exposed to such trauma, residents with diabetes have several factors working against them to prevent or delay healing. They include: elevated blood glucose levels, immunopathy, peripheral arterial disease (PAD) or venous disease, smoking, and simply not practicing preventive foot behaviors, such as wearing shoes or visually inspecting their feet daily.

While all long-term care residents can benefit from preventive foot care, it could be life/limb saving for those who have lost protective sensation. The costs are minimal, especially when weighed against the potential expense for treatment. Diagnosis of loss of protective sensation with a monofilament testing device can easily be accomplished. Even if the resident is not able to provide self-care, nursing home staff can be educated in assisting with a daily routine whose benefits well outweigh the costs of treating an ulcer or infection in the hospital or an amputation, not to mention the lifetime rehabilitation costs.

A common problem

Amputations of lower extremities done for patients with diabetes are neither rare nor extreme.
In the United States, more than 83,000 are amputated yearly at a cost of more than $5 billion. Worldwide, 1 million lower extremity amputations are done for patients with diabetes. That’s one every 30 seconds.

What’s worse is that approximately 38% of patients who lose a leg will lose the other within three years. Nearly half of those who lose a leg won’t survive five years. However, there is hope. The U. S. Centers for Disease Control and Prevention estimates that up to 85% of these amputations can be prevented.

Long-term care facilities can focus on those statistically most vulnerable for lower extremity amputations. These patients fall into Category 3 in the evaluation scheme of the International Working Group for the Diabetic Foot.

First, they all have loss of protective sensation (LOPS) as defined by an inability to feel the 5.07/ 10 gm monofilament testing device on the bottom of their feet. They usually have a combination of autonomic, sensory or motor neuropathy that complicate healing of a foot wound. Many share a history of a previous amputation, foot ulcer, gangrene, claudication, rest pain, osteomyelitis, end-stage renal disease, previous vascular surgery on the legs, or a history of smoking.

Key evaluations that determine the patient’s risks for lower extremity amputation include:

* Vascular Evaluation of pulses in both feet.

* Neurological Evaluation with the 5.07/10 gm monofilament testing device to establish if the patient has or lacks protective sensation (LOPS).

* Foot Deformities Evaluation to classify osseous, soft tissue or nail deformities. Osseous deformities include any joint deformity of the foot such as hallux abducto valgus or bunion deformity, contracted digits that create hammer toe, claw toe, or mallet toe deformities and a tailor’s bunion-a deformity of the 5th metatarsal-phalangeal joint.  Such bone deformities can create pressure points that rub against shoes or bedding, become inflamed, and lead to soft tissue breakdown or ulcers. Infected ulcers lead to osteomyelitis. The geriatric patient with diabetes will be challenged to heal these ulcers as they have neuropathy, PAD, and immunopathy. This combination of co-morbidities oftentimes delays or prevents healing, and because of infection and risk to the patient’s life, leads to amputation.  Pressure against bony structures causes the body to protect itself by creating soft tissue deformities, called keratosis, or thickened skin lesions, called corns or calluses, that if left untreated can cause abscesses underneath them. Undetected and unfelt, these abscesses can lead to osteomyelitis and result in amputation.

* Nail deformities can also lead to amputation. A hypertrophic nail is vulnerable to pressure from the shoe pressing against it, causing an abscess underneath it. A thick, deformed and long nail can lacerate the adjacent digit. In both situations, if osteomyelitis results, amputation may be necessary.
To learn more about foot health, ulcers infection and lower extremity amputation prevention, visit my Web site at www.amputationprevention.com. The Web site has more information on amputation prevention and “Keep the Legs You Stand On,”  the first educational book written for patients with diabetes and their caregivers on amputation prevention.

Dr. Mark Hinkes is chief of podiatry and director of podiatric medical education at the Veterans Affairs Medical Center/Tennessee Valley Healthcare System in Nashville, TN, and author of “Keep the Legs You Stand On,” a comprehensive guide for professionals and patients with diabetes on foot care and amputation prevention.