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Thursday, May 19, 2011

Hanging on to Your Feet!

The View from the Office






Hanging on to Your Feet!

    Now this article will only apply directly to relatively few readers. I would nonetheless urge you all to read it (it is brief and with pictures) because undoubtedly you know people--friends and relatives--who have problems like this with their feet. You can be very helpful in their care. The biggest problem for these persons and their feet is the natural and understandable urge to put off seeking intensive medical care. But that is exactly what is needed. And in so many cases it is the prodding of friends and relatives (especially spouses, if they have them) that finally brings them to the office.
     The problem with the foot disorders that I am talking about is that, if you do not take early and aggressive care of ulcers in your feet, you are at risk for losing them--that is an amputation, which is, of course, a disaster.
     The people who tend to get the kinds of foot problems I illustrate below are those primarily with one of two conditions (or perhaps both at the same time)--diabetes and/or peripheral vascular disease. Take a look at 3 different variations on the same theme.

Figure 1: Early severe heel blister which often turns into an ulcer. Get in to see your physician as soon as possible when you see this in order to prevent the problem seen in Figure 2.

Figure 2: Evolving heel ulcer: This will be difficult to heal at this point.


Figure 3: Severe foot ulcer over the ball of the foot. These are extremely hard to heal because they are subjected to dirty conditions and constant pressure.


Figure 4: Early gangrene of the 2nd toe. The tip of this toe clearly has to be amputated. The real problem, however, is that it is poor circulation that led to all of these ulcers. If the underlying problem with circulation is not diagnosed and treated, the patient will just continue to lose more and more of his foot until finally s/he has a below knee amputation. Below knee amputations are generally entirely preventable if patients receive the proper evaluation in these early stages of diabetic foot complications and peripheral vascular disease.

     So what happens when patients with this kind of foot problem presents to the doctor or the emergency room. The treatment that is usually focused on is antibiotics to control any related infection; these can be given either orally or intravenously in the hospital. What you have to remember is that the primary problem here is not infection; infection is only a secondary side-effect. The primary problem is inadequate circulation.
     To get these wounds to heal there are two basic steps are required
  1.  You have to surgically clean the wound and remove all excess dead tissue. The nature of the circulatory insufficiency process is that tissue gradually dies and leaves behind yellow, soupy dead tissue. This dead tissue is just a natural breeding ground for bacteria, which is how the infections get started. But remember--infection is NOT the primary problem. All the antibiotics in the world won't do any good unless you remove the dead tissue, which creates the seeds for continuing infection. The problem here is that 99% of all primary care physicians (including most Emergency Physicians) have no specific training in the cleaning (surgical debridement) of these wounds, which is so crucial to care. You really want to take these wounds to someone with a lot of experience and expertise. In most major hospitals, the doctor who takes care of these wounds is a VASCULAR SPECIALIST. Thus, effective care of these kinds of wounds requires evaluation by a vascular specialist. In our area I have already had good experience with two vascular specialists in Reno, Dr. Ahktar and Dr. Desai; in Truckee, we have Dr. Kitz.
  2. You have to perform an evaluation of the circulation to the feet. This process starts with a measurement of your blood pressure in the ankle comparing it to your blood pressure in the arm--a measurement that is called the "Ankle-Brachial Index". If the blood pressure in the ankle is less than 90% of the blood pressure in the arm, it is likely that there is a circulation problem. This is usually considered an indication for a vascular specialist to perform an "angiogram" (injecting dye into the arteries in the leg to see where the flow is good and where it is not). There are a number of highly effective procedures to restore circulation to areas of the leg with impaired blood flow. These include balloon angioplasty--stretching the artery out with an inflated balloon to improve flow; a kind of "roto-rooter" procedure where a special instrument is passed through a catheter in your artery that chops up the plaque that is blocking circulation. These are the two quick and simple procedures. There are a number of full surgical bypass approaches to the problem where the arteries are reconnected in a special way to bypass the area of worst obstruction.  

Bottom LIne: Foot ulcers tend to occur in patients with diabetes and/or peripheral vascular disease. If not adequately treated initially, they tend to progress to a need for amputation over many years. These ulcers can NOT be treated just with antibiotics and dressings. They require surgical wound cleaning (debridement) and vascular evaluation. Good healing does not take place without an adequate circulation.  Don't ever ignore this kind of problem or resort to just hoping it will go away. Get the full evaluation early in order to prevent having similar ulcerations and infections occurring again and again over many years.

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