The approach involves high-risk surgery to clean infected limbs, heal wounds, ensure blood flow in the leg, often coupled with managing other complications of diabetic wounds like neuropathy and gangrene.
“At least half of the (diabetic) people who are amputated are dead in three to five years,” said Dr. David G. Armstrong, a podiatric surgeon who co-directs the Southern Arizona Limb Salvage Alliance (SALSA) at the University of Arizona Medical Center – University Campus. “Up to 80 percent in some studies.”
A recent study by the U.S. Centers for Disease Control and Prevention, published Jan. 24 in the journal Diabetes Care, said the rate of leg and foot amputations among U.S. adults age 40 and older with diagnosed diabetes declined by 65 percent between 1996 and 2008.
The study’s authors noted that improvements in blood-sugar control, foot care and diabetes management, along with declines in cardiovascular disease, likely have contributed to the decline.
Though the data are “life affirming and very exciting,” Armstrong said, he is cautious about celebrating.
Diabetes remains the leading cause of lower-limb amputations in the U.S. Obesity rates are climbing in the U.S. and in other countries, too. And 85 percent of Type 2 diabetics are obese or overweight.
“Should we congratulate ourselves that amputations went down? Or gird ourselves for a demographic catastrophe?” Armstrong said. “Demography is destiny, and more people are getting diabetes, and more people are living longer with complications of diabetes.”
If there’s anyone qualified to save lower limbs, it’s Armstrong. He has earned numerous accolades for his work with diabetic patients, and his guidelines for wound care have been recognized by worldwide medical organizations.
In 2010, he was the youngest-ever recipient of the equivalent to a lifetime achievement award from the American Diabetes Association for his work in the field of the diabetic foot. He’s also part of an international working group on diabetic foot care and co-founded the Diabetic Foot Global Conference, which doctors have nicknamed “DFCon.” It’s the largest diabetic-foot gathering in the world.
Armstrong’s skills are complemented by local vascular surgeon Dr. Joseph Mills, the clinic’s co-director. They share a mantra: Save a leg, prolong a life. The clinic gets about 13,000 patient visits per year.
For patient Rosemarie Sales, who has Type 2 diabetes, Armstrong and Mills’ clinic has been a bright spot during a terrible health crisis.
Seven months ago, her right foot was raw with almost no skin on the sole. It was also horribly infected, and she was terrified of hearing what she knew doctors would say: It needs to come off. Sales had already lost a toe on each foot to amputations after severe infections.
“It looked like someone had poured acid on my foot. I just cried. I didn’t know what to do,” said Sales, a 53-year-old IT specialist who lives in Catalina. “I didn’t want to go to the hospital. I even avoided going.”
And, indeed, the first doctor she saw in the emergency room told Sales: “You are probably going to lose your foot.”
But Sales’ recent infection did not result in the setback she so dreaded. Her foot was saved by the clinic’s doctors.
Not everyone’s limb can be saved, of course. Armstrong has been to “limb funerals” when people lose legs and feet to amputations, and he has watched the emotional toll that losing limb brings. His goal is to save the limb whenever possible.
“I thought I was going to die; I wasn’t even thinking about my foot,” said James Conley Jr., the 68-year-old publisher of Tucson Lifestyle magazines, a diabetic who is still recovering from a staph infection that began with a blister on his right foot. The infection traveled quickly up his leg and ate into his bone.
The easiest surgery would have been amputation, but he wound up in surgery with Armstrong and vascular surgeon Dr. Kaoru Ruth Goshima, who decided to save the foot. As Armstrong puts it: Goshima evaluated the plumbing, and he did the landscaping.
“I used to be an orderly, and I know that everything worked out really well for me,” said Conley, who is still wearing an orthopedic shoe to take pressure off his foot. “I thank Dr. Armstrong.”
Armstrong noted that the CDC study should not be a reason for anyone to relax.
For one thing, the diagnostic criteria for diabetes changed and expanded in the late 1990s, to include people with lower blood sugar. Since people with lower blood sugar are also at lower risk for complications, they are also less likely to need an amputation and are responsible for some of the statistical improvements, Armstrong said.
“The denominator changed. There are more people with slightly lower blood sugar included in the definition,” he said. “A population that was once called pre-diabetic is now included in the (diabetes) population.”
Still, rates of diabetes in Arizona quadrupled in the past 15 years – a startling number even when the broader definition of the disease is considered. And with the new phenomenon of children being increasingly diagnosed with Type 2 diabetes, Armstrong has huge concerns for the future.
He also worries about indigent patients in Arizona, whose Medicaid program recently eliminated podiatrist visits from coverage, which has been a hardship for many diabetics.
By Arizona Daily Star