Aging Begins at 30

Two Legs Are Much Better Than One

Four out of five limb amputations in the U.S. are performed on diabetic patients. The incidence of diabetes increases as the population ages and about 18% of the over 65 population has diabetes mellitus. Diabetes is a "running through," referring to the increased urination. Mellitus means it is sweet, as the Romans got their sweetening from honey imported from the Island of Malta (Melita). The U.S. Department of Health has set a goal of reducing diabetic foot amputations by 40% by the year 2000. Of the three million people hospitalized yearly with diabetes, 120,000 have leg infections. Infections in the elderly diabetic foot are superficial, mild, non-limb threatening and deeper, serious life- and limb-threatening infections. But the first leads to the second. Prevention is the key. First, tight control of the diabetes by insulin or other treatment leads to less skin, nerve, and blood vessel damage and fewer foot ulcers. Nerve damage means non-recognition by the patient that a disease process or injury is occurring. In loosely controlled diabetes, there is poor scavenging of organisms by white cells, poor attraction of white cells to an area of infection, and poor killing of bacteria actually eaten by white cells. Immune levels in the blood are also low.

Gregory, a 53-year-old former carpenter, I remember, years ago had numbness and tingling in his feet. From time to time, he had burning or shooting pains down his legs and, although parts of his skin were hypersensitive, he was unable to detect heat, cold, and vibration. His feet did not sweat normally and he had huge corns over his weight-bearing areas of the big toe, the heel, and the heads of the deep bones of the toes. He was cheerful, fun to talk to, and careless about his diabetes. He lost several toes, the leg below his knee, and then his life. He could have enjoyed another ten years of life with attention to the care of his diabetes.

There may be a crack from dry skin, injury from banging the furniture, or an undetected thumb tack from walking barefooted. Organisms are easily transferred from the gut after defecation. First it's oxygen-using staphylococci, but later, when the way has been prepared by them, there are virulent organisms that grow best away from oxygen (anaerobes) and do a lot of damage. Therefore, all cracks and infections need prompt attention. The severity of the infection is directly related to the number of organisms in the wound so surgical drainage can help a lot. Dead skin and muscle must be removed as they make excellent food for the bacteria. The infection may go so deep that bones are infected (osteomyelitis).

To get a proper specimen to culture to find the correct antibiotic to use, one has to use a surgical spoon (curette), needle, and syringe or scalpel and there must be no delay in getting the specimen to the lab. Too much oxygen destroys the anaerobes. Certain procedures, such as foot soaking and special antibiotics to treat organisms. The antibiotics are given by mouth or injection. Applied topically, they make things soggy and sometimes cause a local allergy from emulsifying agents. Antibiotics have to be chosen carefully to kill both oxygen loving and oxygen hating (anaerobic) bacteria. Attention must also be paid to protective foot wear. Corn removal by an expert, wound cleansing, and swelling reduction are needed. Weight bearing must be redistributed.

Prevention involves education of the patient, their families, and caregivers.

Diabetic foot infections are a major cause of disease and health care expense in elderly patients. Properly treated toes, feet and legs can be saved. The quality of life is sharply reduced when you have a leg amputated. At all cost, preserve your mobility.

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See related Patient Topics Amputees, Bones, Joints and Muscles, Diabetes, Endocrine System (Hormones), Food, Nutrition and Metabolism, Immune System/AIDS or Seniors' Health.

See related Provider Topics Bones, Joints and Muscles, Diabetes, Endocrine System (Hormones), Food, Nutrition and Metabolism, Immune System/AIDS or Seniors' Health.

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