When I first learned about the prevalence of diabetes, I was insensitive, or should I say ignorant, of how much it affects a person's life. As a podiatrist, I see some unbelievable consequences of diabetes in the feet, which then can alter a person's life physically, emotionally, spiritually. Through my professional journey in medicine, I have become hypersensitive to those living with diabetes. There is no glorifying amputations, I hate doing them and feel a little defeated when I have to be the one to deliver the awful news. Early diagnosis of diabetes and patient education can prevent a lot of these cases.
The case here is one that came to me way too late. Graphic images to follow.
A 50 year old male with poorly controlled diabetes presents with a red, swollen foot but feels no pain. He says there is some"leakage" coming from his foot and thinks it's only a blister.
To me, anyone presenting with poorly controlled diabetes and a red, fat foot I think of Charcot neuroarthropathy as a diagnosis until proven otherwise. And especially if there is a skin break on the bottom of the foot, which provides a clue that there is way too much pressure in this area. A functional foot has an arch in the middle to distribute the weight of the body in the right places allowing us to walk efficiently. Charcot Foot causes this to collapse, resulting in excessive pressure in the wrong places.
What exactly is Charcot Foot? It happens in people with long-term peripheral neuropathy (loss of feeling in the legs or hands). Originally described in people with syphilis but now more commonly seen in people with diabetes, both share a common thread that is neuropathy. The dysregulation of blood flow that occurs in diabetes affects the nerves, vessels, and bone that then causes destruction (seen as a collapse) of the bone structure in the feet. (Other theories exists, no one is exactly sure how it happens.)
You can see it frankly in the xray image above, it looks like a tiny bomb exploded in the midfoot, displacing joints and bones. Often it occurs in one foot, but some may develop it in both at variable times.
Can people live with Charcot Foot and not get amputated? Absolutely. Many people live with this through accommodative (customized) shoes/boots. Our understanding of foot biomechanics and technology has helped many people live with this. Tight sugar control and monitoring by a podiatrist is key in preventing further problems.
When is amputation necessary? This is a loaded question but in general, Charcot Foot is not a problem in itself. An orthotist/prosthetist can help take pressure off through customized shoes and orthotics. However, when the bones collapse and the patient continues to walk without support, new areas of pressures develop and because the patient does not have any feeling in the feet, an ulcer forms. Often times it starts as a blister but can progress into an ulcer (open wound) which then propagates infection. Skin infection can be managed medically with antibiotics but infection involving the bones is more complicated. Infection in the bone is approached with antibiotics and surgery to remove dead bone. If too much bone is affected and the foot becomes unstable, that is when an amputation becomes necessary in preventing a localized infection become a systemic one.
My patient here had several issues working against him. He was homeless and was determined to not follow recommendations that included daily sugar control, no weight on the surgical foot, and diet. Unfortunately, what he thought was a blister was just the tip of the iceberg of what was underneath. The foot had been brewing a serious infection that was apparent with clinical evaluation (fever, squishy sensation of the foot from pus that was filling up inside) and then proven with surgery.
The first picture is an xray of the lateral (side) foot with the midfoot collapsed and unstable. The middle picture was taken during surgery with the incision following the pus track. Extensive bone loss was seen and dead bone was removed. The third picture was my desperate attempt to save his limb by applying antibiotic beads locally (along with IV infusion) hoping for a miracle that it would resolve the infection from both ends. Needless to say, I already knew it to be a futile attempt having seen so many of these. The patient did ultimately end up with a below knee amputation.
Sometimes I beat myself up for what I perceive as failing the patient. I always hope for a glimmer of a miracle but know that I have to be realistic and accept that sometimes it is just too late. I try not to let my patients or colleagues or even my husband see how much my patient's outcome affects me personally. That is why I harp (with compassion!) to my patients to not miss an appointment and to establish podiatry care as soon as you are diagnosed with diabetes.
Some patients admit that they didn't know what poorly controlled diabetes can do to them and I understand. I was too once ignorant but I hope to deliver enough educational material for patients to take action and establish care sooner rather than later.