Every day, 230 Americans with diabetes undergo an amputation. Through education about the insidious dangers of diabetes as well as specialized wound care, the team behind Roper St. Francis Healthcare’s new Limb Amputation Prevention Program aims to eliminate this common but avoidable complication
WRITTEN BY Alex Keith
PHOTOGRAPHS BY Maggie Wilcox & Scott Henderson
“I check my feet with a mirror every morning and night,” says 63-year-old William Kern. Since being diagnosed with diabetes eight years ago, the James Island resident has struggled with troublesome wounds on his lower extremities that will not heal. One serious foot infection resulted in the loss of Kern’s right pinky toe. Then, in 2021, an ingrown toenail spiraled into another infection that ended with the amputation of two toes and the side of his left foot.
“Diabetes is like a shark,” says Dr. Mary Hanley, a wound care and hyperbaric medicine specialist affiliated with Roper St. Francis Healthcare. But while the finned predators attack less than 50 people each year in the United States, diabetes affects more than 37 million Americans. “You can go into the ocean every day and have a wonderful time, but that shark is there. Diabetes acts the same way, always circling,” she says. “I tell my patients that they might be fine, but just one wound that won’t heal because of diabetes can take their toes or leg.”
Diabetes is the leading cause of nontraumatic amputation in the United States, in large part due to its connection with peripheral arterial disease (PAD). The disease is the narrowing or blockage of vessels that carry blood from the heart to the legs. “Circulation to the feet and lower limbs becomes compromised, because the tubes are narrower,” says Dr. Hanley. “It’s like a clog in the drain that prevents water from getting through effectively.” While it’s possible to have diabetes without PAD and vice versa, “the two get lumped because they’re so frequently found together,” explains Roper St. Francis Healthcare affiliated vascular surgeon Dr. Zachary Arthurs.
When it comes to vascular troubles, people with diabetes are prone to both microvascular and macrovascular disease. “Unfortunately, it’s a double whammy for them,” says Dr. Hanley, who codirects the Limb Amputation Prevention Program with Dr. Arthurs. Microvascular disease affects the smaller blood vessels, like those found in the eyes, kidneys and toes. “High sugar levels in the blood are toxic to those small vessels,” she explains. This can lead to complications such as blindness, renal failure and amputations.
By contrast, macrovascular disease is associated with plaque buildup in the larger arteries responsible for supplying blood to the heart, brain and limbs. For those suffering from this plaque buildup, a sensation of cold feet and toes is the first warning sign of PAD.
In addition to cold and even discolored feet (typically a red or dusky hue), patients with PAD may complain of muscle cramps. “Blocked arteries eventually strangulate blood flow to the muscles, which then lock up. The pain can be horrific,” says Dr. Arthurs. Called claudication, this pain is caused by a lack of oxygen to the leg and foot muscles. Patients often find they’re unable to walk more than 20 feet without stopping for relief, Dr. Hanley adds. “Some also complain of trouble while lying in bed, noting that their legs feel better when down on the floor.” This chronic pain severely impacts a person’s quality of life and, in the worst cases, may result in amputation.
Of the 130,000 amputations taking place each year among people with diabetes, the majority begin with a nonhealing wound. “When most of us think of a wound, we envision a traumatic event like stepping on glass,” says Dr. Arthurs. But in those with PAD, something as minor as a toenail pushing against another toe and causing a small skin break can be deadly. If left untreated, these open wounds often become infected or develop gangrene, a decomposition of body tissue resulting from poor circulation.
The window of time between a wound’s first appearance and treatment becomes absolutely critical to a patient’s outcome. Vascular surgeons often rely on stents or bypass surgery to the legs to open up blocked arteries. “Without enough blood flow to close that crack, bacteria get in it. That small cut then becomes a very large wound that puts the patient at risk of losing a toe, their forefoot or even their entire foot and ankle,” Dr. Arthurs explains. “The larger the wound becomes, the more resources are needed to heal it.”
Because of the size and severity of the infection in his left foot, doctors gave Kern a slim 30 percent chance of avoiding major amputation. In an effort to stimulate healing, Dr. Hanley used a combination of therapies, including a hyperbaric chamber that delivered pure oxygen to fight bacteria and a wound VAC (vacuum-assisted closure) to decrease pressure around the site. Kern also began taking a nutrition powder designed to promote wound healing and, three times a week, saw a home health nurse, who measured and rewrapped his wound. “We try everything possible before resorting to amputation,” says Dr. Hanley, who recognizes that major amputations can lead to further complications or even early death.
“Anywhere from 40 to 60 percent of Americans with diabetes will have PAD at age 60. That’s one in two,” says Dr. Arthurs. With cases rising rampantly across the country, doctors are questioning what has changed both culturally and in the world of medicine over the last several decades. “We are more sugar dependent than we have ever been before,” Dr. Arthurs says. “There’s going to have to be a major shift in how we process our food and in the stuff we put in our food. We need to be aware of how much sugar is in those foods. Otherwise, people who think they’re eating healthy are going to continue to get fooled.” (Read about the benefits of kicking the sugar habit at housecallsmag.com/sugarcoated.)
While both diabetes and PAD can be controlled with lifestyle changes and medications such as statins and aspirin, “a lot of it is primary prevention,” Dr. Hanley says. Along with limiting your sugar intake, she emphasizes, “Don’t smoke. Watch your weight. Eat a healthy diet. Try to limit saturated fats.” In addition to a healthy daily routine, regular visits to your primary care doctor to monitor cholesterol and lipid profiles are essential to preventing PAD, regardless of your gender or genetic history.
“What I see in the Lowcountry is multigenerational type 2 diabetes. It’s an accepted part of the aging process, but it shouldn’t be,” says Dr. Hanley. For the Limb Amputation Prevention Program team, education is as much a part of the job as providing treatment. As the only system in the Lowcountry to house a multidisciplinary team under one roof, this prevention program brings together highly trained specialists with one common goal: to decrease the incidence of major amputations and ultimately save lives. “Chronic disease is tough,” Dr. Hanley admits, “but the alternative is much harder.”
Kern spent nearly six months off his feet before doctors declared him out of the danger zone for a major amputation. By April, his wound had shrunk by roughly 85 percent, and he could slowly begin bearing weight again. He now wears special shoes molded to fit the small amputations on his feet. “When I first met Dr. Hanley, she said to me, ‘I’m certified to save limbs.’ And she did. She saved my foot.”
Dire Consequences: The frightening statistics surrounding diabetes, peripheral arterial disease and limb loss
- One in 10 Americans faces diabetes. Of those people, 1 in 3 over age 50 have PAD.
- As much as 70% of nontraumatic lower-extremity amputations are associated with diabetes and PAD.
- After undergoing a major amputation (above or below the knee), a person with diabetes faces a 50% risk of losing their other leg within three to five years.
- Following a major amputation, a person with diabetes has a 33% chance of dying within one year and a roughly 70% chance of dying within five years.
In Pursuit of Healing
In May, the Roper St. Francis Healthcare Limb Amputation Prevention Program (LAMP) opened with an ambitious mission: to eliminate nontraumatic amputations by identifying and treating diabetic wounds before they progress too far. “We’ve teamed wound care doctors and hyperbaric medicine specialists with a vascular surgeon, and we have access to infectious disease specialists, prosthetists and orthotists (the people who make artificial limbs),” explains LAMP codirector Dr. Mary Hanley. “By creating a one-stop experience, we can come up with a comprehensive, multidisciplinary plan of care in a single visit.”