Distal revascularisation and the diabetic foot

The scale of the problem More hospital beds in the United Kingdom are occupied by diabetic patients with foot problems than by patients with diabetes with any of the other complications of diabetes. These foot problems are caused by a combination of neuropathy and ischaemia, which may co-exist and together predispose to development of infection and subsequent tissue necrosis. Without skilled, multi-disciplinary, management these foot problems can easily progress to amputation. The scale of the problem cannot be understated. Twenty per cent of amputees referred to limb fitting centres have diabetes, and a third of all vascular amputations are carried out in people with diabetes. Fifty per cent of these patients with diabetes who lose a leg will lose the other one within five years. These figures are almost certainly an underestimate of the proportion of diabetic amputations as they only refer to patients seen in limb fitting centres: people with diabetes often have other major system disorders including, for example, cardiac or visual problems which may preclude limb fitting. How can this limb loss be averted? Until recently, the ischaemic complications of diabetes were said to be due to so-called 'small vessel disease' and therefore were not amenable to any form of surgical intervention. Indeed, for many years it was taught that if the popliteal pulse was palpable, no form of vascular reconstruction was possible.