(The Star) As one of the roughly 30 vascular surgeons in Malaysia, Dr Edward Choke’s passion lies in saving the limbs of diabetic patients.
He is concerned about the lack of awareness when it comes to diabetic foot ulcers, resulting in so many patients losing their lower limbs.
The statistics are alarming: globally, it is estimated that every 30 seconds, one leg is amputated due to diabetes.
According to the World Health Organization (WHO), 0.5% of the population of a developing country have a disability that will require a prosthesis or orthosis, and related rehabilitation services.
While we do not have data for Malaysia, this prediction suggests that around 170,500 locals need prosthetic or orthotic devices, based on our 2024 population of 34.1 million.
It is likely that more than half are due to diabetes.
Contrary to what people think, a foot ulcer does not necessarily occur only because of uncontrolled diabetes; even patients with longstanding, well-control-led diabetes can develop this complication as their blood sugar levels will never be as perfectly controlled as a healthy person’s.
Typically, diabetic ulcers form furthest from the heart; so, if the artery going down to the foot is blocked, the toes get affected first.
If there is a lack of sensation in the foot, ulcers tend to develop in the pressure areas, i.e. the balls of the foot or on the heel where repetitive stress occurs.
Normal people will naturally shift their weight to the other leg to walk without pain, but diabetics don’t do that because they don’t feel pain due to nerve damage, and thus, continue exerting the same amount of pressure on the ulcer, preventing it from healing.
If the patient has an infection, ulcers can form anywhere on the foot.
Dr Choke explains: “If the main cause is lack of blood supply (and there is no wound), then the patient needs a vascular surgeon to get blood flowing down immediately.
“If there is an infection, we may cut off the infected portion and prescribe antibiotics.
“If there is a lack of blood supply (and a wound), for the time period while the wound is healing, we do something called off-loading, i.e. we don’t apply any pressure to the particular wound.”
Provided all these things are done well, the chances of saving the foot or limb is more than 90%.
“The most dangerous ulcers are the ones that spontaneously occur, i.e. the tissues die off naturally.
“Those that result from trauma because of a cut are less dangerous, but risky, as a cut can cause a deeper ulcer.
“In a normal person, cuts will heal in two or three days, but in diabetics, they may never heal and this gives a chance for infection to set in.
“I’ve seen many patients who ignore a cut, don’t seek medical advice, and eventually, lose their limb,” says the Penang-based surgeon.
supply from a blocked artery in the leg.
Which doctor?
Due to the dearth of vascular surgeons and the lack of awareness about this surgical speciality, patients may go to an orthopaedic surgeon for consultation.The tissue in this diabetic patient’s toe was in the process of dying and turning black (gangrenous) due to lack of blood supply from a blocked artery in the leg.
The tissue in this diabetic patient’s toe was in the process of dying and turning black (gangrenous) due to lack of blood supply.
“Without blood supply, no matter how well you deal with the problem, ultimately, the patient is still going to end up losing his limb,” says Dr Choke, who returned to Malaysia recently after more than 20 years abroad.
By the time the patient is referred to the vascular surgeon – if they are referred at all – the ulcer may have worsened.
Here’s the usual scenario, according to Dr Choke:
The patient notices a small wound and waits a week. thinking it will heal naturally.
However, the wound gets bigger and he then goes to see a general practitioner (GP).
The GP cleans the wound, prescribes antibiotics and asks him to monitor it.
A week passes and the wound is still not healed; the patient goes back to the GP for another round of stronger antibiotics.
A week later, the wound starts to blacken and the patient is referred to the orthopaedic surgeon.
At this point, precious time has lapsed and the surgeon may not be able to save the limb.
“We don’t need to go through this roundabout pathway because the blood supply is the most important component of a diabetic foot ulcer.
“Ideally, any diabetic patient who has a foot ulcer needs to see a vascular surgeon first.
“If the blood supply is normal, then we can refer him to an orthopaedic surgeon to deal with the foot problem, but we are doing the opposite here because there are so few of us around,” he opines.
Should there be a problem, vascular surgeons can unblock the blood vessel leading to the leg.
And 90% of the time, it’s through a minimally-invasive method, just like unblocking a coronary artery.
“We stick a small needle via the groin or arm, do an angioplasty and place a balloon or stent to open the block.
“Since we are also trained to do debridement, we do it all in one setting,” says Dr Choke.
Afterwards, the team does meticulous wound management, prescribes special footwear and instructs the physiotherapists to move patients in a certain way to minimise pressure.
At the same time, other specialities will come in to manage the patient’s diabetes and nutrition for faster recovery.
The whole journey takes three to six months.
Timing is everything
Dr Choke cites a case of a patient with a diabetic foot ulcer, who ultimately lost all his toes on the left foot over the course of three years.After improving the blood supply to the leg via an angioplasty procedure, the tissues in the toe (from the photo above) regenerated and healed in two months.
After improving the blood supply to the leg via an angioplasty procedure, the tissues in the toe (from the photo above) regenerated and healed in two months.
“We performed multiple operations on him and it took a year for his wounds to close.
“During his last follow-up, he told me he was still working as a taxi driver, but I didn’t believe him (as he wasn’t a compliant patient, and thus, not in the best of health).
“I was actually presenting his case at an international congress in London (Britain), and after I landed back home, I stopped to get a taxi.
“I heard someone calling, ‘Doctor! Doctor!’ and it was this patient.
“By sheer coincidence, I was his next passenger and I was so happy that he was still able to work as he was the sole breadwinner for his family,” he recalls.
Dr Choke adds: “But at the airport, he was barefooted and not taking precautions such as wearing proper shoes.
“Clearly, he was not looking after himself – unfortunately, that’s our typical patient.”
Patients with amputated toes may opt to get fitted with various types of partial foot and toe prosthetics, including silicone toe fillers, but Dr Choke says one can still walk without toes.
“You don’t really need to grip your toes to be able to walk – they just give you extra balance and stability.
“This chap was in his 60s and walking quite normally,” he says.
Another case was of an Indonesian diabetic patient who was fit and well, but developed an infection, which overwhelmed the body system.
Dr Choke says: “His foot infection was so bad that doctors amputated a few toes and prescribed antibiotics.
“He booked a flight ticket to consult me, but unfortunately, he passed on a few hours after buying his ticket.
“So, look for signs of any skin breaks or discontinuity – don’t wait until it turns black to see a doctor because the assumption is that every little wound will heal.
“It can turn into a bag of pus.”
His advice for the public and doctors:
Irrespective of wound size, treat it as an emergency, as if left untreated, the ulcer will always progress and the patient could potentially lose his limb and life.
Seek treatment early and don’t underestimate the problem.
Go to the correct doctor as soon as possible.
If all the steps above are followed, the chances of saving the lower limb are 90%.
And some tips for looking after the feet:
Check and control blood glucose levels.
Keep the feet dry.
Never go barefoot.
Cut toenails carefully.
If the foot is numb, wear proper footwear for protection and don’t apply too much pressure on the part of the foot that is numb.
Consult a GP or search online for diabetic shoes.
It is important for diabetic patients to note though, that despite all the preventative action they may take, it is still essential for them to go for the necessary medical monitoring and follow-ups.
