Health & Fitness

Treatments aim to save the leg for diabetics with wounds

A. Enrique Whittwell, M.D. of general surgery and medical director of South Miami Hospital's wound care division, along with Osvaldo Artigas, R.N., assess a patient, who declined to be identified, at South Miami Hospital.
A. Enrique Whittwell, M.D. of general surgery and medical director of South Miami Hospital's wound care division, along with Osvaldo Artigas, R.N., assess a patient, who declined to be identified, at South Miami Hospital. MAX REED / FOR THE MIAMI HERALD

Dr. Robert Beasley is on a mission to save legs.

Beasley, director of vascular interventional radiology and director of the Vascular and Wound Healing Center at Mount Sinai Medical Center in Miami Beach, wants to save diabetic patients from ever facing leg amputation. So he is traveling the country, speaking at podiatric conferences and one-on-one with podiatrists to educate them on how to spot potential ulcers on legs and feet and to ensure patients are getting proper circulation to their legs and feet.

“In small-town hospitals, and even places in South Florida, doctors may not do ultrasound, they will just amputate when they see a diabetic patient with a foot ulcer,” said Beasley. “Psychologically, it’s so horrible losing a leg. It completely changes the whole way you see yourself. It’s pretty much a death sentence. I’ve tried to preach the gospel to other doctors, ‘Let’s catch these problems early on so we can get people walking again.’”

Diabetics are highly prone to foot and leg ulcers or wounds. One factor: They lack proper circulation and oxygen to their legs and the arteries leading to their feet tend to harden over time. Another factor is that diabetics frequently develop neuropathy, or a lack of feeling in their feet. As a result, they may develop sores due to tight shoes or normal strain and not feel them.

The best way to avoid such wounds, say doctors, is by making sure their disease is properly treated with medication and seeing doctors regularly. Additionally, diabetics should wear loose and comfortable shoes.

Some patients are “on top of their illness” as Beasley puts it, visiting him or other wound centers before they develop wounds, to ensure their legs and feet are getting good levels of oxygen and there are no blockages. Others are “non-compliant,” notes Dr. A. Enrique Whittwell, medical director of Wound Care at South Miami Hospital. “They don’t take their medicine; they don’t see their doctors. When they follow their therapy, they tend to do well.”

Dr. Blane Shatkin, medical director of the Center for Wound Healing and Hyperbaric Oxygen Therapy at Memorial Hospital Pembroke, also preaches prevention through education of patients.

“When we see diabetics, it’s a lot of education to teach them to check their feet frequently,” Shatkin said. “Diabetics have to realize they have problems with wound healing.”

Once wounds and ulcers develop, the situation gets more complicated. Their doctors often refer them to hospital wound care centers. There, their wounds are debrided—a procedure in which dead tissue is cleaned out—and dressed as a first step.

At Memorial’s Center for Wound Healing and Hyperbaric Oxygen Therapy, if the patient doesn’t improve after four weeks of wound care and debridement, doctors move to the next step—applying skin grafts to the affected area.

The third approach is for patients to get 90-minute treatments daily in the hyperbaric oxygen chamber (the procedure is fully covered by Medicare). There, they can watch television and speak to the doctor while getting their treatment, designed to pour oxygen into the body to aid healing throughout the body.

Memorial’s healing rate for diabetic wounds is 95 percent, above the national average of 91 percent, said Shatkin. The small percentage who do not respond to any of the treatments must face amputation before gangrene sets in.

Beasley has a different approach at Mount Sinai. After wound care and cleaning, he almost exclusively relies on a surgical bypass in the leg to open up the arteries and “revascularize” the limb. He said this procedure has only been in use for about five years and many doctors still aren’t aware of it or using it widely.

Mount Sinai offers on-site demonstrations of the technique to any interested doctors.

“We’ve been able to open up the main arteries that were blocked,” he said. “By blocking the arteries, you block the blood supply and oxygen getting to the tissue. Then, when they get ulcers, it can lead to gangrene and folks lose their legs. The sooner you can get to somebody who has the condition, the better. There are not enough doctors that know about this.”

The new techniques can be used even when gangrene has set in, said Beasley, although in some cases a patient will still lose one or more toes. However, the leg can usually be saved, he noted.

Beasley recently used the procedure successfully with a 53-year-old Miami man. The patient had already lost one leg when the other leg developed an ulcer. Beasley was intent on saving the man’s other leg. “He had a 12-year-old son who played sports and it would kill him to be in a wheelchair and have to miss his son’s basketball games,” Beasley said.

In some cases, however, the disease is so advanced that the arteries in the leg have hardened so they are stone-like. In those cases, the bypass method does not work and the arteries cannot be opened up.

South Miami Hospital uses a variety of methods to combat diabetic ulcers—debridement, the bypass and angiogram to open the arteries, and the hyperbaric oxygen chamber. The hospital only uses the hyperbaric chamber as a last resort when other treatments have failed.

“There are very strict guidelines for the hyperbaric chamber,” noted Whittwell of South Miami Hospital. “It’s not indicated unless there is an infection of the bone coupled with a lack of circulation in the leg.”

Sometimes, the hospital turns to the hyperbaric chamber after an amputation to aid healing. South Miami Hospital has a 91 percent success rate in treating diabetic wounds and ulcers, Whittwell said.

Wound Care Centers

▪ Mount Sinai Vascular Center

4300 Alton Rd., Miami Beach. Call 305-674-2071.

▪ Wound Care and Hyberbaric Medicine at South Miami Hospital

6250 Sunset Dr., first floor, South Miami. Call 786-662-5558.

▪ Memorial Center for Wound Healing and Hyperbaric Oxygen Therapy

7800 Sheridan St., Pembroke Pines. Call 954-883-8014.