Doctors try new ways to improve diabetics' blood circulation, help wounds heal better
Orthopaedic surgeon Chee Yu Han tries to save the limbs of every patient who ends up on his operating table, but that is not always possible.
This is especially the case for people with diabetes, who run a higher risk of having a small foot blister develop into an infected wound.
"As surgeons, we try not to amputate any part of the leg or foot," said Dr Chee, who is from the National University Hospital's orthopaedic surgery department.
"But it is often a necessary operation... to remove the gangrenous or infected part of the limb in order to save a patient's life or prevent serious infection."
Amputation among diabetics is increasingly becoming a last resort, as doctors find new ways of saving patients' legs.
For example, many doctors are now inserting stents or tiny balloons to "open up" narrowed or blocked blood vessels. Some also carry out surgery to bypass the problem parts altogether.
This improves blood circulation in the legs and helps wounds to heal better. Poor control of diabetes can cause blood circulation problems, which slow down the wound healing process and make diabetics more susceptible to infections.
Other techniques being tested include injecting stem cells from a patient's own body into his or her legs, said Dr Benjamin Chua, a vascular and endovascular surgeon at Farrer Park Hospital.
"Over a period of months, the growth of new arteries takes place, and these can help supplement blood flow down the legs and promote wound healing," he said.
Dr Chua added that many clinical trials overseas have already taken place with "very encouraging" results.
In Singapore, hospitals perform around four diabetes-related amputations a day, or roughly 1,500 a year. A 2015 report by the International Diabetes Federation revealed that Singapore has the second-highest proportion of diabetics among developed nations.
Dr Chong Tze Tec, who heads the vascular surgery department at the Singapore General Hospital, said eight in 10 diabetes-related amputations carried out there are minor - that is, involving anything below the ankle.
Most common are toe amputations, with one taking place nearly every day. However, in more serious cases, people have had to undergo surgery to remove their leg up to the knee or hip.
"If they come in early, the chances of amputation are quite low," Dr Chong said. "If we let it fester, sometimes it's not possible to save the foot."
He added: "It's quite common that they present (themselves) quite late."
In many cases, people with diabetes may not even notice small wounds as many tend to lose the feeling in their feet. Doctors believe this happens because persistently high blood sugar levels damage nerves, often irreversibly.
"They are not able to feel well - it's like walking on cotton wool," Dr Chong said.
And after amputation, different problems can arise. "People tend not to walk after amputation," said Dr Chong . "Many prefer to be in a wheelchair, and there is a loss of mobility."
This in turn can lead to physical issues such as pressure sores, and also have a negative impact on the person psychologically, he added.
The experts believe that more can be done to make sure such patients know of the dangers of such wounds, and to help them get the support they need.
For example, said Dr Chua, having a "one-stop" clinic for diabetic patients with foot injuries could help to make things more convenient and less stressful for them.
"Currently, a patient with a diabetic foot wound may end up seeing many different specialists in different locations of the hospital," he said. "(This is) more so if the patient has a wound that needs to be dressed and nursed to recovery over a few months."
A person with diabetes, for example, could see surgeons, podiatrists and even social workers to make sure they are keeping their wounds clean at home.
"If they go back and there's nobody to change the dressing ... probably the outcome won't be very good," Dr Chong said.