Josephine Kulman has had type 1 diabetes for 45 years, ever sinceshe was five years old. For much of her life, her blood sugars wererarely in control.
Before she went on the pump a few years back,her A1c used to hover around 10%, and she'd often drag herself towork with blood glucose levels of up to 600 mg/dl.
In her forties, it all started to catch up with her. She gotgastroparesis, lost vision in one eye, suffered a left-foot ulcer,and developed carpal tunnel syndrome and kidney problems.
On December 8, 2006, while walking in Manhattan, Josephine tripped.Three days later, she couldn't get her right shoe on. Looking down,she was appalled to find that her right foot was three times itsnormal size. In mid-December she entered the hospital for tests todiscover why her foot was so inflamed.
Cellulitis was suspected, but eventually x-rays revealed thatJosephine had Charcot foot. "My foot was shaped like an S," shesays. "My ankle bone on the inside of my leg was underneath my arch.The one on the outside of my leg was in front of my foot. My footwas split from the big toe straight up, so half of my foot was goingone way and half of it was going the other way."
Charcot foot is a softening of the bones of the foot that occurs inpeople with severe peripheral neuropathy. Their muscles lose theability to support the foot, leading to a slackness of ligaments,dislocation of joints, damage to bone and cartilage, anddeformity.
The bones slip out of position and then push on the soft tissue,breaking it down and leading to ulcers. The patient, unable to feelthe pain that warns healthy people of injury, continues to walk onthe broken foot, exacerbating the damage. That's exactly whathappened to Josephine.
Amputation has always been a very real threat in cases of Charcotfoot. But Josephine's story has a different ending, largely becauseshe was fortunate enough to come under the care of Dr. Andrew Sands.Dr. Sands, the chief of foot and ankle surgery at St. Vincent'sCatholic Medical Centers in Manhattan, is one of an innovative groupof surgeons who is breaking new ground in the treatment of Charcotfoot.
Dr. Sands was inspired to help people with diabetes by his cousin,who had type 1 diabetes and died at age 38 from a heart attack. "Iwent through everything with him," says Dr. Sands, "including partlyamputating his foot." As a result of his cousin's influence, "I stayinvolved with diabetes and do new and exciting things for peoplewith diabetes to save their feet."
In the past, says Dr. Sands, "people were very afraid to operate ondiabetic feet, and a lot of people treated them in casts or in bulkyboots or shoes. Wound care centers can treat the ulcers, but if thebone malposition isn't addressed, the foot is going to break downagain the instant the patient starts walking on it again.More and more, people like me are operating on them and fixingthe deformities. We're developing new and better implants, whichare metal screws that fit inside the bones. Basically, it's likewhen a foundation collapses and then the walls start collapsing.You can shore it up with implants and allow the patients to keeptheir foot. Suddenly, a lot of people who before would have becomewheelchair-bound or had an amputation are staying active on theirown feet."
In Josephine's case, says Dr. Sands, "her forefoot was basicallyswept away from the rest of her foot. One row of bones 'bayoneted'over another row, shifting up, over, and on top of other bones. Toget that back into alignment, you have to bring it all down and holdeverything with screws. We took her forefoot and brought it aroundand lined it up again, and put big stainless steel screws throughher bones to hold everything. The most important screw, which wasabout 4-1/2 inches long, went from the base of her big toe up intothe big bone under her ankle. We recreated her entire arch."
These new operations are the product of a change in philosophy overthe past ten to fifteen years, away from conservative treatmentslike casts and boots and toward more aggressive reconstruction. Thetrend has been fueled by advances in technology.
The older implants were too bulky to work well in a foot, but nowthe screws have been redesigned, says Dr. Sands, "to have a smallerhead and a stronger shaft, so that they are strong enough to use ina foot, which bears the entire weight of the body."
"It used to be," says Dr. Sands, "that if someone had a terribledeformity in their hind foot or their ankle, the only option was toamputate. Now we have new implants that we can put through the heeland up through the sole of the foot, and we can lock the foot to theleg and save the foot. Sometimes the heel bone is still intact andthe bones around it are destroyed, but now we can fix it."
Dr. Sands emphasizes that to benefit from foot reconstruction,patients must be "good partners" in the process. They must have goodcontrol of their blood sugar, and they must definitely notsmoke.
"If you have a foot ulcer and you smoke," says Dr. Sands, "stop.If you're not a smoker and you have good circulation, if your footis warm, then chances are strong that we can at least try to saveyour foot. Even if you have numbness up to your knee, as long as youhave good circulation, we can get you to heal."
With regard to smoking with diabetes, Dr. Sands is adamant. "Weguarantee very little in medicine," he says. "But to the degree thatit is possible to guarantee anything in medicine, I can guaranteethat if you have diabetes and you are a smoker, you will have anamputation. It's just that bad." Stop smoking, he advises, and then"keep your hopes up and keep your health up, because we're going tobe able to do a lot more" when it comes to saving feet.
As for Josephine, she will be required to wear a special boot forabout six months, but she expects to be fully healed once the bootcomes off. Her best advice to people with a similar dilemma is tofind the very best doctor they can.
"That was the key," she says. "It took time to get to Dr. Sands,but nobody else would have even considered doing a footreconstruction. The foot would have eventually healed in an S shape,and I would have had problems for the rest of my life."