Esteemed Foot and Ankle Surgeon to present at Arab Health 2017


Esteemed foot and ankle surgeon presents at Arab Health on diabetic foot pathology

In the Middle East, diabetes is a huge problem and one that is growing rapidly. The region has the highest global prevalence of the disease, with around 20% of the population affected. This number is expected to rise and countries such as Saudi Arabia, Qatar, Bahrain, Kuwait, and the United Arab Emirates will be significantly impacted.

This year for the first time, Harley Street Medical Area and UK Orthopaedic Foot and Ankle Surgeon Dr Ros Miller FRCS Tr & Orth will be talking about the global problem and her pioneering solutions at the Arab Health Congress. Dr Miller specialises in foot and ankle pathology and is internationally renowned in all foot and ankle conditions, from Minimally Invasive Surgery to Total Ankle Replacements. She is also a pioneer of NEMISIS (Neuropathic Minimally Invasive Surgeries), a pioneering solution for the treatment of diabetic foot pathology.

  • Dr Ros Miller FRCS Tr & Orth

“Surgery for people with diabetic foot pathology is extremely complex and are some of the most challenging surgeries facing orthopedic foot and ankle surgeons,” said Dr Miller.

“The Middle East has the highest global prevalence of diabetes and therefore greatest risk of diabetic foot ulceration, so I am delighted to be invited to Arab Health to share my experiences of diabetic foot screening and stratification, and to present on NEMISIS - the work that I have pioneered to improve quality of life and reduce the requirement for amputation”.

Dr Miller explains that one of the worst side effects of diabetes is non-traumatic lower limb amputation, with diabetic foot ulcers preceding around 85% of amputations.

A patient with diabetes is up to 30 times more likely to have an amputation than the general population. The mortality rates for patients following a trans-tibial amputation can be as high as 70% at five years, which is worse than the mortality for prostate and breast cancer combined. It is estimated that around 50% of patients will die within 5 years.

There are also several pathologies that affect the feet of patients who have diabetes such as ulcers, infection and destruction of the deep tissues. The likelihood of a diabetic patient having an ulcer at some point in their lives is around 15%.

“As well as mortality, diabetes can also have a huge impact on patients’ quality of life,” added Dr Miller. “Repeated hospital visits for regular dressing and modification of footwear have a significant role in preventing amputation and reducing mortality, however this has a significant impact on the patients’ and their families’ quality of life.”

“It also impacts on their work life, with many having to give up their jobs and this may have a knock-on effect on their social life and relationships as they are unable to go out socially or go on holiday. Unsurprisingly, patients can develop low mood and self-esteem and in some cases, can result in depression.”

Appropriate screening and risk stratification is essential and vital for educating patients and health care practitioners to identify ‘at risk’ patients who will benefit from a multidisciplinary team approach to management of their feet and crucial early surgical intervention when appropriate.

  • Traffic Light System

In the UK, Dr Miller has joined the multidisciplinary diabetic foot and ankle team in Scotland, where the Diabetic “Traffic Light” Risk Stratification and Screening already existed to ensure that diabetic patients have their risk of developing diabetic foot pathology risk assessed, stratified and managed accordingly to prevent the development of ulceration and subsequent amputation.

She said: “Traditionally when diabetic patients require surgery, this is usually when their life is at risk from overwhelming sepsis and amputation is the only option to save their life. Vascular surgeons do perform interventional surgery to improve the circulation to lower limbs when there is a blockage that can be opened or bypassed. Orthopaedic surgeons are called upon when the sepsis is not related to arterial disease, but instead, neuropathy.”

Patients who have neuropathy are at increased risk of ulceration due to the change in shape of the foot due to Charcot Neuroarthropathy and as a result of the loss of their protective sensation.

Minimally Invasive Surgery (MIS)

Although minimally invasive foot surgery is becoming more common in Europe for conditions such as bunions, claw toes, hallux valgus and hammer toes, preventative and salvage diabetic foot surgery is extremely rare. Dr Miller is one of the few surgeons globally specialising in it. It is performed through tiny percutaneous skin incisions and done underneath the skin, thus protecting the soft tissues and reducing the risk of infection.

Dr Miller has taken this one step further by extending the use of MIS to the diabetic population who are at significant risk of complications following open surgery, due to decreased or sluggish blood supply and neuropathy.

Neuropathic Minimally Invasive Surgeries (NEMESIS) provides a permanent surgical solution, whilst reducing the risk from the significant complications associated with surgery for diabetic patients’ foot pathology.

It can be applied to all aspects of Diabetic Foot Syndrome, including debridement of osteomyelitis, realignment of the toes to expedite the time to healing of ulcers and reduce recurrence. It can also be used for major deformity correction for patients who have developed deformity and risk of ulceration secondary to Charcot Neuroarthropathy.

Due to the reduction in risk of recurrence of ulceration, there is also a theoretical risk in reduction of mortality associated with Diabetic Foot Syndrome that has early intervention with NEMESIS.

Dr Miller added: “The initial results suggest NEMESIS may offer potentially better surgical outcomes than traditional open surgical correction. There are complications associated with this type of surgery and postoperative management, but these can be anticipated, and close supervision and the combined care of a multi-disciplinary team, the major goals of prevention of re-ulceration, avoidance of major amputation, and death can be achieved.”

Correct foot positions can also be maintained, despite subsequent removal of metalwork or fibrous non-union. The surgery is dependent on access to good multi-disciplinary clinical working to ensure the best outcomes and improve quality and duration of life of the diabetic patient with foot abnormality. NEMESIS may facilitate earlier stabilisation and therefore shorten the treatment period and reduce risk of amputation in this challenging patient group.