A tale of two soles: sociomechanical and biomechanical considerations in diabetic limb salvage and amputation decision-making in the worst of times

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Abstract

Foot ulcerations complicated by infection are the major cause of limb loss in people with diabetes. This is especially true in those patients with severe sepsis. Determining whether to amputate or attempt to salvage a limb often requires in depth evaluation of each individual patient's physical, mental, and socioeconomic status. The current report presents and juxtaposes two similar patients, admitted to the same service at the same time with severe diabetic foot infections complicated by sepsis. We describe in detail the similarities and differences in the clinical presentation, extent of infection, etiology, and socioeconomic concerns that ultimately led to divergent clinical decisions regarding the choices of attempting diabetic limb salvage versus primary amputation and prompt rehabilitation.

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Risk factors for foot infections in individuals with diabetes.

S Brismar-Wendel, Lawrence A. Lavery, Kendall M. Mohler … (2006)

To prospectively determine risk factors for foot infection in a cohort of people with diabetes. We evaluated then followed 1,666 consecutive diabetic patients enrolled in a managed care-based outpatient clinic in a 2-year longitudinal outcomes study. At enrollment, patients underwent a standardized general medical examination and detailed foot assessment and were educated about proper foot care. They were then rescreened at scheduled intervals and also seen promptly if they developed any foot problem. During the evaluation period, 151 (9.1%) patients developed 199 foot infections, all but one involving a wound or penetrating injury. Most patients had infections involving only the soft tissue, but 19.9% had bone culture-proven osteomyelitis. For those who developed a foot infection, compared with those who did not, the risk of hospitalization was 55.7 times greater (95% CI 30.3-102.2; P 30 days (4.7), recurrent wounds (2.4), wounds with a traumatic etiology (2.4), and presence of peripheral vascular disease (1.9). Foot infections occur relatively frequently in individuals with diabetes, almost always follow trauma, and dramatically increase the risk of hospitalization and amputation. Efforts to prevent infections should be targeted at people with traumatic foot wounds, especially those that are chronic, deep, recurrent, or associated with peripheral vascular disease.

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Diabetic foot syndrome: evaluating the prevalence and incidence of foot pathology in Mexican Americans and non-Hispanic whites from a diabetes disease management cohort.

R. Wunderlich, Stephen Tredwell, Gretta Armstrong … (2003)

To report the incidence of diabetes-related lower-extremity complications in a cohort of patients enrolled in a diabetes disease management program. We evaluated screening results and clinical outcomes for the first 1,666 patients enrolled in a disease management program for a period of 24 months (50.3% men, aged 69.1 +/- 11.1 years). The incidence of ulceration, infection, amputation, and lower-extremity bypass was 68.4, 36.5, 5.9, and 7.7 per 1,000 persons with diabetes per year. Amputation incidence was higher in Mexican Americans than in non-Hispanic whites (7.4/1,000 vs. 4.1/1,000; P = 0.003, odds ratio [OR] 1.8, 95% CI 1.2-2.7). The amputation-to-ulcer ratio was 8.7%. The incidence of Charcot arthropathy was 8.5/1,000 per year. Charcot was more common in non-Hispanic whites than in Mexican Americans (11.7/1,000 vs. 6.4/1,000; P = 0.0001, 1.8, 1.3-2.5). The prevalence of peripheral vascular disease was 13.5%, with no significant difference based on ethnicity (P = 0.3). There was not a significant difference in incidence of foot infection (P = 0.9), lower-extremity bypass (P = 0.3), or ulceration (P = 0.1) based on ethnicity. However, there were more failed bypasses in Mexican Americans (33%) than in non-Hispanic whites (7.1%). Mexican Americans were 3.8 times more likely to have a failed bypass (leading to an amputation) or be diagnosed as "nonbypassable" than non-Hispanic whites (75.0 vs. 44.0%; P = 0.01, 3.8, 1.2-11.8). The incidence of amputation is higher in Mexican Americans, despite rates of ulceration, infection, vascular disease, and lower-extremity bypass similar to those of non-Hispanic whites. There may be factors associated with failed or failure to bypass that mandate further investigation.

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What is the most effective way to reduce incidence of amputation in the diabetic foot?

J. Apelqvist, Catherine Larsson (2015)

Approximately 40-60% of all amputations of the lower extremity are performed in patients with diabetes. More than 85% of these amputations are precipitated by a foot ulcer deteriorating to deep infection or gangrene. The prevalence of diabetic foot ulcers has been estimated to be 3-8%. The complexity of these ulcers necessitates a multifactorial approach in which aggressive management of infection and ischemia is of major importance. For the same reason, a process-oriented approach in the evaluation of prevention and management of the diabetic foot is essential. Healing rates of foot ulcers are unknown with the exception of specialised centres where it is between 80-90%. The negative consequences of diabetic foot ulcers on quality of life include not only morbidity but also disability and premature mortality. Costs for healing ulcers are high and even higher for ulcers resulting in amputation, due to prolonged hospitalisation, rehabilitation, and need for home care and social service for disabled patients. Therefore, one of the most important steps to reduce cost in the management of the diabetic foot is to avoid amputations. A cost-effective management should not only be focused on the short-term cost until healing but also on the long-term cost, since foot ulcer and especially amputation are related to increased re-ulceration rate and lifelong disability. A multidisciplinary approach including preventive strategy, patient and staff education, and multifactorial treatment of foot ulcers has been reported to reduce the amputation rate by more than 50%. Copyright 2000 John Wiley & Sons, Ltd.

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Author and article information

Journal

Journal ID (nlm-ta): Diabet Foot Ankle

Journal ID (iso-abbrev): Diabet Foot Ankle

Journal ID (publisher-id): DFA

Title: Diabetic Foot & Ankle

Publisher: Co-Action Publishing

ISSN (Electronic): 2000-625X

Publication date (Electronic): 01 October 2012

Publication date Collection: 2012

Volume: 3

Electronic Location Identifier: 10.3402/dfa.v3i0.18633

Affiliations

Southern Arizona Limb Salvage Alliance (SALSA), Division of Vascular and Endovascular Surgery, Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA

Author notes

[* ] David G. Armstrong, Southern Arizona Limb Salvage Alliance (SALSA), 1501N Campbell Avenue, PO Box 245072, Tucson, AZ 85724-5072, USA. Email: Armstrong@ 123456usa.net

Article

Publisher ID: 18633

DOI: 10.3402/dfa.v3i0.18633

PMC ID: 3464045

PubMed ID: 23050063

SO-VID: 2065ad2f-d49b-4085-b2a8-16cfd0e4a7b6

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License, permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

A tale of two soles: sociomechanical and biomechanical considerations in diabetic limb salvage and amputation decision-making in the worst of times

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Journal of the ASEAN Federation of Endocrine Societies

Most cited references 12

Risk factors for foot infections in individuals with diabetes.

Diabetic foot syndrome: evaluating the prevalence and incidence of foot pathology in Mexican Americans and non-Hispanic whites from a diabetes disease management cohort.

What is the most effective way to reduce incidence of amputation in the diabetic foot?

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