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Lower
Extremity
Major
and Minor
Amputations
in the 57
High Risk
Patient
These procedures come with high morbidity
and mortality rates.
By Kirsti A. Diehl, DPM, Latricia Allen, DPM, MPH,
Michael French, JD, and Vickie R. Driver, DPM
P
artial lower limb ampu- ripheral arterial disease (PAD). The healing. For example, patients with
tation is a common out- literature recognizes that approxi- ischemic wounds may require revas-
come in the high risk pa- mately 80%-85% of non-traumatic cularization to restore proper blood
tient with lower extremity
chronic ulcerations, isch-
emia, and infection. The significant Factors leading to the chronicity of a wound
decline in the quality of life and eco-
nomic burden caused by lower ex- are variable and must be constantly evaluated and
tremity infections leading to ampu-
tations in the high risk population treated to promote wound healing.
warrants further study in order to
© Stuart Miles | Dreamstime.com
Amputations (from page 57) tremity amputations. Approximate- It has been estimated by the
ly 185,000 lower limb amputations United States government that ap-
casting, or advanced wound healing occur in the United States of America proximately two out of every five
therapies. Of note, only three prod- annually, with the majority (54%) Americans will develop type 2 diabe-
ucts are approved by the Food and performed to treat peripheral arterial tes at some point during their adult
Drug Administration (FDA) to treat disease (PAD) with or without diabe- lives. 10 These statistics correspond
diabetic foot ulcers (Figure 1). tes.6,7 Diabetes has recently reached with high expense, with costs in the
pandemic status with approximately United States reported in 2014 to be
Topical Wound Healing Agents 387 million people worldwide suffer- around $612 billion (see Figure 2).9
Apligraf and Dermagraft are both ing from the disease and 4.9 million Chronic diabetes causes peripheral
bio-engineered skin substitutes (by deaths in 2014 caused directly by di- arterial disease (PAD) and sensory
Organogenesis) and Becaplermin (Re- abetes.8,9 It is estimated that in the neuropathy, a combination that leads
granex) is a recombinant platelet-de- United States, 29.1 million people (or to ulcers, diabetic foot infections, and
rived growth factor (PDGF) applied 9.3% of population) have diabetes, often the need for lower extremity
topically as a gel.4,5 The forecast for with 21 million being diagnosed and amputation.11
other diabetic foot ulcer treatments 8.1 million being undiagnosed.10 Continued on page 61
is promising, with multiple products
currently in clinical trial (Figure 1).
Topical wound healing agents
likely to be available within the next Figure 1:
five years include: Aclerastide by
Derma Sciences (angiotensin analog Diabetic Foot Ulcer
58
NorLeu3-A1-7 with the active pharma-
ceutical ingredient DSC127), Trafer-
Wound Care Products 4,5
Figure 2:
Diabetes Statistics 9,10
Amputations (from page 58) lesion.20 If a lesion is suspected, it must be localized, usu-
ally through conventional angiogram.20
About 50% of patients who have foot amputations Revascularization is then completed if adequate ves-
die within five years, which is a worse mortality rate than sels or collateral vessels are seen proximal and distal
most cancers.12 It has been reported that 55% of diabetics to the occlusion via open surgery versus endovascular 61
with a lower extremity amputation will require amputa- surgery.20,21 The gold standard is open revascularization,
tion of the contralateral leg within two to three years.13 Continued on page 62
Foot ulcers are expensive to treat, with uncomplicated
diabetic foot ulcers costing up to $8,000 and infected foot
ulcers up to $17,000.14 If amputation is required to resolve
the ulcer, the cost skyrockets to $45,000.14
In 1998, a large study obtained the hospital discharge
records for all veterans hospitals to examine the epidemiol-
ogy of lower extremity disease in veterans with diabetes.15
It was found that only 16% of the population was com-
prised of diabetics; however, half of all patients hospital-
ized due to lower extremity ulcerations had diabetes.15 A
more recent study from 2012 stated that 20% of veterans
using the Veterans Health Affairs Hospitals are affected by
diabetes (or more than one million veterans at any given
time).16 The 1998 study showed that 10,532 hospital dis-
charges consisted of diabetics with ulcerations.15 34% of
peripheral vascular disease procedures and 64% of ampu-
tations were performed on patients with diabetes.15
Amputations (from page 61) Unfortunately, within the United puted tomography scan (CT scan)),
States, limb preservation teams are possible bone biopsy if osteomyelitis
which surpasses endovascular pro- habitually consulted late in the dis- is suspected, debridement, post-de-
cedures in terms of durability and re- ease process, after foot infections have bridement wound culture and sen-
duced re-occurrence. For this reason, caused significant pathology, which sitivity (with gram stain), and infec-
tious disease specialists should be
consulted, if necessary.24
Non-invasive vascular studies
Vascular surgical procedures, should be completed when evalu-
although often initially successful, frequently fail ating all patients with chronic
non-healing ulcerations and vascular
over time. surgery should be consulted in the
setting of PAD.24 Arterial blood flow
must be restored prior to debride-
if a patient is expected to live beyond commonly results in necessity of par- ment or amputation for a successful
two years, open revascularization is tial foot or limb amputation.3 Distal outcome. If arterial flow cannot be
generally recommended.21 However, lower-limb amputations (i.e., partial reconstituted via open bypass or an
endovascular surgery does hold an or complete toe amputation, partial endovascular approach, a BKA or
important place in modern practice ray amputation, total ray amputation, AKA may be the necessary ampu-
due to reduced surgical complica- Lisfranc joint amputation, trans-meta- tation of choice. If the patient does
tions and faster recovery rates, and tarsal amputation (TMA), Chopart have adequate blood flow, the sur-
is often chosen over open revascular- joint amputation, sub-total calcanec- geon will evaluate the extent of the
ization for this reason.22 tomy, etc.), when unavoidable, are infectious process and amputate at
62 Vascular surgical procedures, al- performed to treat severe wound pa- the appropriate level.
though often initially successful, fre- thology and are considered to be ad- For example, in the setting with
quently fail over time. According to vanced limb salvaging procedures, as minimal involvement of a toe, a par-
one study, limb loss with a patent by- they can prevent the need for partial tial toe amputation may be warrant-
pass is reported to be only be 4%-9% leg amputation, if successful.25 ed. Although less may seem more
effective.23 However, within the ampu- appropriate, there are times when
tation group, the incidence of amputa- Partial Leg Amputations amputating further proximally and
tions performed with a patent bypass Partial leg amputations are major removing unaffected toes is warrant-
is higher (up to 50%) in certain pa- surgeries and include below-knee ed (such as TMA) due to biomechan-
tient subgroups, including those with amputation (BKA) and above-knee ical benefit. For example, if a patient
diabetes mellitus, end stage renal dis-
ease, and limited runoff.23 This goes to
show that despite vigorous efforts by
the medical and surgical teams, these Partial leg amputations are major surgeries
high-risk patients may go on to limb and include below-knee amputation (BKA) and
loss, as this is the natural progression
of the disease. above-knee amputation (AKA) and come with higher
The vast economic burden of the
aforementioned is projected to wors- mortality and morbidity rates as compared to
en as time goes on and the rate of the limb salvaging amputations.
diabetes increases. However, mod-
ern-day limb preservation team ser-
vices have been shown to reduce
costs associated with foot ulcers.3,14,24 amputation (AKA) and come with has gangrene of digits 1, 2, and 4,
higher mortality and morbidity rates the patient may benefit from a TMA
A Multidisciplinary Team as compared to the limb salvaging over amputation of the affected digits
Approach amputations. Before choosing a type alone.
A multidisciplinary team ap- of amputation procedure, the sur- Overall, the long-term outcomes
proach to treatment of the diabetic geon must evaluate the entire clinical of major amputations have been sug-
foot could lead to avoidance of 47% status of the patient including but gested to include a five-year survival
of amputations.3 Higher cost in treat- not limited to nutrition, kidney func- rate of 30%-40%. 26 The long-term
ment of wound care is associated tion, blood glucose control, cardiac outcomes of minor amputation is de-
with ulceration, infection, hospital- reserve, neuropathy, and anemia. A batable due to the lack of literature,
ization, and amputation. Therefore, complete evaluation of the patient’s but one study suggests a survival rate
prevention is cost-effective.14 How- ulcer must be done, which includes of 89.3% at one year and 43.5% at
ever, early referral is needed for pre- imaging studies (i.e., x-rays, mag- five years.27 Although good outcomes
vention to be successful.14 netic resonance imaging (MRI), com- Continued on page 64
Amputations (from page 62) will eventually allow for developing References
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2
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3
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Hackethal, V. Progress stalled in
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5
Opportunity analyzer: diabetic foot
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64 patients do very well with custom those at risk for limb loss.15 As part of the United States: 2005 to 2050. Archives
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Centers for Disease Control and
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