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This editorial accompanies "Diabetes-Related Major and Minor Amputation Risk Increased During the COVID-19 Pandemic," by Dominick J. Casciato, DPM, Sara Yancovitz, DPM, John Thompson, DPM, Steven Anderson, DPM, Alex Bischoff, DPM, Shauna Ayres, MPH, CHES, and Ian Barron, DPM, available at https://doi.org/10.7547/20-224
Subtotal Pedal Amputations
Biomechanical and Intraoperative Considerations
Proper treatment for the compromised diabetic foot often requires surgical correction and subtotal pedal amputation. This article discusses various levels of amputation of the human foot, including digital, ray, transmetatarsal, midfoot, and Syme amputations. Surgical techniques and biomechanical considerations are presented in order to assist the surgeon in planning for the most functional outcome of the patient. A review of the literature and the experiences of the authors are presented. (J Am Podiatr Med Assoc 91(1): 6-12, 2001)
Syme’s Amputation
Surgical Technique, Prosthetic Considerations, and Case Reports
Amputation at the level of the ankle joint is a valuable but underused procedure for a variety of conditions affecting the foot and ankle. The procedure provides a comfortable and durable stump that allows the lower-extremity amputee to function with minimal disability. This article reviews the indications for Syme’s amputation, provides a detailed surgical description of the procedure, and discusses postoperative prosthetic considerations. In addition, three case reports are presented in which Syme’s procedure was successfully used as an alternative to higher-level amputation. (J Am Podiatr Med Assoc 92(4): 232-246, 2002)
Background
The Amputation Prevention Initiative is a project conducted jointly by the Massachusetts Public Health Association and the Massachusetts Podiatric Medical Society that seeks to study methods to reduce nontraumatic lower-extremity amputations from diabetes.
Methods
To determine the rate of diabetes-related lower-extremity amputations in Massachusetts and identify the groups most at risk, hospital billing and discharge data were analyzed. To examine the components of the diabetic foot examination routinely performed by general practitioners, surveys were conducted in conjunction with physician meetings in Massachusetts (n = 149) and in six other states (n = 490).
Results
The average age-adjusted number of diabetes-related lower-extremity amputations in 2004 was 30.8 per 100,000 and 5.3 per 1,000 diabetic patients in MA, with high-risk groups being identified as men and black individuals. Among the general practitioners surveyed in Massachusetts, only 2.01% reported routinely conducting all four key components of the diabetic foot examination, with 28.86% reporting not performing any components.
Conclusions
These findings suggest that many general practitioners may be failing to perform the major components of the diabetic foot examination believed to prevent foot ulcers and lower-extremity amputations.
Data from 37 patients who underwent a transmetatarsal amputation from January 1993 to April 1996 were reviewed. The mean age and diabetes duration of the subjects were 54.9 (± 13.2) years and 16.6 (± 8.9) years, respectively. The follow-up period averaged 42.1 (± 11.2) months. At the time of follow-up, 29 (78.4%) of the 37 patients still had foot salvage, 8 (21.6%) had progressed to below-the-knee amputation, and 15 (40.5%) had undergone lower-extremity revascularization. Twelve (80%) of the 15 revascularized patients preserved their transmetatarsal amputation level at a follow-up of 36.4 months. The authors concluded that at a maximum of 3 years follow-up after initial amputation, transmetatarsal amputation was a successful amputation level. (J Am Podiatr Med Assoc 91(10): 533-535, 2001)
Background: Diabetes-related lower-extremity amputations are largely preventable. Eighty-five percent of amputations are preceded by a foot ulcer. Effective management of ulcers, which leads to healing, can prevent limb loss.
Methods: In a county hospital, we implemented a six-step approach to the diabetic limb at risk. We calculated the frequency and level of lower-extremity amputations for 12 months before and 12 months after implementation of the amputation prevention program. We also calculated the high-low amputation ratio for the years reviewed. The high-low amputation ratio is a quality measure for the success of amputation prevention measures and is calculated as the ratio of the number of high amputations (limb losses) over the number of low (partial foot) amputations.
Results: The frequency of total amputations increased from 24 in year 1 to 46 in year 2. However, the number of limb losses decreased from 7 to 2 (72%). The high-low amputation ratio decreased eightfold in 1 year, which serves as a marker for limb salvage success.
Conclusions: Improvement in care organization and multidisciplinary-centered protocols can substantially reduce limb losses. (J Am Podiatr Med Assoc 100(2): 101–104, 2010)
Background:
Below-the-knee amputation (BKA) can be a detrimental outcome of diabetic foot osteomyelitis (DFO). Ideal treatment of DFO is controversial, but studies suggest minor amputation reduces the risk of BKA. We evaluated risk factors for BKA after minor amputation for DFO.
Methods:
This is a retrospective cohort of patients discharged from Denver Health Medical Center from February 1, 2012, through December 31, 2014. Patients who underwent minor amputation for diagnosis of DFO were eligible for inclusion. The outcome evaluated was BKA in the 6 months after minor amputation.
Results:
Of 153 episodes with DFO that met the study criteria, 11 (7%) had BKA. Failure to heal surgical incision at 3 months (P < .001) and transmetatarsal amputation (P = .009) were associated with BKA in the 6 months after minor amputation. Peripheral vascular disease was associated with failure to heal but not with BKA (P = .009). Severe infection, bacteremia, hemoglobin A1c, and positive histopathologic margins of bone and soft tissue were not associated with BKA. The median antibiotic duration was 42 days for positive histopathologic bone resection margin (interquartile range, 32–47 days) and 16 days for negative margin (interquartile range, 8–29 days). Longer duration of antibiotics was not associated with lower risk of BKA.
Conclusions:
Patients who fail to heal amputation sites in 3 months or who have transmetatarsal amputation are at increased risk for BKA. Future studies should evaluate the impact of aggressive wound care or whether failure to heal is a marker of another variable.
Background: Transmetatarsal amputations are limb salvage surgical procedures that preserve limb length and functional ankle joints. Indications for transmetatarsal amputations include forefoot trauma, infection, and ischemia. Prior research demonstrates patients who undergo transmetatarsal amputations have a lower 2-year mortality rate compared to those who undergo more proximal amputations. The aim of this study was to determine whether primary closure of a transmetatarsal amputation is a superior treatment compared to secondary healing of a transmetatarsal amputation for forefoot abnormality of infection, gangrene, or chronic ulceration.
Methods: A retrospective chart review was performed on patients aged 18 years or older requiring a transmetatarsal amputation because of forefoot abnormality between September of 2011 and December of 2019. Foot and ankle surgeons performed transmetatarsal amputations. Outcome variables measured included healing time of transmetatarsal amputation site, recurrent infection, recurrent gangrene, and the need for revision surgery or higher level amputations.
Results: Of the original 112 patients, 76 met the inclusion criteria; 47 of these had primary closure of transmetatarsal amputation and 29 of these had an open transmetatarsal amputation performed. Primarily closed transmetatarsal amputations resulted in a significantly greater overall healing rate of 78.8% (37 of 47) compared to open transmetatarsal amputations, with a healing rate of 37.9% (11 of 29) (P < .01). Closed transmetatarsal amputations were statistically significantly less likely than open transmetatarsal amputations to have recurrent gangrene, require revision pedal operations, or progress to higher level amputations.
Conclusions: Our research demonstrated that primary closure of transmetatarsal amputations is a superior treatment compared with secondary healing of transmetatarsal amputations in specific cases of infection, dry gangrene, or chronically nonhealing ulcerations.
Decreasing Amputation Rates in Patients with Diabetes Mellitus
An Outcome Study
The lower-extremity amputation rate in people with diabetes mellitus is high, and the wound failure rate at the time of amputation is as high as 28%. Even with successful healing of the primary amputation site, amputation of part of the contralateral limb occurs in 50% of patients within 2 to 5 years. The purpose of this study was to provide valid outcome data before (control period) and 18 months after (test period) implementation of a multidisciplinary team approach using verified methods to improve the institutional care of wounds. Retrospective medical chart review was performed for 118 control patients and 116 test patients. The amputation rate was significantly decreased during the test period, and the amputations that were required were at a significantly more distal level. No above-the-knee amputations were required in 45 patients during the test period, compared with 14 of 76 patients during the control period. These outcome data suggest that unified care is an effective approach for the patient with diabetic foot problems. (J Am Podiatr Med Assoc 92(8): 425-428, 2002)
Negative-Pressure Wound Therapy and Diabetic Foot Amputations
A Retrospective Study of Payer Claims Data
Background: This study was undertaken to assess the benefits of negative-pressure wound therapy (NPWT) versus traditional wound therapies in reducing the incidence of lower-extremity amputations in patients with diabetic foot ulcers.
Methods: Administrative claims data for patients with diabetic foot ulcers from commercial payers (n = 3,524) and Medicare (n = 12,795) were retrospectively analyzed. Patients were divided into NPWT and control/traditional therapy groups on the basis of administrative codes. Risk-adjustment procedures were then performed to match patient risk categories (through total treatment costs) and wound severities (through debridement depth).
Results: The incidence of amputations in the NPWT groups was lower than that in the control groups. For the cost-based risk-adjustment analysis, amputation incidences with NPWT versus traditional therapy were 35% lower in the Medicare sample (10.8% versus 16.6%; P = .0077) and 34% lower in the commercial payer sample (14.1% versus 21.4%; P = .0951). Whereas overall amputation rates increased progressively with increasing wound debridement depth in both control groups, the same increasing trend did not occur in the NPWT groups.
Conclusions: Patients with diabetic foot ulcers in the Medicare sample treated with NPWT had a lower incidence of amputations than those undergoing traditional wound therapy; this finding was evident in wounds of varying depth in both populations studied. (J Am Podiatr Med Assoc 97(5): 351–359, 2007)
