AMPUTATIONS IN DIABETIC AMPUTATIONS IN DIABETIC FOOTFOOT

PROF. RAMA KANTKING GEORGE MEDICAL UNIVERSITY

LUCKNOW

ramakantkgmc@rediffmail.com

• Diabetes mellitus increases risk of amputation by 20-fold.

• Declining rate of foot amputations parallels decrease in hospitalizations for skin and soft tissue infections.

• This reflects better and effective outpatient care for diabetic foot ulcers and infections.

Do we waste time trying to save Do we waste time trying to save some feet ?????some feet ?????

Should we be aiming for local minimal surgery at all costs, or is there a case for primary radical amputation?

Technological advances and improvements in local treatments for diabetic foot disease place clinicians under ever increasing pressure to preserve the foot (Watkins PJ, 2003; Smith J, 2003).

These are real challenges for decision……

CHANGE YOUR PERCEPTION

STILL THERE IS HOPE…………

CHANGE YOUR PERCEPTION

STILL THERE IS HOPE…………

Health-economic consequences of Health-economic consequences of diabetic foot infectionsdiabetic foot infections

• Result in huge costs for society and individual. • Costs of antibiotics also substantial… ..• Total costs for topical treatment high . • Total costs for healing of infected ulcers not

requiring amputation - $17,500

• Costs for lower-extremity amputations are above $30,000

Often a successful outcome is followed by a rapid recurrence necessitating further hospitalisation.

Clinicians should always consider whether the best interests of the patient might be served by primary amputation or often prolonged, expensive and failure bound local aggressive surgical traetment ????

The aim of any treatment is to deliver a fully mobile patient back into the community.

Levels of lower extremity amputations

MAJOR AMPUTATION-MAJOR AMPUTATION-

• Advantages• No more surgery• Shorter hospital stay• Disadvantages• Major procedure and risk• Difficult & expensive rehabilitation• Independence threatened

FOOT—REVISION-BELOW KNEE---REVISION—ABOVE KNEE---STILL NEEDS REVISION

NOW HEALED ABOVE KNEE AMPUTATION

Indications for primary BKAIndications for primary BKA instead of local amputation instead of local amputation

Previous extensive hospitalisation

Limited life expectancy

Patient choice

Age

State of circulation

Effect of failed distal bypass

Failed conservative management.

• We should aim to minimise the time spent in hospital as these patients are often towards the end of their lives…….

Approximately 50% of patients ended up with a

BKA

a very high proportion indeed…..

• Major amputation should be considered as an option for every patient with diabetic foot disease.

EFFORTS TO RESTORE THIS FOOT TO NORMAL MOST PROBABLY WILL FAIL……

HE MAY BE BETTER OFF WITH AMPUTAION AND PROSTHESIS

50% of lower extremity amputations performed in 50% of lower extremity amputations performed in the United States are due to diabetes.the United States are due to diabetes.

9% foot, 9% foot,

31% lower leg, 31% lower leg,

30% above knee.30% above knee.

Ipsilateral higher amputations occur in 22% of Ipsilateral higher amputations occur in 22% of cases. cases.

Contralateral amputations 10% per year.Contralateral amputations 10% per year.

After 5 years, amputees with diabetes have a After 5 years, amputees with diabetes have a 50% chance of bilateral amputation, 50% chance of bilateral amputation,

Number of operations

• Diabetes

• Toe BKA AKA

• 282 (67%) 110 (49%) 39 (18%)

MINOR AMPUTATIONMINOR AMPUTATION

Advantages• Limb preserved• Reduced anaesthetic risk• Independence preserved

Disadvantages• Prolonged healing time• Prolonged hospitalisation• Prolonged re-mobilisation• Risk of failure of healing• Risk of further treatment

• Decisive factors in type of treatment provided to patients..

• They must participate

CENTRAL PLANTAR ABSCESS WITH

OSTEOMYELITIS

TOE AMPUTATION

WRONG DECISION FOR LEVEL OF AMPUTATION

BILATERAL DEFORMED BUT WALKABLE FOOT

FUNCTIONAL BUT DEFORMED FOOT

EVEN THIS IS MUCH BETTER THAN THE BEST PROSTHESIS…….This is also a view

• Patient choice• Patients should always be offered three

choices: • No treatment• Continued conservative management

involving minor amputation• Major amputation.

• Surprisingly, patients often choose the major amputation route.

Age

• Younger people adapt very well to BKA, but are likely to have better circulation and heal local amputations.

• However, young people are young enough to return with further problems.

• Elderly people are less likely to adapt well to major amputation, but are also less likely to have good circulation and the ability to heal locally within the foot.

State of circulationState of circulation

For local amputation in the foot to heal, the circulation must be adequate. In practice, this means at least one patent artery to ankle level.

Some patients may have been treated for months in hospital clinics without success.

In patient with neuropathic foot even if healing is eventually achieved, there is a very high risk of new ulceration despite very careful attention to footwear

Failed conservative treatment

Algorithm for management of Patients

38% of patients have a foot which is not salvageable and these patients should have a major amputation from the outset.

• Circulation normal, foot is salvageable, and patient is young, then local amputation is an option.

• However, 19% will fail their local amputation and require major amputation.

• What is life expectancy ?

• Previous treatment they have had

• Morphology of foot

• Circulation of foot.

• Mobility of patient

• Whether patient has a job and what it is ?

• What is the family situation

?

Transmetatarsal Amputation Transmetatarsal Amputation (TMA)(TMA)

• Gangrene must be limited to the toes and should not involve the web space. Infection should be controlled.

• Preserves the attachment of the dorsiflexors and plantar flexors and their function.

• These amputations can be fitted with sole stiffeners and toe fillers with minor apparent loss of function during stance and walking on level surfaces.

Other Foot AmputationsOther Foot Amputations

• Lisfranc amputation at the tarso-metatarsal junction

• Chopart amputation is a midtarsal, talo-navicular, calcaneo-cuboid amputation. Only talus and calcaneus bones remain

• Pirogoff is a vertical calcaneal amputation (in this amputation, the lower articular surfaces of the tibia/fibula are sawn through)

• Boyd is a horizontal calcaneal amputation (all tarsals removed except calcaneus/talus)

Syme's AmputationSyme's Amputation

• Indications: Trauma above the foot, congenital anomalies, tumors, and deformities that necessitate amputation.

• Disadvantages: healthy plantar heel skin is necessary for weight bearing in this area. The patient also must have good perfusion in this area, thus making it a difficult procedure for the dysvascular patient.

Pros: Functionally, this procedure represents an excellent level of amputation because:

It maintains the length of the limb preservation of the heel pad, excellent weight-bearing stump Immediate fitting of prosthesis is possible with excellent results Stump weight bearing is possible almost immediately after the procedure (~ within 24 hrs)

Cons: cosmesis (bulbous, bulky residual limb); fitting for a prosthesis may be more difficult than for other amputation levels.

Trans-metatarsal amputation ready for a split- thickness skin graft.

Transmetatarsal amputation with a skin graft.

Trans-metatarsal amputation with a plantar flap.

Primary closure by the plantar flap ideal due to vast arterial supply from the plantar artery.

MODIFIED SHOES AND AIDS FOR WALKING AND OFF LOADING…KEY TO SUCCESS

Partial Foot AmputationsPartial Foot Amputations

• Small-toe amputations do not affect ambulation

• Usually require no replacement

• Partial foot prostheses are used to restore foot function

• Amputation of the great toe reduces push-off force, thus requiring a resilient toe filler and also a molded insole with arch support to maintain the alignment of the amputated foot.

Partial foot amputations involving the forefoot, such as ray resections and trans-metatarsal amputations, generally require only shoe fillers or shoe modifications.

Will require stiff sole, the addition of a spring steel shank extending to the metatarsal heads, a rocker sole and/or padding of the tongue of the shoe to help hold the hind foot firmly in the shoe.

Transtarsal amputationsTranstarsal amputations

As Chopart, Lisfranc, and Boyd will have better functional results if there is an active balanced dorsiflexion and plantar flexion with normal skin and heel pad present.

• The best prosthetic option for a hind foot amputation - use of a custom prosthetic foot with a self-suspending split socket

It should not be too difficult to determine break points at which effectiveness of treatment is

cost effective, or even cost saving.

Conclusions

Major amputation should be considered as an option for every patient with diabetic

foot disease.

THANKS