Amputation? Surely Not!

When I was growing up in our small West Texas town, I was used to seeing people with lower extremity amputations, some with prostheses and some without. Some were veterans of World War II and the Korean conflict, but I discovered more were victims of diabetes mellitus.    On questioning my father about the problem, he said there was no other treatment than amputation for diabetic patients when they developed bad ulcers and infections in their feet. I took that as gospel for many years until I learned more of the pathophysiology of diabetes mellitus and diabetic foot problems. In medical school, I learned there were treatment options for these patients and limb amputation was not inevitable. In the past 20-plus years, many treatment options have resulted in great strides in limb salvage for patients with diabetes. A study of amputation rates in the United Kingdom showed the major amputation rate (below knee or above knee) decreased 61.5% from all causes and 81.6% in diabetic patients from 1995 to 2005.¹ This is remarkable and shows that we do have the capability to reduce the number of these disabling procedures. Another study from The Netherlands in 1996 showed a 34% reduction in major amputations in diabetic patients when limb salvage techniques were utilized.² Unfortunately, there are still a number of physicians and surgeons who believe that once a diabetic patient develops a foot ulcer, amputation is the best treatment. I have done my best to educate these physicians about limb salvage techniques and procedures that are better for the patient but, unfortunately, there are still those out there who will not be persuaded.

Some will argue the treatment of diabetic foot ulcers is hugely expensive and amputation is the most cost-effective way to treat diabetic foot ulcers and problems. There is no question treatment of diabetic foot ulcers and their complications is expensive,³ but numerous authors have shown amputation is even more expensive. Dr. Eckman and colleagues⁴ showed the most expensive therapy for diabetic foot ulcers was, and still is, immediate amputation. Even when the cost studies are done, they rarely include the cost the patient pays. Good studies have shown that for wound center patients who have been ambulatory, 65% of those undergoing a below-knee amputation and 80% of those undergoing an above-knee amputation never walk again,⁵ and the 5-year survival after a major amputation is only 40 percent!^3,6 Most all agree that avoiding amputation is probably the most important means of reducing costs and achieving cost effectiveness in the management of diabetic foot ulcers.⁷

I have heard amputation is the best treatment because the wounds are so hard to heal, the patient will probably end up with an amputation anyway. Most of this has to do with the physician’s lack of knowledge of the current treatment of diabetic ulcers or their unwillingness to put forth the effort to treat the patient. If a physician does not know how to appropriately treat the patient or does not want to take the time required to do it, the patient deserves to be referred to someone who will. In today’s world, there is no excuse for routinely recommending primary major amputation for patients with uncomplicated diabetic foot ulcers and problems. Hopefully all of us will continue to try to educate those who refuse to believe otherwise.

“He is a good surgeon who can amputate a limb, but he is a better surgeon who can save a limb.”
-- Sir Astley Cooper, British surgeon