The current burden of diabetic foot disease

Neuropathy and ischaemia are two great pathologies of the diabetic foot which lead to the characteristic features of foot ulceration (neuropathic and ischaemic) and Charcot neuroarthropathy. These can be complicated by infection and eventually may result in amputation (minor or major) and increased mortality. All of these features contribute to considerable clinical and economic burden.Peripheral nerves in the lower limbs are susceptible to different types of damage in patients with diabetes leading to distinctive syndromes. These include symmetrical sensory neuropathy associated with autonomic neuropathy, which advances gradually, and acutely painful neuropathies and mononeuropathies which have a rather acute presentation but usually recover. Ischaemia in the form of peripheral arterial disease is an important contributor to the burden of the diabetic foot. The incidence of atherosclerotic disease is raised in patients with diabetes and its natural history is accelerated. Diabetes causes severe and diffuse disease below-the knee. The lifetime risk of developing a diabetic foot ulcer is between 19% and 34%. Recurrence is common after initial healing; approximately 40% of patients have a recurrence within 1 year after ulcer healing, almost 60% within 3 years, and 65% within 5 years. Charcot neuroarthropathy is characterised by bone and joint destruction on the background of a neuropathy. Its prevalence in diabetes varies from 0.1% to 8%.Infection develops in 50%–60% of ulcers and is the principal pathology that damages diabetic feet. Approximately 20% of moderate or severe diabetic foot infections result in lower extremity amputations. The incidence of osteomyelitis is about 20% of diabetic foot ulcers.Every 20 s a lower limb is amputated due to complications of diabetes. Of all the lower extremity amputations in persons with diabetes, 85% are preceded by a foot ulcer. The mortality at 5 years for an individual with a diabetic foot ulcer is 2.5 times as high as the risk for an individual with diabetes who does not have a foot ulcer. The economic burden exacted on health care systems is considerable and includes direct and indirect costs, with loss of personal earnings and burden to carers. The diabetic foot is a significant contributor to the global burden of disability and reduces the quality of life. It remains a considerable public health problem.     

Amputations in diabetic patients: a plea for footsparing surgery

The authors observed a rather high rate of primary major amputation (above-knee or below-knee) performed for diabetic foot problems as well as an important revision rate for minor amputations (forefoot or toe) in diabetics. They reviewed their experience in order to compare it with more recent data from the literature, pleading for foot-sparing surgery. From 1993 to 1998, 186 amputations were performed on 146 diabetic patients. The cause of foot ulcers was neuropathy in 43 of them (51 episodes of diabetic foot problems) while in the remaining 103 patients (135 episodes of diabetic foot problems), diabetic macroangiopathy (absent ankle pulses) was on cause. For neuropathic foot problems, amputations were almost minor, resulting in a limb salvage rate of 90%. Only five of these patients (12%) had primary major limb amputation versus 43 of the dysvascular patients (42%). The reasons for major amputation by first intention were extensive tissue loss, intractable infection or non-reconstructible occlusive vessel disease, as judged by the surgeon. A foot-sparing surgery was attempted in 92 dysvascular cases. In only 44 of them, a preliminary vascular repair was performed. Twenty eight percent of the primary toe amputations and 24% of the forefoot amputations required secondary revision to a more proximal level. Minor amputations in case of diabetic neuropathy were characterized by a more favourable outcome: only 14% of the toe and 9% of the forefoot amputations failed. During follow-up, only 63% of the major amputations regained an autonomic walking capability with their prosthesis. Wound healing problems in diabetic foot are mainly due to infection and poor tissue perfusion. An aggressive control of the infection and distal revascularization of calf- or foot arteries, whenever possible, could improve the results of diabetic foot surgery. The poor functional recovery after major amputation (only 63% autonomic gait with limb prosthesis) argues for foot-sparing surgery whenever possible.     

The development and application of diabetic foot protocol in Chiang Mai University Hospital with an aim to reduce lower extremity amputation in Thai population: a preliminary communication

Lower extremity amputation is a frequent complication of diabetes, and the authors' region did not have effective strategies to minimize it. From August 2005 to July 2006, a diabetic foot protocol (DFP) for out-patient management based on a multidisciplinary team approach was tried at the local teaching hospital. There are devices to reduce pressure and educate. After healing, there are custom fabricated orthoses and footwear, and monitoring of progressive ambulation. This report compares the amputation rate in patients receiving DFP care from August 2005 to July 2006 with those who had standard care from August 2003 to July 2005. Sixty-one and 110 diabetic foot ulcer patients received DFP and standard foot care, respectively. Their sex distribution and mean age were similar. The incidence of major amputations in the DFP and standard care groups was 3.3% and 13.6%, respectively (P = .03). The incidence of minor amputations in the DFP and standard care groups was 3.4% and 15.8%, respectively (P = .02). DFP was associated with improved diabetic foot care outcomes. It may be used by clinical teams with a view to improve outcomes for patients with diabetes.     

Can major amputation rates be decreased in diabetic foot ulcers with hyperbaric oxygen therapy?

Although hyperbaric oxygen therapy has been used for diabetic foot ulcer since the 1980s, there is little information on its efficacy. The aim of this study is to evaluate whether hyperbaric oxygen can decrease major amputation rates and to determine the predictive factors. A total of 184 consecutive patients were treated with hyperbaric oxygen therapy as an adjunct to standard treatment modalities for their diabetic foot ulcer. Of these patients, 115 were completely healed, 31 showed no improvement and 38 underwent amputation. Of the amputations, nine (4.9%) were major amputations (below knee) and 29 were minor. Major amputations were associated with the Wagner grade (p < 0.0001), with the age of the patients (p = 0.028) and with the age of the wounds (p = 0.018). Hyperbaric oxygen therapy can help to reduce the major amputation rates in diabetic foot ulcer. However, further large, multicentre, randomised controlled studies are needed to make more accurate conclusions.     

Effect of lower extremity amputation on caregiving burden in caregivers of patients with diabetic foot: Prospective cohort study

Lower extremity amputation as a treatment of diabetic foot ulcer is probably a major burden for the patient's family and friends, who typically act as caregivers and support the patient in coping with the physical disabilities and emotional distress. In the present prospective study, we investigated the effects of different lower extremity amputation levels for diabetic foot ulcer treatment on caregivers of patients with diabetes using the Zarit Burden Interview (ZBI‐12) scale. Patients with diabetic foot ulcers who underwent unilateral major amputation (above‐below knee) and minor amputation of foot (heel sparing) and their caregivers were requested to volunteer to participate in this study from June 2016 to December 2018. The ZBI‐12 form was completed immediately preoperatively and 3 and 6 months after postoperatively. In the minor amputation group, the mean age of the 51 patients was 72.1 years. In the major amputation group, the mean age of the 88 patients was 73.7 years. Both groups of caregivers of patients with minor amputation and major amputations showed a significant improvement in ZBI‐12 score when compared preoperatively and at 3‐ and 6‐month follow‐up visits. The mean ZBI‐12 score was significantly higher in the major than in the minor amputation group in preoperative and all postoperative visits. The absence of the ankle joint in the below‐ or above‐knee amputation renders it more difficult for the amputee to quickly learn the use of prosthesis, thereby increasing the burden of the patient and caregivers. We found that lower extremity amputation for the treatment of chronic diabetic foot ulcers has significantly favourable effect on the caregiver burden, and thereby heel sparing was considerably more effective for the caregiver burden.     

Total-contact casting as an adjunct to promote healing of pressure ulcers in amputees

Partial foot amputations have become increasingly prevalent among long-lived diabetic patients. These patients have lower extremity neuropathy and are prone to ulceration at their amputation site. These ulcers are difficult to heal, and they place a significant financial and resource burden on the healthcare system. We examined the efficacy of total-contact casts (TCC) in diabetic amputees with nonhealing partial foot amputation site neuropathic ulcers. Data were collected retrospectively on all patients with amputations who were treated with a total-contact cast between December 2000 and December 2003. Seventeen patients (13 men, 4 women) with amputation site ulceration were identified. All patients were diagnosed with neuropathy secondary to diabetes and none had wound healing compromised by ischemia. The initial ulcer averaged 1,169 mm(2) with a depth of 2.77 mm. Patients were treated with an average of 7.9 cast applications over 8.4 weeks; 47% (8/17) of ulcers healed, but 29% (5/17) of patients were unable to complete their recommended treatment course secondary to complications from the TCC. Of the patients who were able to complete their treatment course, the healing rate was 66.7% (8/12). The recurrence rate for healed ulcers was 63% (5/8). Partial foot amputations with neuropathic ulcers present a very difficult problem to the vascular surgeon. Patient compliance and underlying medical comorbidities limit the success rate. In patients who can complete a TCC treatment course, good short term results can be expected. However, recurrence rates are high following discontinuation of mechanical TCC off-loading.     

Prognosis of critical limb ischemia: Major vs. minor amputation comparison

Healthcare providers treating wounds have difficulties assessing the prognosis of patients with critical limb ischemia who had been discharged after complete healing of major amputation wounds. The word “major” in “major amputation” gives the impression of “being more severe” than “minor amputation.” Therefore, even if wounds are healed after major amputation, they imagine that prognosis after major amputation would be poorer than that after minor amputation. We investigated the prognosis of diabetic nephropathy patients 2 years after amputations. Those patients underwent dialysis as well as amputation following percutaneous transluminal angioplasty for their foot wounds. They were ambulatory prior to these surgeries. Among 56 cases of minor amputation, 45 were males and 11 were females, and mortality was 41.1%. The mortality of cases with and without a coronary intervention history was 53.1% and 25.0%, respectively (p = 0.034). Among 10 cases of major amputation, 9 were males and 1 was female, and mortality was 60%. The mortality of cases with and without a coronary intervention history was 75.0% and 0%, respectively. Although we predicted poor prognosis in cases with major amputation, there was no significant difference in mortality 2 years after amputations (p = 0.267). Thus far poor prognosis has been reported for major amputation. It might be due to inclusion of the following patients: patients with wounds proximal to ankle joints, patients with extensive gangrene spreading to the lower legs, patients with septicemia from wound infection and who died around the time of operation, and patients with malnutrition. The results of our present study showed that the outcomes at 2 years postoperatively were similar between patients with major amputations and those with minor amputations, if surgical wounds were able to heal. We should not estimate the prognosis by the level of amputation, rather we should consider the effect of coronary intervention history on prognosis.     

Factors associated with lower‐extremity amputation in patients with diabetic foot ulcers in a Chinese tertiary care hospital

Providing a better understanding of the risk factors for amputation in this particular region, Hunan province, in China might help patients with diabetic foot ulcers receive timely and appropriate medical care and help prevent amputation. Diabetic foot ulcer patients referred to the Third Xiangya Hospital during the period between December 2014 and September 2018 were enrolled. Participants who underwent amputations and received conservative treatments were compared using univariate and multivariate analyses to identify the independent predictors of amputation. Those who required amputation presented significantly higher levels of white blood cell counts, platelet counts, erythrocyte sedimentation rate, C‐reactive protein, and glycated haemoglobin (HbA1c) levels. However, levels of haemoglobin, postprandial plasma C‐peptide, triglyceride, high‐density lipoprotein cholesterol, albumin, and uric acid were decreased in patients with amputations. Patients with more advanced Wagner grades had much higher rates of amputation. Multivariable‐adjusted odds ratios in stepwise logistic regression model was 1.317 for HbA1c (95% CI: 1.015‐1.709), 0.255 for triglyceride (95% CI: 0.067‐0.975), and 20.947 for Wagner grades (95% CI: 4.216‐104.080). Independent risk factors for amputation in these Chinese diabetic foot ulcer patients included an elevated HbA1c level, lower triglyceride level, and higher Wagner grades.     

Angiosome‐targeted revascularisation in diabetic foot ulcers

Peripheral vascular disease is a common complication of type 2 diabetes and is often more severe and diffuse than in non‐diabetic individuals with a higher risk of major amputations in the lower limbs. Diabetic foot revascularisation using both traditional bypass surgery and endovascular therapy are often burdened by the failure and the inevitable subsequent massive amputation. In this study, we examined the clinical response of diabetic patients with critical limb ischaemia and extended ischaemic wounds, treated with a new angiosome‐based revascularisation technique. In a 3‐year period, nine diabetic patients with imminent amputation threatening and foot ulcers with no feasible arterial revascularisation options were treated by the angiosome‐based surgical technique by means of deep vein arterialisation. The postoperative tcPO2 evaluation showed a mean increase in the cutaneous oxygen tension in all patients treated. The overall survival rates were 88·88%, 88·88% and 77·77% at 12, 24 and 36 months, respectively. Limb salvage was 100% at 1 year and steady at 88·88% thereafter. Surgical deep venous arterialisation might be considered as an extreme alternative to attempt tissue preservation in limbs unfit for conventional arterial revascularisations. This technique would give advantages to the patients in terms of better compliance to the minor amputations and thus avoiding major limb amputations.     

Hyperbaric oxygen therapy for nonischemic diabetic ulcers: A systematic review

Diabetic foot ulcers are a common complication of diabetes, which affects 25% of patients and may ultimately lead to amputation of affected limbs. Research suggests hyperbaric oxygen therapy improves healing of these ulcers. However, this has not been reflected in previous reviews, possibly because they did not differentiate between patients with and without peripheral arterial occlusive disease. Therefore, we performed a systematic review of published literature in the MEDLINE, Embase, and Cochrane CENTRAL databases on nonischemic diabetic foot ulcers with outcome measures including complete ulcer healing, amputation rate (major and minor), and mortality. Seven studies were included, of which two were randomized clinical trials. Two studies found no difference in major amputation rate, whereas one large retrospective study found 2% more major amputations in the hyperbaric oxygen group. However, this study did not correct for baseline differences. Two studies showed no significant difference in minor amputation rate. Five studies reporting on complete wound healing showed no significant differences. In conclusion, the current evidence suggests that hyperbaric oxygen therapy does not accelerate wound healing and does not prevent major or minor amputations in patients with a diabetic foot ulcer without peripheral arterial occlusive disease. Based on the available evidence, routine clinical use of this therapy cannot be recommended. However, the available research for this specific subgroup of patients is scarce, and physicians should counsel patients on expected risks and benefits. Additional research, focusing especially on patient selection criteria, is needed to better identify patients that might profit from this therapy modality.     

Minor environmental trauma and lower extremity amputation in high-risk patients with diabetes: incidence, pivotal events, etiology, and amputation level in a prospectively followed cohort

This study determined the incidence, pivotal events, etiology, and levels of amputation in a prospectively followed cohort of 400 people with diabetes and a prior healed foot ulcer who participated in a randomized footwear trial. Participants were seen every 17 weeks for 2 years. Subjects with foot lesions were referred to their healthcare provider for treatment. In this cohort, 11 participants required lower limb amputation (rate 13.8 per 1000 person-years). Pivotal event analysis revealed that only one amputation was related to footwear, six amputations were due to non-footwear-related minor environmental trauma, two were due to progression of vascular disease (dry gangrene from critical ischemia), one was due to a self-care injury while cutting the toenails, and one was due to a decubitus ulcer. Previously proposed strategies to reduce the amputation rates in individuals with diabetes have focused heavily on footwear and education. However, even with this emphasis, amputation rates in the United States are still high. This study suggests that the prevention of minor environmental trauma, including household accidents, merits additional attention. We believe that further efforts to reduce amputation rates for individuals with diabetes will need to emphasize the prevention of minor trauma, especially in those already compromised with neuropathy and vascular disease.     

Limb salvage in diabetics with foot ulcers

The healing results in 491 ulcers in 272 diabetic patients are reported. Soft moulded insoles and shoe corrections were the main part of the therapy. There were 329 (67%) neuropathic, 87 (17%) traumatic, 44 (9%) ischaemic and 31 (6%) ulcers of other various pathogenesis. Thirty seven per cent of the ulcers were complicated with invasive infection. Within the period of observation of 18 months (3-39 months) healing was obtained in 79% of the patients (88% of the ulcers) and major amputation was carried out in 8% (4% of the ulcers). There were 21 major amputations, which in 18 cases was due to ischaemia. Thus in only 3 cases (1% of the patients) neuropathy as complicated by invasive infection caused major amputation. Fifty nine ulcers (12%) were classified as relapsing ulcers or ulcers with new localizations and were caused by severe deformity of the foot (58 cases) often in combination with neglect of prophylaxis (7 cases). Only one recurrent ulcer was caused by ischaemia. The series shows that shoe corrections and insoles are effective in treating diabetic neuropathic ulcers. Recurrent ulcerations are caused by severe foot deformity and neglect of therapy. Loss of limbs is caused by ischaemia and invasive infection.     

Zehenamputation und Strahlresektion

BackgroundAlthough toe amputation and ray resection are suitable for the treatment of many pathologies, diabetic foot syndrome is the main cause for these amputations. In recent years there has been an increase in minor amputations compared to major amputations. By avoiding or turning away from major amputations, the minor amputations of the foot and their procedures have become the focus of surgical attention.Material and MethodsThe aim of this overview is to present the surgical technique of toe amputation and ray resection and its results in the current literature.ConclusionsToe amputations and ray resections are safe minor amputation procedures for many indications and offer quick weight bearing postoperatively. Despite good primary healing rates, interdisciplinary perioperative treatment in diabetic patients is substantial to keep re-amputation and mortality rates low.     

Diagnostik und Therapie des diabetischen Fußsyndroms aus gefäßchirurgischer Sicht

There are more than 6 million diabetic patients in Germany. Due to neuropathic and angiopathic long term damage the number of patients with diabetic foot syndrome has been increasing dramatically over the past years. Despite all efforts for prevention, early diagnosis and adequate therapy, more than 20,000 diabetics undergo major limb amputation in Germany every year. A major portion of these amputations could be avoided if an improvement of the arterial perfusion would be timely considered. By consequent therapy in interdisciplinary centres, and by applying all methods of arterial revascularization, the amputation rate in patients with diabetic foot problems could be reduced by 80%. This article describes the diagnostics and therapy of the diabetic foot syndrome from a vascular surgical point of view. The importance of endovascular, vascular surgical as well as combined (hybrid) procedures of revascularization is emphasized.     

Prevention of major amputations in the diabetic patient

Five of six major amputations of the lower extremity involve diabetic patients. It should be possible to reduce the number of major amputations by substituting reconstructive for destructive surgery, by radical local surgical debridement, by achieving healing of chronic foot lesions, by the early diagnosis of spread of infections from foot to leg, by limiting minor amputations, by improving the blood supply, and by providing a continuum of care by experienced personnel who supervise the foot status of the patient on an ongoing basis. In my experience, the application of these principles over the past seven years has precluded major amputation in the treatment of 48 diabetic patients with serious lower extremity lesions.     

Resurrection of the amputations of Lisfranc and Chopart for diabetic gangrene

When a patient with neuropathic diabetic gangrene of the foot has sepsis, it is not always necessary to do a below-knee guillotine amputation or a Syme's amputation. In more than six years we have done 18 successful open Lisfranc's and Chopart's amputations. Improved ambulation has been achieved in three months using simple shoe prostheses. All flaps are fashioned immediately and never sutured. No equinus deformities have developed.     

A case-control study of the risk factors for toe amputation in a diabetic population

Toe amputations are becoming more prevalent in the diabetic population. To prevent toe amputations, those individuals with the highest risk must be identified prior to developing a precipitating event. There are obvious risk factors for toe amputations, such as digital deformity, diabetic neuropathy, and ischemia. Other, less obvious, systemic comorbidities may be linked to toe amputations. This study also shows that gender plays a significant role as a risk factor for toe amputation. A foot infection, foot abscess, osteomyelitis, diabetic retinopathy, and diabetic nephropathy were also significant risk factors for toe amputations. This suggests a significant relationship between these complications and comorbidities that put these individuals at a higher risk for toe amputations.     

Are Transmetatarsal Amputations a Durable Limb Salvage Option? A Single-Institution Descriptive Analysis

In limb and life-threatening diabetic foot infections, transmetatarsal amputations are often indicated as a limb salvage procedure. The aim of this study is to analyze the long-term durability of initially successful transmetatarsal amputations in the diabetic population. We defined a successful transmetatarsal amputation as one which had clinical healing 1 year after surgery. A retrospective review of transmetatarsal amputations completed at our institution over an 11-year period was performed. We identified 83 amputations that met inclusion criteria. The mean follow-up was 4 years. The mean time to surgical healing was 109.8 days. After successfully healing the transmetatarsal amputation the long-term outcomes were analyzed. Re-ulcerations occurred in 44% of the transmetatarsal amputations a mean of 15 months after surgical healing. Patients who re-ulcerated were noted to be significantly younger (p value 0.02) with a significantly higher preprocedure hemoglobin A1c (p value < .001). Additional procedures after successful healing included 13 (15.66%) revision surgeries and 12 (14.46%) more proximal amputations. While transmetatarsal amputations remain a viable and durable limb preserving surgery, all patients who have undergone a transmetatarsal amputation should be monitored lifelong as they remain at risk for re-ulceration and more proximal amputation.     

Limb-threatening and Life-threatening Diabetic Extremities: Clinical Patterns and Outcomes in 56 Patients

Limb- and life-threatening hand and foot infections in diabetic patients account for a large proportion of amputations and a substantial number of deaths. Between August 2006 and the end of July 2008, we conducted a prospective cohort study of consecutive diabetic patients with serious hand or foot infections, in an effort to identify clinical patterns and outcomes related to the treatment of these infections. Infections were categorized as dry, gas, and wet gangrene; necrotizing fasciitis or cellulitis; acute extensive osteomyelitis; and any of these infections involving the hand. All of the patients underwent a standard examination and treatment protocol, although none of the patients received vascular surgical care. End points included healing following debridement or minor amputation, major (transtibial or more proximal) amputation, or death. A total of 56 patients were included in the final analyses, and their mean age was 70 (range 51 to 86) years. Of the patients, 17 (30.36%) had necrotizing cellulitis, 12 (21.43%) had wet gangrene, 9 (16.07%) had acute extensive osteomyelitis, 5 (8.93%) had dry gangrene, 5 (8.93%) had gas gangrene, 4 (7.14%) had necrotizing fasciitis, and 4 (7.14) had diffuse hand infections. Five (8.93%) patients died (2 after prior amputation), 26 (46.43%) underwent debridement and/or minor amputation, and 27 (48.21%) required major amputations. Based on our findings, we concluded that 7 patterns of serious limb- or life-threatening infection were identified and, in the absence of vascular surgical intervention, mortality can be reduced at the expense of more amputations.     

Minoramputationen bei diabetischem Fußsyndrom

Minor amputations are frequently performed for neuroischemic or neuropathic lesions of the diabetic foot. Depending on the definition used, minor amputations can range from toe to Syme amputations. Minor amputations are often combined with necrosectomy and débridement. For early and optimal rehabilitation, as much vital tissue as possible should be conserved, especially considering the skeletal structures of the foot (borderline amputation). Minor amputations are of utmost importance for the prevention of ascending infections and reduce the duration of clinical and outpatient treatment. Minor amputations should be performed only by experienced surgeons and only if arterial perfusion is sufficient. They should be as tissue-conserving as possible and structured interdisciplinary postoperative care is mandatory. Metabolic control should be optimized. Controversial opinions exist with respect to the use of tourniquets, conservation or resection of cartilage and sesamoid bones, open amputation or primary closure of the wound, interdigital spacer function of toes, aseptic proximal transection of tendons, postoperative wound care, negative-pressure wound treatment and antibiotic therapy. In view of these controversies the most important minor amputation techniques are described and discussed.