Ulcer recurrence following first ray amputation in diabetic patients: a cohort prospective study

OBJECTIVE: To evaluate the reulceration and reamputation rates in a cohort of diabetic patients following first ray amputation. RESEARCH DESIGN AND METHODS: We evaluated a cohort of 89 diabetic patients, 63 men and 26 women, who underwent first ray amputation in the period from January 2000 to December 2001. The first ray lesions were Wagner grade 2 in 3 patients, Wagner grade 3 in 47 patients, and Wagner grade 4 in 39 patients. Following surgical wound healing, all patients wore special footwear with rocker bottom soles and custom molded insoles and were put on an intensive secondary prevention program. RESULTS: The mean follow-up duration was 16.35 +/- 6.76 months (range 7-28). Fifteen patients developed new ulcerations, with 11 lesions occurring ipsilaterally and 4 contralaterally to the first ray amputation. In seven patients, the new lesion was treated and healed with dressing. Eight patients underwent a new surgical procedure: panmetatarsal head resection in four patients, toe amputation in two patients, a transmetatarsal amputation in one patient, and Lisfranc's amputation in one patient. CONCLUSIONS: In the population studied, the first ray amputation presented a lower reulceration and reamputation rate with respect to that reported in the literature. This finding should therefore be attributed to the follow-up program, which uses shoes with a rocker bottom sole and custom molded insoles and intensive ambulatory check-ups.     

Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations

OBJECTIVES: To examine 12-month reamputation and mortality rates as well as acute and postacute medical care costs among a large cohort of persons with dysvascular amputations. DESIGN: Retrospective cohort study. SETTING: General community. PARTICIPANTS: Medicare beneficiaries identified from the Centers for Medicare and Medicaid Services data as undergoing a lower-limb amputation secondary to vascular disease in 1996. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Twelve-month reamputation and mortality rates, and acute and postacute medical care costs, by initial amputation level and presence or absence of diabetes. RESULTS: A total of 3565 persons, corresponding to 71,300 Medicare beneficiaries nationwide, were identified from the claims data as undergoing lower-limb amputations in 1996. Twenty-six percent of them required subsequent amputation procedures within 12 months, and more than one third died within 1 year of their index amputation. Acute and postacute medical care costs associated with caring for beneficiaries with a dysvascular amputation exceeded $4.3 billion yearly. There were marked differences in patient characteristics, progression of amputation to higher levels, service use, and mortality among dysvascular amputees with and without a comorbidity of diabetes. Diabetic amputees were younger than those without diabetes; they were also more likely to be men, to have more comorbidities, and to have undergone their first amputation at an earlier age than persons with dysvascular amputations who did not have diabetes. Although diabetic amputees were less likely to die within 12 months of the index amputation, they died at a significantly younger age than their nondiabetic counterparts. Progression to a higher level of limb loss occurred most frequently (34.5%) among persons with an initial foot or ankle amputation. Diabetic amputees were more likely than nondiabetic amputees to experience progression to a higher amputation level for all initial amputation levels. CONCLUSIONS: This study provides information that can be used by physicians when counseling patients about expected outcomes of dysvascular amputations at different levels.     

Amputation prevention by vascular surgery and podiatry collaboration in high-risk diabetic and nondiabetic patients. The Operation Desert Foot experience.

OBJECTIVE: To describe a unique multidisciplinary outpatient intervention for patients at high risk for lower-extremity amputation. RESEARCH DESIGN AND METHODS: Patients with foot ulcers and considered to be high risk for lower-extremity amputation were referred to the High Risk Foot Clinic of Operation Desert Foot at the Carl T. Hayden Veterans Affairs' Medical Center in Phoenix, Arizona, where patients received simultaneous vascular surgery and podiatric triage and treatment. Some 124 patients, consisting of 90 diabetic patients and 34 nondiabetic patients, were initially seen between 1 October 1991 and 30 September 1992 and followed for subsequent rate of lower-extremity amputation. RESULTS: In a mean follow-up period of 55 months (range 3-77), only 18 of 124 patients (15%) required amputation at the level of the thigh or leg. Of the 18 amputees, 17 (94%) had type 2 diabetes. The rate of avoiding limb loss was 86.5% after 3 years and 83% after 5 years or more. Furthermore, of the 15 amputees surviving longer than 2 months, only one (7%) had to undergo amputation of the contralateral limb over the following 12-65 months (mean 35 months). Compared with nondiabetic patients, patients with diabetes had a 7.68 odds ratio for amputation (95% CI 5.63-9.74) (P < 0.01). CONCLUSIONS: A specialized clinic for prevention of lower-extremity amputation is described. Initial and contralateral amputation rates appear to be far lower in this population than in previously published reports for similar populations. Relative to patients without diabetes, patients with diabetes were more than seven times as likely to have a lower-extremity amputation. These data suggest that aggressive collaboration of vascular surgery and podiatry can be effective in preventing lower-extremity amputation in the high-risk population.     

New ulceration, new major amputation, and survival rates in diabetic subjects hospitalized for foot ulceration from 1990 to 1993: a 6.5-year follow-up

OBJECTIVE: To evaluate 1) the new ulceration, the new major amputation, and the survival rates of 115 diabetic subjects hospitalized for foot ulceration from 1990 to 1993, with an average follow-up of 6.5 years, and 2) the demographic and clinical characteristics associated with these events. RESEARCH DESIGN AND METHODS: A total of 115 subjects, 31 women and 84 men, were monitored until 31 December 1998. All subjects were provided with therapeutic shoes and received intense education. Data concerning new ulceration, new major amputation, and reamputation events and the date and cause of death were recorded for each patient. The prognostic factors for these events were then evaluated. RESULTS: The average follow-up was 78.3 +/- 15.3 months (range 60-106). During this time, 13 homolateral and 12 contralateral episodes of new ulceration occurred. At univariate analysis, none of the variables considered were significantly associated with the new ulceration. There were three major amputations: two of the limb previously healed and one of the contralateral limb. Of the 115 subjects, 51 (44.3%) died: 24 of the 31 women (77.4%) and 27 of the 84 men (32.1%). Ischemic cardiopathy was the most frequent cause of death (60.8%). Mortality concerned 20 of the 27 subjects (74.1%) undergoing major amputation from 1990 to 1993 and 31 of the 88 healed subjects (35.2%), with a significant difference (P < 0.0001). Multivariate analysis showed the independent role of the ankle-brachial index < or =0.5 (P = 0.005), age (P = 0.003), and female sex (P = 0.027). CONCLUSIONS: We believe that the use of therapeutic shoes and intense educational training, including the education of the family, have contributed to the low incidence of new ulceration and major amputation in our study population. The high frequency of ischemic cardiopathy as a cause of death should, perhaps, lead to a more aggressive diagnostic and therapeutic attitude toward this pathology in diabetic subjects admitted to hospitals for foot ulceration.     

Incidence of Lower-Limb Amputation in the Diabetic and Nondiabetic General Population: A 10-year population-based cohort study of initial unilateral and contralateral amputations and reamputations

OBJECTIVE—The purpose of this study was to compare the incidence of vascular lower-limb amputation (LLA) in the diabetic and nondiabetic general population.RESEARCH DESIGN AND METHODS—A population-based cohort study was conducted in a representative Swedish region. All vascular LLAs (at or proximal to the transmetatarsal level) performed from 1997 through 2006 were consecutively registered and classified into initial unilateral amputation, contralateral amputation, or reamputation. The incidence rates were estimated in the diabetic and nondiabetic general population aged ≥45 years.RESULTS—During the 10-year period, LLA was performed on 62 women and 71 men with diabetes and on 79 women and 78 men without diabetes. The incidence of initial unilateral amputation per 100,000 person-years was 192 (95% CI 145–241) for diabetic women, 197 (152–244) for diabetic men, 22 (17–26) for nondiabetic women, and 24 (19–29) for nondiabetic men. The incidence increased from the age of 75 years. Of all amputations, 74% were transtibial. The incidences of contralateral amputation and of reamputation per 100 amputee-years in diabetic women amputees were 15 (7–27) and 16 (8–28), respectively; in diabetic men amputees 18 (10–29) and 21 (12–32); in nondiabetic women amputees 14 (7–24) and 18 (10–28); and in nondiabetic men amputees 13 (6–22) and 24 (15–35).CONCLUSIONS—In the general population aged ≥45 years, the incidence of vascular LLA at or proximal to the transmetatarsal level is eight times higher in diabetic than in nondiabetic individuals. One in four amputees may require contralateral amputation and/or reamputation.Severe peripheral arterial disease indicating critical ischemia has been found in 1.2% of a general population aged ≥60 years (1) and in almost 5% of primary care patients aged ≥65 years (2). It has been reported that one in four diabetic individuals develops peripheral vascular disease that, when severe, may require amputation (3). Estimating the incidence of vascular lower-limb amputation (LLA) in diabetic and nondiabetic individuals can provide important information regarding changes in the incidence over time. This can assist in the planning of preventative care and rehabilitation and facilitate assessment of the effects of interventions, such as arterial reconstruction and amputation at specific levels, and the success of prosthetic rehabilitation (4,5).The reported annual incidence of LLA related to peripheral vascular disease has ranged from approximately 20 to 35 per 100,000 inhabitants (5,6). These incidence rates were usually based on the total population rather than on age-groups of the diabetic or the nondiabetic general population in which severe peripheral vascular disease usually occurs (7). Furthermore, different definitions and incidence estimation methods have been used, and problems of incorrectly registered diagnoses and missing data have been described (3,8). Individuals with diabetes have accounted for less than half of all patients with LLA in studies from Finland and Sweden (5,9) but for as much as two-thirds of patients with LLA in a German general population study (6).Compared with amputations in nondiabetic individuals, amputations due to diabetes have more often involved younger individuals and lower amputation levels (10). Because vascular LLA in diabetic and nondiabetic individuals may differ with regard to patient characteristics, initial amputation level, clinical management, and prognosis (including mortality rates), it is important to study the epidemiology of LLA related to peripheral vascular disease with and without diabetes independently (10). Few population-based studies have estimated the incidence of LLA in the diabetic general population based on validated data concerning the age- and sex-specific prevalence of diabetes at the time of study. Despite the availability of data on amputations (11), the utility of these data to accurately determine the incidence of LLA in the general population may be limited because the data are usually based on hospital discharges, which do not accurately detail procedures performed and concurrent diagnosis of diabetes. Moreover, accurate incidence rates cannot be derived unless the data are related to validated estimates of the sex- and age-specific prevalence of diabetes in the general population.The aim of this population-based cohort study was to estimate the incidence of LLA (at or proximal to the transmetatarsal level) performed for peripheral vascular disease among the diabetic and the nondiabetic general population over a 10-year period, with particular consideration of the rate of reamputation and contralateral amputation.     

腔内血管成形术治疗糖尿病膝下动脉长段闭塞病变的价值

目的探讨经皮腔内血管成形术治疗糖尿病膝下动脉长段闭塞病变的临床疗效及价值。方法本组56例糖尿病膝下动脉长段闭塞病变患者,男34例,女22例,年龄48～76岁,中位年龄62岁。Fontaine分期,Ⅱb期(中至重度间歇跛行)19例,Ⅲ期(缺血性静息痛)21例,Ⅳ期(不同程度的溃疡和坏疽)16例。所有患者术前均行患肢CT血管造影及数字减影血管造影检查;术后定期门诊随访12个月,观察记录临床症状和体征变化;并于术前和术后1、3、6和12个月行患肢跛行距离、足趾皮温、踝肱指数(ABI)、趾肱指数(TBI)、CT血管成像(CTA)或彩色多普勒显像检查。结果 56例患者的103条病变肢体共有膝下动脉长段闭塞血管127支,平均闭塞长度(14.51±5.62)cm;其中106支长段闭塞动脉通过球囊扩张成形得以再通,经皮腔内血管成形术成功率为83.5%。术后所有开通成功的患肢皮温改善明显,术后患者的疼痛症状明显缓解或消失。跛行距离、足趾皮温、ABI、TBI等在术后1、3、6、12个月均较术前有显著性改善,P<0.05。共38条肢体(40.9%)发生了再狭窄,12个月的肢体保全率高达92.2%(95/103)。结论经皮腔内血管成形术治疗糖尿病膝下动脉长段闭塞病变,近期疗效确切,安全性较高,虽然其远期再狭窄率较高,但能有效控制病情的发展和缓解临床症状,有助于提高缺血肢体的肢体保全率。     

腘动脉以远血管腔内成形术治疗糖尿病足:附65例报告

目的 探讨腘动脉以远血管腔内成型术对糖尿病足的救肢疗效.方法 总结65例(69条肢体)糖尿病足患者行腘以下闭塞动脉血管腔内长球囊扩张成形术的救肢治疗经验.结果 全组无死亡.即时成功60例64条肢体,失败5例5条肢体,即时技术成功率92.75%.成功的60例64条肢体术后肢温明显改善、疼痛缓解,踝肱指数(ABI)增加至0.84±0.11以上,有39条肢体术后即可触到再通动脉(胫前或胫后动脉)搏动.足、趾感染经清创换药等愈合21条肢体,皮肤软组织小面积坏疽自行脱落愈合10条肢体,清除坏疽愈合6条肢体,截趾后Ⅰ期愈合22条肢体,半足截除1条肢体.无一例截肢.成功病例出院后每月复查彩超1次,随访率100%.术后再阻塞6例6条肢体(3个月1例,6月1例,12个月2例,18个月2例),此6例均进行了二次扩张再通.结论 腘以下动脉腔内长球囊扩张成形对动脉闭塞的搪尿病足是一种有效的救肢方法 ,具有微创、安全、并发症少、可重复扩张等优点,可作为首选治疗方法 . 39条肢体术后即可触到再通动脉(胫前或胫后动脉)搏动.足、趾感染经清创换药等愈合21条肢体,皮肤软组织小面积坏疽自行脱落愈合10条肢体,清除坏疽愈合6条肢体,截趾后Ⅰ期 合22条肢体,半足截除1条肢体.无一例截肢.成功病例出院后每月复查彩超1次,随访率100%.术后再阻塞6例6条肢体(3个月1例,6月1例,12个月2例,18个月2例),此6例均进行了二次扩张再通.结论 腘以下动脉腔内长球囊扩张成形对动脉闭塞的糖尿病足是一种有效的救肢方法 ,具有微创、安全、并发症少、可重复扩张等优点,可作为首选治疗方法 . 39条肢体术后即可触到再通动脉(胫前或胫后动脉)搏动.足、趾感染经清创换药等愈合21条肢体,皮肤软组织小面积坏疽自行脱落愈合10条肢体,清除坏疽     

Diabetic neuropathic pain in a leg amputated 44 years previously

The mechanism of neuropathic pain in the diabetic limb is far from clear. Phantom limb pain likewise is of obscure aetiology. The development of typical pain in an absent leg in a patient with diabetes many years after the amputation stimulates thought as to the mechanism, not only of neuropathic pain, but also of phantom limb pain. A 58-year-old man was diagnosed with type 2 diabetes 44 years after having undergone left below knee amputation for congenital AV malformation, at the age of 13. Eight months before the diagnosis of diabetes he began to complain of pain in the leg on the amputated side-pain very similar to that described in typical diabetic neuropathy. This was followed by similar pain in the right leg. MR scan of the spine revealed a small syringohydromyelia of the thoracic cord in addition to a prolapse of disc at L(5)/S(1) level on the left side, which was first noted 5 years previously. There were no other features of S(1) compression. The typical neuropathic character of the pain involving both the amputated and the intact limbs that developed with the diagnosis of type 2 diabetes suggest that the neuropathic pain may originate from centres higher than peripheral nerves.     

Rehabilitation outcome of patients with dual disability of hemiplegia and amputation

The records of 30 patients with the dual disability of hemiplegia and amputation were reviewed. Six factors noted to have influenced the success of rehabilitation were: (1) age; (2) sequence of onset of disability, whether amputation or hemiplegia first; (3) localization of dual disability, whether ipsilateral or contralateral; (4) side of hemiplegia; (5) level of amputation; (6) availability of prolonged hospital stay and training. The final functional status was better if: (1) the amputation preceded the CVA; (2) the amputation and hemiplegia were ipsilateral; (3) amputation and hemiplegia were both on the right side. The hospital stay of patients with dual disability ranged from 4 months to 1 year. Those who had disability on contralateral sides and those who had left hemiplegia required a more prolonged hospital stay.     

Long-Term Prognosis of Diabetic Foot Patients and Their Limbs: Amputation and death over the course of a decade

OBJECTIVE There is a dearth of long-term data regarding patient and limb survival in patients with diabetic foot ulcers (DFUs). The purpose of our study was therefore to prospectively investigate the limb and person survival of DFU patients during a follow-up period of more than 10 years. RESEARCH DESIGN AND METHODS Two hundred forty-seven patients with DFUs and without previous major amputation consecutively presenting to a single diabetes center between June 1998 and December 1999 were included in this study and followed up until May 2011. Mean patient age was 68.8 ± 10.9 years, 58.7% were male, and 55.5% had peripheral arterial disease (PAD). Times to first major amputation and to death were analyzed with Kaplan-Meier curves and Cox multiple regression. RESULTS A first major amputation occurred in 38 patients (15.4%) during follow-up. All but one of these patients had evidence of PAD at inclusion in the study, and 51.4% had severe PAD [ankle-brachial pressure index ≤0.4]). Age (hazard ratio [HR] per year, 1.05 [95% CI, 1.01-1.10]), being on dialysis (3.51 [1.02-12.07]), and PAD (35.34 [4.81-259.79]) were significant predictors for first major amputation. Cumulative mortalities at years 1, 3, 5, and 10 were 15.4, 33.1, 45.8, and 70.4%, respectively. Significant predictors for death were age (HR per year, 1.08 [95% CI, 1.06-1.10]), male sex ([1.18-2.32]), chronic renal insufficiency (1.83 [1.25-2.66]), dialysis (6.43 [3.14-13.16]), and PAD (1.44 [1.05-1.98]). CONCLUSIONS Although long-term limb salvage in this modern series of diabetic foot patients is favorable, long-term survival remains poor, especially among patients with PAD or renal insufficiency.     

Neuropathic osteoarthropathy in the diabetic foot

OBJECTIVE: To discuss a case involving a 55-year-old diabetic woman with neuropathic osteoarthropathy initiated by a fall. CLINICAL FEATURES: The patient fell into a hole, injuring her left foot. Because of the anesthesia associated with her diabetic peripheral neuropathy, she did not notice the ensuing plantar puncture wound. The patient assumed that her swelling was a result of a sprain. Mild dislocation and osseous fragmentation was noted within the midfoot on radiographs. The neuropathic osteoarthropathy progressed until the patient was later casted. Plain films taken at the time of cast removal demonstrated resorption and consolidation of fragmentation, but the dislocation was unaltered. INTERVENTION AND OUTCOME: The patient was scheduled for surgery and wound debridement. However, before surgery, complications of a burn sustained on the contralateral foot required fifth ray amputation. Surgery of the left foot has been postponed until adequate postsurgical healing has occurred at the right foot amputation site. CONCLUSION: This article provides tools for the timely diagnosis and treatment of neuropathic osteoarthropathy. An increased understanding of this entity will help lead to a reduction in the incidence of delayed treatment resulting from misdiagnosis.     

Autologous transplantation of granulocyte colony-stimulating factor-mobilized peripheral blood mononuclear cells improves critical limb ischemia in diabetes

OBJECTIVE: To assess the application of autologous transplantation of granulocyte colony-stimulating factor (G-CSF)-mobilized peripheral blood mononuclear cells (PBMNCs) in the treatment of critical limb ischemia (CLI) of diabetic patients and to evaluate the safety, efficacy, and feasibility of this novel therapeutic approach. RESEARCH DESIGN AND METHODS: Twenty-eight diabetic patients with CLI were enrolled and randomized to either the transplant group or the control group. In the transplant group, the patients received subcutaneous injections of recombinant human G-CSF (600 microg/day) for 5 days to mobilize stem/progenitor cells, and their PBMNCs were collected and transplanted by multiple intramuscular injections into ischemic limbs. All of the patients were followed up after at least 3 months. RESULTS: At the end of the 3-month follow-up, the main manifestations, including lower limb pain and ulcers, were significantly improved in the patients of the transplant group. Their laser Doppler blood perfusion of lower limbs increased from 0.44 +/- 0.11 to 0.57 +/- 0.14 perfusion units (P < 0.001). Mean ankle-brachial pressure index increased from 0.50 +/- 0.21 to 0.63 +/- 0.25 (P < 0.001). A total of 14 of 18 limb ulcers (77.8%) of transplanted patients were completely healed after cell transplantation, whereas only 38.9% of limb ulcers (7 of 18) were healed in the control patients (P = 0.016 vs. the transplant group). No adverse effects specifically due to cell transplantation were observed, and no lower limb amputation occurred in the transplanted patients. In contrast, five control patients had to receive a lower limb amputation (P = 0.007, transplant vs. control group). Angiographic scores were significantly improved in the transplant group when compared with the control group (P = 0.003). CONCLUSIONS: These results provide pilot evidence indicating that the autologous transplantation of G-CSF-mobilized PBMNCs represents a simple, safe, effective, and novel therapeutic approach for diabetic CLI.     

A foot care program for diabetic unilateral lower-limb amputees

OBJECTIVE: To assess the efficacy of a specialist foot care program designed to prevent a second amputation and to assess peripheral vascular disease (PVD) and peripheral neuropathy in diabetic unilateral lower-limb amputees. RESEARCH DESIGN AND METHODS: Investigations were carried out in 143 diabetic lower-limb unilateral amputees referred to a subregional rehabilitation center for prosthetic care from a catchment area of approximately 3 million people. Peripheral vascular and nerve assessment, education, and podiatry were provided for each patient. RESULTS: For the patients referred to the foot care program, there were no baseline differences between the patients who proceeded to a bilateral amputation (n = 22) and those who remained as unilateral amputees (n = 121) in their level of foot care knowledge and mean neuropathy scores. Mean ankle-brachial pressure index was significantly lower for the bilateral amputees (0.75 +/- 0.04) compared with the unilateral amputees (0.90 +/- 0.03, mean +/- SEM, P < 0.05), but there was no difference in the level of oxygen in the skin. However, the level of carbon dioxide was significantly lower in patients with bilateral amputation (24.21 +/- 2.16 vs. 31.20 +/- 0.85 mmHg, P < 0.03). Overall, the establishment of a specialist foot care program made no impact on contralateral limb amputation (22 of 143, 15.4%) compared with matched patients without the program (21 of 148, 14%) over a 2-year outcome period for each patient. CONCLUSIONS: PVD is more closely associated with diabetic bilateral amputation than neuropathy or level of foot care knowledge. Preventative foot care programs for diabetic unilateral amputees should therefore place greater emphasis on peripheral vascular assessment to identify patients at risk and on the development of timely intervention strategies.     

Referred pain from amputation stump trigger points into the phantom limb

OBJECTIVES: The aim of the study was to examine whether/how myofascial stump trigger points (TPs) after lower leg amputations are able to produce stump pain (SP), phantom pain (PP), and sensations (PS) in the phantom limb. METHODS: Palpation of the 5 most striking stump TPs of 30 leg amputees (12 transfemoral, 18 transtibial) was documented in a standardized manner. Patients were asked to localize SP, PP, and PS. RESULTS: Of 150 TPs, 14 produced involuntary stump movements and 10 stump fasciculations. Dorsal PP after ventral TP palpation occurred as well as PP in the toes from TPs near the hip. Of 30 patients, 20 reported PS and 8 PP; 60 of 150 TPs produced PS and 17 PP. Phantom phenomena were localized in 62.8% in the toes (1st toe 19.8%, toes 2-5 about 10% each), 17.9% midfoot, and the rest were more proximal. TPs were localized more in the lateral/dorsal stump than medial/ventral. About 70% of the TPs were found between 3 and 7 cm from the stump end, those with toe projections more distal than those with tibial projections. CONCLUSIONS: Myofascial TPs in amputation stumps are common and able to produce sensations and pain in the phantom limb. Most reported experiences were localized in the toes, as phantom pain usually is. There seems to be a "stump representation" and it seems possible that "referred TP pain" and "phantom pain" may develop from similar origin.     

Foot ulceration and lower limb amputation in type 2 diabetic patients in dutch primary health care

OBJECTIVE: To determine the incidence of foot ulceration and lower limb amputation in type 2 diabetic patients in primary health care. RESEARCH DESIGN AND METHODS: Data on type 2 diabetes were collected by the Nijmegen Monitoring Project between 1993 and 1998 as part of a study of chronic diseases. The records of all patients recorded as having diabetic foot problems and those who died, moved to a nursing home, or were under specialist care were included. The annual incidence of foot ulceration was defined as the number of type 2 diabetic patients per patient-year who developed a new foot ulcer. Incidence of lower limb amputation was similarly defined. Additional information was collected on treatment of foot ulcers. RESULTS: The study population of type 2 diabetic patients increased from 511 patient-years in 1993 to 665 in 1998. The annual incidence of foot ulceration varied between 1.2 and 3.0% (mean 2.1) per year; 25% of the patients had recurrent episodes. The annual incidence of lower limb amputation varied between 0.5 and 0.8% (mean 0.6). Ten of the 15 amputees died, and 12 of 52 (23%) patients with ulceration had a subsequent amputation or a previous history of amputation. In 35 of the 73 (48%) episodes of ulceration, only the family physician provided treatment. Patients with foot problems were older and had more cardiovascular disease, retinopathy, and absent peripheral pulses. CONCLUSIONS: The incidence of foot ulceration and lower limb amputation in type 2 diabetes is low; nevertheless, recurrence rates of ulceration and risk of amputation are high, with high mortality.     

Immediate stenting of iliofemoral occlusive lesions: a surgeon's early experiences.

PURPOSE: To report the early and midterm results of balloon angioplasty and immediate stenting of atherosclerotic iliofemoral lesions in an operating room setting. METHODS: Sixty-one patients (41 men, mean age 70 +/- 8 years, range 49 to 86) underwent balloon dilation and systematic stenting for 80 stenotic and occlusive lesions in the iliac (n = 47) and superficial femoral (n = 33) arteries in 72 limbs. One hundred two stents (63 VascuCoil, 33 Wallstent, and 6 miscellaneous) were placed. Patients were followed with serial duplex scans at 3-month intervals. RESULTS: Initial technical success by intention-to-treat was 96.2% (77/80) (iliac: 100%, femoral: 90.9% [30/33]). There were 9 (11.3%) procedure-related complications and no deaths. Initial success by anatomic, hemodynamic, and clinical limb criteria were 100%, 95%, and 94.4%, respectively. Thirty procedures were performed for limb salvage with a success rate of 86.7%. Six patients (7 limbs) died during follow-up of unrelated causes. Fifty-nine (81.9%) limbs were available for duplex follow-up over a mean 17.7 months (range 3 to 37). Cumulative patency rates were 87.3% at 2 years for iliac stents and 66.6% at 18 months for femoral stents with an overall 2-year patency rate of 76.3%. The only independent risk factors affecting late patency were the site of angioplasty, stent diameter, lesion grade, and the preoperative ankle-brachial index. Stents placed with a diameter < or = 5 mm and > 5 mm had 1-year patency rates of 51.0% and 97.6%, respectively (p = 0.004) CONCLUSIONS: Iliac and femoral angioplasty and immediate stenting have acceptable midterm patency rates. The patency of femoral stenting is inferior and is adversely affected by stents < or = 5 mm in diameter.     

Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer

The prognostic value of distal blood pressure measurements has been studied in 314 consecutive diabetic patients with foot ulcers. Systolic toe blood pressure was measured with a strain-gauge technique, and ankle pressure was measured with strain-gauge or Doppler techniques. Wound healing was defined as intact skin for at least 6 mo. One hundred ninety-seven patients healed primarily, 77 had amputations, and 40 died before healing had occurred. In 294 of 300 patients, it was possible to measure either ankle or toe pressure. Fourteen patients were not available for pressure measurements. Of these, 10 patients healed primarily, and 4 died before healing occurred. Both ankle and toe pressures were higher (P less than .001) among patients who healed without amputation compared with those who underwent amputation or died before healing. No differences were seen in ankle or toe pressure levels among those who had amputations or died. No patient healed primarily with an ankle pressure less than 40 mmHg. An upper limit above which amputation was not required could not be defined. Primary healing was achieved in 139 of 164 patients (85%) with a toe pressure level greater than 45 mmHg, whereas 43 of 117 patients (36%; P less than .001) healed without amputation when toe pressure was less than or equal to 45 mmHg. In conclusion, a combination of ankle and toe pressure measurements is a useful tool to predict primary healing in diabetic foot ulcers.     

Vascular surgery: possible adverse effect on extent of subsequent lower limb amputation.

The influence of previous vascular surgery on the level of amputation was examined retrospectively in 345 amputations (66 bilateral) in 279 patients with peripheral vascular disease. Seventy-two patients (38% diabetic) had previous vascular surgery on 74 limbs and 207 (65% diabetic) had no history of vascular surgery on 271 limbs. In patients with previous vascular surgery, above-knee amputation was done on 55% of limbs versus 71% of limbs in patients with no previous vascular surgery (P < .05), despite a lower incidence of diabetes in the former group. We conclude that although reconstructive vascular surgery is an effective treatment for vascular insufficiency, occasionally it not only fails, but is associated with an increased incidence of above-knee amputation.     

Health related quality of life and related factors in 539 persons with amputation of upper and lower limb

Purpose : Limb amputation is followed by an important rehabilitation process, especially when a prosthesis is involved. The objective of this study is to assess the nature of factors related to health related quality of life (HRQL) of persons with limb amputation.

Method : The Nottingham Health Profile (NHP) treated 1011 subjects with major amputation of one or several limbs. Correlations were sought in multivariate regression model analyses between the six categories of distress explored by the NHP and age, sex, cause and level of amputation and rehabilitation programme.

Results : Response rate was 53.3%. HRQL measured by the NHP was mostly impaired in the categories of physical disability, pain and energy level. Controlling for sex and age, young age at the time of amputation, traumatic origin and upper limb amputation were independently associated with better HRQL.

Conclusion : It is concluded that HRQL is largely related to factors which are inherent to the patient and the amputation.     

Residual Limbs of Amputees Are Significantly Cooler than Contralateral Intact Limbs

Objective: To test the hypothesis that distal residual limbs (DRLs) have significant vasomotor abnormalities. Design: Comparative surface temperature studies of DRLs using paired samples (DRL vs. similar site on intact contralateral limb). Subjects/Patients: Thirty‐six volunteer subjects with unilateral, upper or lower limb amputations were recruited and evaluated at a pain research center in an urban academic rehabilitation facility. Methods: Our main outcomes were subjects’ residual limb temperature as measured by quantitative infrared telethermography (qIRT), temperature strips, and examiner's palpation, compared with the contralateral limb. Results: The qIRT showed that the DRLs were significantly cooler than the corresponding area of the contralateral intact limbs (P < 0.01). The difference using temperature strips supported this finding (P < 0.05); while on physical examination, 39% of the residual limbs were perceived by the examiner as cooler than the corresponding unaffected limbs. Conclusions: DRLs as measured by qIRT were significantly cooler than the corresponding area of the contralateral intact limbs. A better understanding of these findings may be important in elucidating the pathophysiology of relevant clinical features such as a potential sympathetic component of postamputation pain. ?