Lower Extremity Amputation in Diabetic Patients

Abstract

One hundred and seventy-eight lower extremity amputations performed on 103 diabetic patients were reviewed. Although the healing rate for the above-the-knee amputation was higher, the probability of prosthetic use and ambulation was greater with the mid-leg amputation, particularly if the patient required bilateral amputation. Late breakdown of the mid-leg stump, once healing had occurred, was not a significant problem. We feel that the proper amputation level is best determined by the skin temperature and appearance at the proposed amputation site rather than rigid reliance on the presence of pulses, oscillometry, or arteriography and that every effort should be directed to retaining a functioning knee. DIABETES J9: 189-95, March, 1970. The principal reason for lower extremity amputation is undoubtedly ischemia, frequently associated with diabetes. Diabetic amputees pose particular problems with respect to wound healing, associated disability, survival, and potential functional attainment. As a result, for many years the popular philosophy has been that the first amputation in a diabetic should be the last. The present study was undertaken in part to evaluate the validity of this philosophy. Federal regulations requiring maximum rehabilitation of hospitalized patients, uninhibited by monetary considerations, provide an excellent opportunity to study healing, durability, and functional results in a series of patients. MATERIALThe series totaled 103 diabetic patients on whom 178 amputations were performed from 1952 to 1965. The surgery was performed by the resident staff under the supervision of many different attending surgeons. All of the patients were -male, reflecting the characteristic From the Orthopaedic Service-Bronx Veterans Administra-

Diabetic amputees in Singapore.

“…The range varies from one week to thirty-two years. These data are comparable to those reported by investigators in the Western na tions5, 16,18,21) The principal reason for lower extremity amputation is undoubtedly ischae mia. Although neuropathy and susceptibility to infection contribute to the high rate of gangrene in diabetics, vascular disease is the major factor.…”

“…Peripheral vascular disease accounted for 49-86% of cases. In the Western world, diabetes accounts for about 50% of amputations of the lower extremity because of gangrene14, 15,16). In the present study, diabetes accounts for 59.2% of the causes for amputations in the Singapore General Hospital.…”

“…Others have reported similar findings5, 16,18,20) The diabetics, as a group, had their amputation about ten years earlier than the nondiabetic group who had amputation because of atherosclerosis. Like others, we report that amputation is uncommon in diabetics under forty years.…”

Factores fisiopatológicos y metas terapéuticas perioperatorias que influyen en procedimientos quirúrgicos reconstructivos mediante colgajos en pacientes con Diabetes Mellitus

“…La tasa de mortalidad a los cinco años posterior a una amputación mayor puede alcanzar hasta el 78% 14,20 , y la incidencia de una segunda amputación de la extremidad contralateral se aproxima a la mitad de los casos dentro de dos años siguientes 21 . Por lo anterior, se han realizado esfuerzos en mejorar las técnicas y consideraciones quirúrgicas, dado que es otra de las variables que pueden influir en los resultados, utilizando aquellas que se han asociado a mayores tasas de éxito, como las utilizadas en el estudio realizado por Kallio y colaboradores, con una muestra de 63 pacientes diabéticos con lesiones en pie y realizando un seguimiento a 1,5 y 10 años 22 , en el que se dio cobertura realizando transferencia de colgajos libres con una excelente tasa de supervivencia libre de amputación del 90% a largo plazo, siempre y cuando este indemne la arteria encargada del aporte vascular en dicha zona.…”

Prevention and Treatment of Ulcerations of the Foot in Unilaterally Amputated Diabetic Patients

“…In the diabetic patient with unilateral amputation of the lower extremity the prognosis for the remaining extremity is poor (Goldner 1960, Smith & Casingal 1969, Viskum 1969, Ebskov & Josephsen 1980) and the mortality is high (Smith 1956, Whitehouse et al 1968, Ecker & Jacobs 1970, Editorial 1972 1980). In the unilaterally amputated diabetic the walking pattern will often change and the remaining foot almost invariably becomes deformed.…”