Management of the Diabetic Foot: Preventing Amputation

Marvin E. Levin, MD

Disclosures

South Med J. 2002;95(1) 

In This Article

Introduction

Of the many complications of diabetes, amputation is the one most feared. This anxiety is valid in light of the fact that the number of lower extremity amputations performed on patients with diabetes is increasing annually in the United States. In 1979, the number of nontraumatic amputations in diabetic patients was 31,691. Despite efforts to reduce this number, it has gradually increased; by 1990, the number was 53,832. In 1996, the number had reached 85,530.[1,2] This number did not include approximately 3,000 amputations that occurred in Veterans Affairs hospitals.

Diabetes is the cause of 50% of all the nontraumatic amputations in the United States. This can be explained by the fact that the number of persons with diabetes is increasing rapidly, the diabetic population is aging, and a coding system enables the number of diabetic amputations to be accurately reported. Twenty-four percent of these amputations are of the toe, 5.8% are mid-foot, 38% are below the knee, and 21.4% are above the knee; the remaining 10% include the hip, pelvis, knee, and other sites.[3]

The loss of a lower extremity, or even part of a lower extremity, significantly impacts quality of life ( Table 1 ). Depression is common after amputation. Loss of a limb limits daily and leisure activities; it is difficult to play golf or tennis with a lower leg prosthesis. Worse still, loss of a limb frequently leads to early retirement and loss of income. In addition, "friends" often desert a person who has a disability.

Epidemiologic data indicate that most diabetic patients have foot problems after age 40 and that the incidence of these problems increases with age.[4] Amputation is more common in African Americans,[5] and there is a higher incidence of amputation in men than in women.[4,6]

Risk factors for lower extremity amputation vary from series to series. Most diabetic amputations, however, are due to peripheral arterial disease (PAD), peripheral neuropathy (PN), and infection. This triad is the harbinger of the final pathologic events, gangrene and amputation. The various pathways leading to amputation are noted in the Figure.[7]

Figure.

Pathogenesis of diabetic foot lesions. Adapted from: Levin ME: Pathogenesis and management of diabetic foot lesions. The Diabetic Foot. Levin ME, O'Neal LW, Bowker JH (eds). St. Louis, Mosby Year Book, 5th Ed, 1993 (Figure modified from Kerstein MD, White JW , eds. Alternatives to Open Vascular Surgery. Philadelphia, JP Lippincott Co, 1995.)

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