Diabetic Foot Amputation: The Need for an Objective Assessment Tool

Raj Mani, PhD, FACA, AJ Krentz, MD, FRCP, CP Shearman, MS, FRCS


Wounds. 2003;15(7) 

In This Article

Abstract and Introduction

The diabetic patient is at increased risk of peripheral arterial disease that may lead to critical ischemia with subsequent sequelae for the legs and feet. Too frequently, surgical amputation is the only option for managing nonviable digits and feet. While it is desirable to prevent this state by risk factor management, patients will develop these complications. What is a satisfactory measure of tissue viability of the lower extremity in these patients?

Diabetic foot disease is a sequel of diabetes mellitus that is a growing problem worldwide. It is estimated that 221 million people will be affected with diabetes globally in 2010.[1] Patients with diabetes suffer blindness, kidney complications, and peripheral arterial disease.[2] Peripheral arterial disease is a significant risk factor for diabetic foot disease that may lead to critical limb ischemia, limb loss, and lower-extremity wounds in many patients.[2] Surgical management includes bypass grafting, angioplasty, wound debridement, and when inevitable, amputation.[3] The Saint Vincent declaration[4] called for a multidisciplinary team approach with an objective to reduce the amputation rate in diabetics by 50 percent; this target has not been achieved in the United Kingdom.

Typically, a patient may have critical ischemia of the lower limbs with digital gangrene, loss of diabetic control, and underlying complications of the heart and kidneys. Another patient may have significant loss of nerve function in the feet and nonhealing wounds in the plantar surfaces that are complicated by infection that has tracked to the deeper foot tissues. There could be bone and joint deformities in the foot serving to complicate the condition. Multiple organ disease may also complicate the patient's condition. In both instances, the viability of the foot must be evaluated in order to determine the best option for management. A surgical decision to amputate is based on assessment of the extent of necrotic digit/organ, the extent of tissue perfusion to sustain healing, and the general condition of the patient. The aim of this paper is to examine the objective measures of tissue viability available for clinical management.