AMPUTATIONS IN DIABETIC FOOT

PROF. RAMA KANT KING GEORGE MEDICAL UNIVERSITY LUCKNOW

Diabetes mellitus increases risk of amputation by 20-fold. Declining rate of foot amputations parallels decrease in hospitalizations for skin and soft tissue infections. This reflects better and effective outpatient care for diabetic foot ulcers and infections.

Do we waste time trying to save some feet ????? Should we be aiming for local minimal surgery at all costs, or is there a case for primary radical amputation? Technological advances and improvements in local treatments for diabetic foot disease place clinicians under ever increasing pressure to preserve the foot (Watkins PJ, 2003; Smith J, 2003).

These are real challenges for decision……

CHANGE YOUR PERCEPTION STILL THERE IS HOPE………… CHANGE YOUR PERCEPTION STILL THERE IS HOPE…………

Health-economic consequences of diabetic foot infections Result in huge costs for society and individual. Costs of antibiotics also substantial….. Total costs for topical treatment high. Total costs for healing of infected ulcers not requiring amputation - $17,500 Costs for lower-extremity amputations are above $30,000

Often a successful outcome is followed by a rapid recurrence necessitating further hospitalisation. Clinicians should always consider whether the best interests of the patient might be served by primary amputation or often prolonged, expensive and failure bound local aggressive surgical traetment ????

The aim of any treatment is to deliver a fully mobile patient back into the community.

Levels of lower extremity amputations

MAJOR AMPUTATION- Advantages No more surgery Shorter hospital stay Disadvantages Major procedure and risk Difficult & expensive rehabilitation Independence threatened

FOOT—REVISION-BELOW KNEE---REVISION—ABOVE KNEE---STILL NEEDS REVISION

NOW HEALED ABOVE KNEE AMPUTATION

Indications for primary BKA instead of local amputation Previous extensive hospitalisation Limited life expectancy Patient choice Age State of circulation Effect of failed distal bypass Failed conservative management.

We should aim to minimise the time spent in hospital as these patients are often towards the end of their lives…….

Approximately 50% of patients ended up with a BKA a very high proportion indeed…..

Major amputation should be considered as an option for every patient with diabetic foot disease.

EFFORTS TO RESTORE THIS FOOT TO NORMAL MOST PROBABLY WILL FAIL…… HE MAY BE BETTER OFF WITH AMPUTAION AND PROSTHESIS

50% of lower extremity amputations performed in the United States are due to diabetes. 9% foot, 31% lower leg, 30% above knee. Ipsilateral higher amputations occur in 22% of cases. Contralateral amputations 10% per year. After 5 years, amputees with diabetes have a 50% chance of bilateral amputation,

Number of operations Diabetes Toe BKA AKA 282 (67%) 110 (49%) 39 (18%)

MINOR AMPUTATION

Advantages Limb preserved Reduced anaesthetic risk Independence preserved Disadvantages Prolonged healing time Prolonged hospitalisation Prolonged re-mobilisation Risk of failure of healing Risk of further treatment

Decisive factors in type of treatment provided to patients.. They must participate

CENTRAL PLANTAR ABSCESS WITH OSTEOMYELITIS

TOE AMPUTATION

WRONG DECISION FOR LEVEL OF AMPUTATION

BILATERAL DEFORMED BUT WALKABLE FOOT

FUNCTIONAL BUT DEFORMED FOOT EVEN THIS IS MUCH BETTER THAN THE BEST PROSTHESIS… ….This is also a view

Patient choice Patients should always be offered three choices: No treatment Continued conservative management involving minor amputation Major amputation. Surprisingly, patients often choose the major amputation route.

Age Younger people adapt very well to BKA, but are likely to have better circulation and heal local amputations. However, young people are young enough to return with further problems. Elderly people are less likely to adapt well to major amputation, but are also less likely to have good circulation and the ability to heal locally within the foot.

State of circulation For local amputation in the foot to heal, the circulation must be adequate. In practice, this means at least one patent artery to ankle level.

Some patients may have been treated for months in hospital clinics without success. In patient with neuropathic foot even if healing is eventually achieved, there is a very high risk of new ulceration despite very careful attention to footwear Failed conservative treatment

Algorithm for management of Patients 38% of patients have a foot which is not salvageable and these patients should have a major amputation from the outset.

Circulation normal, foot is salvageable, and patient is young, then local amputation is an option. However, 19% will fail their local amputation and require major amputation.

What is life expectancy ? Previous treatment they have had Morphology of foot Circulation of foot. Mobility of patient Whether patient has a job and what it is ? What is the family situation ?

Transmetatarsal Amputation (TMA) Gangrene must be limited to the toes and should not involve the web space. Infection should be controlled. Preserves the attachment of the dorsiflexors and plantar flexors and their function. These amputations can be fitted with sole stiffeners and toe fillers with minor apparent loss of function during stance and walking on level surfaces.

Other Foot Amputations Lisfranc amputation at the tarso-metatarsal junction Chopart amputation is a midtarsal, talo- navicular, calcaneo-cuboid amputation. Only talus and calcaneus bones remain Pirogoff is a vertical calcaneal amputation (in this amputation, the lower articular surfaces of the tibia/fibula are sawn through) Boyd is a horizontal calcaneal amputation (all tarsals removed except calcaneus/talus)

Syme's Amputation Indications: Trauma above the foot, congenital anomalies, tumors, and deformities that necessitate amputation. Disadvantages: healthy plantar heel skin is necessary for weight bearing in this area. The patient also must have good perfusion in this area, thus making it a difficult procedure for the dysvascular patient.

Pros: Functionally, this procedure represents an excellent level of amputation because: It maintains the length of the limb preservation of the heel pad, excellent weight-bearing stump Immediate fitting of prosthesis is possible with excellent results Stump weight bearing is possible almost immediately after the procedure (~ within 24 hrs) Cons: cosmesis (bulbous, bulky residual limb); fitting for a prosthesis may be more difficult than for other amputation levels.

Trans-metatarsal amputation ready for a split- thickness skin graft.

Transmetatarsal amputation with a skin graft.

Trans- metatarsal amputation with a plantar flap. Primary closure by the plantar flap ideal due to vast arterial supply from the plantar artery.

MODIFIED SHOES AND AIDS FOR WALKING AND OFF LOADING…KEY TO SUCCESS

Partial Foot Amputations Small-toe amputations do not affect ambulation Usually require no replacement Partial foot prostheses are used to restore foot function Amputation of the great toe reduces push-off force, thus requiring a resilient toe filler and also a molded insole with arch support to maintain the alignment of the amputated foot.

Partial foot amputations involving the forefoot, such as ray resections and trans-metatarsal amputations, generally require only shoe fillers or shoe modifications. Will require stiff sole, the addition of a spring steel shank extending to the metatarsal heads, a rocker sole and/or padding of the tongue of the shoe to help hold the hind foot firmly in the shoe.

Transtarsal amputations As Chopart, Lisfranc, and Boyd will have better functional results if there is an active balanced dorsiflexion and plantar flexion with normal skin and heel pad present. The best prosthetic option for a hind foot amputation - use of a custom prosthetic foot with a self-suspending split socket

It should not be too difficult to determine break points at which effectiveness of treatment is cost effective, or even cost saving.

Conclusions Major amputation should be considered as an option for every patient with diabetic foot disease.

THANKS