Lower extremity amputation (LEA) is a life changing anddevastating complication of diabetes. For patients withdiabetes it occurs 15 times more commonly than in people without diabetes. Diabetes is now present in nearly50% of all patients undergoing LEA1 in western society. Inthe UK, between 0.5% and 1.3% of all patients with diabetes have undergone LEA,2,3 but worldwide the inci-dence is very variable and may be as high as 7%.4 In themajority of cases foot ulcers are a precursor of LEA. It isestimated that 5% of people with diabetes have ever hada foot ulcer2,4 and around 1.4% of them have a foot ulcerat any one time,4 and that one in six people with diabeteswill have a foot ulcer at some time in their life.

LEA has a devastating impact on a patient’s quality oflife. LEA diminishes mobility and can prevent a patientdriving, being able to work and socialising, with conse-quential effects on low mood and functional capacity.Often LEA could have been prevented, thus avoidingthese consequences. Diabetes UK has recently high-lighted the high rates of amputations due to diabetes inthe UK, and that 100 patients from a diabetes populationof 2.3 million are undergoing amputation each week.5 Alarge number of these amputations are potentially avoid-able. The hope is that improved foot health care mayreduce the rate of amputation, but what is the evidence?

Changes in amputation ratesVarious studies have been reported showing changes in amputation rates. Encouragingly, these generally identify a decrease in amputation rates from population-based studies. Although this may reflect a lack of report-ing of negative studies, improvements have been shownacross a number of different health care services,although mainly in Europe. Baseline rates of amputa-tions for the 1990s are remarkably consistent at around500–550 per 100 000 patients with diabetes.1,6–8 Rateshave been reported to decline to 363 per 100 000 ofpatients with diabetes in the Netherlands,6 around 300 inGermany and Scotland (Krishnan et al.8 and local data),and 160/170 in England,1,8 whilst significant declines inamputations have also been reported in Sweden,9Denmark,10 Spain,11 and Finland.12

The incidence of diabetes-related amputations canalso be reported as the rate per 100 000 of the generalpopulation. Some people prefer this, as it avoids difficul-ties about ascertaining data on the number of patientswith diabetes. However, this will underestimate the success of many programmes as the number of patientswith diabetes is doubling at least every 10 years. Despitethis, some studies have still shown a decrease in amputa-tions using this approach, with decreases from 19.1 to9.4,9 from 27.2 to 6.9,10 and from 7.4 to 2.88 per 100 000of the general population.

As the number of patients with diabetes increases,many patients will have a short duration of diabetes,which may skew the results of changing amputation ratesin a falsely positive direction. However, we have data show-ing a reduction in major amputation rates even after

correcting for diabetes duration, decreasing from 512 to288 per 100 000 people with diabetes.

Many studies show that the main improvements aredue to reductions in the rate of major amputation, whichinclude all amputations above the ankle.1,8,9 The samestudies demonstrate very little change in the rates ofminor amputation, which include anything distal to theankle, and in the majority of cases are toe or ray exci-sions. Such minor amputations are often judged to beappropriate interventions, as they can prevent subse-quent major amputations. Thus, in summary, thereappears to be a decline in the rate of amputations forpatients with diabetes, which is due to a reduction innumbers of major amputations.

Caveats on interpretation of amputation dataMany of these reports come from centres of excellence,and may reflect sporadic and isolated reductions inamputations. Indeed, one study demonstrates that, evenin centres of excellence, amputation rates can start toincrease again if necessary clinical resources are removedfrom the diabetes foot-care team (Krishnan et al.8 andpersonal communication). However, the Dutch study ispossibly one of the only national data sets to demonstratewidespread improvements in amputations6 which mayindicate that the improvements are more than sporadic.In addition, although not established as an epidemiologyresearch project, the Scottish Diabetes Survey has showna reduction in prevalent amputations across Scotlandfrom 0.8% in 2003 to 0.4% in 2006.2

Although all clinicians are keen to avoid amputation,an amputation is not necessarily the worst outcome for apatient. Making an early decision to amputate can be bestfor the patient, if it is thought to be an inevitable out-come. It may well be preferable to allowing a patient tocontinue with a non-healing ulcer. In such a circum-stance, amputation can improve the patient’s quality oflife, improve mobility and decrease dependency onhealth care professionals in the longer term. As a conse-quence, interpreting data on amputations needs to donewith insight given this proviso.

Survival rates for patients with diabetes are increas-ing.13,14 As patients with diabetes live longer, and have diabetes for longer, they will be at increased risk of dia-betic foot problems. It is thus conceivable that there willbe an increase in amputations as patients live longer.However, the hope is that patients’ general health willimprove as their survival increases, but only time will tell!

Amputation preventionWhat are the key elements resulting in a decrease inamputations? Unfortunately, the evidence addressing thisissue is weak.

Development of multidisciplinary foot clinics(MDFCs) has been associated with improved outcomesfor patients with diabetic foot ulcers.9,15,16 Many of thestudies, described above, demonstrating reductions inamputation rates have attributed this to the existence or

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development of MDFCs. The key elements of an MDFCappear to be a specialist podiatrist and orthotist, with a dedicated diabetologist, who has rapid access to a vascular radiologist, a vascular surgeon and an ortho-paedic surgeon when required.

For patients with neuropathic foot ulcers, there isgood evidence that total contact casting is beneficial forhealing,17 which should reduce amputations. However, aremovable cast walker, made irremovable, appears to beas effective at healing ulcers.18

Although purely neuropathic ulcers can lead ontoLEA, the neuro-ischaemic foot ulcer is a greater chal-lenge to achieve healing and prevent amputations.Arteriopathy in the patient with diabetes is different fromstandard peripheral vascular disease. In patients with dia-betes, arterial disease tends to occur more in small distalvessels, rather than larger proximal vessels. Diseased distal vessels mean that bypass surgery is frequently notpossible because there are no adequate distal arteries toanastamose. Also, angioplasty is more difficult in smallerperipheral vessels as distal vessels are more likely to rupture and distal embolisation is a greater risk.

However, small improvements in arterial flow maymake a big clinical difference. In a recent study, patientswho had undergone revascularisation did end up withfewer major amputations than those who were not revascularised.19 However, this was an observational study,and there may have been bias in patient allocation.Additionally, in the small Danish study, reduced amputa-tions were associated with increased vascular interven-tions.10 However, the reduction in amputation rates acrossthe Netherlands was associated with no change in rates ofvascular interventions.6 Although there are clearly someindividual patients who benefit from vascular interven-tion, the role of surgical vascular intervention in prevent-ing amputations overall in diabetes remains controversial.

Of increasing interest is the role of treating modifiablecardiovascular risk factors to prevent amputations. The UKProspective Diabetes Study demonstrated that tight bloodpressure and glycaemic control showed a non-significanttrend towards decreased amputation with a relative risk of 0.5120 and 0.6121 respectively. Canavan et al. showed anincreasing use of statins (5% to 20%), ACE inhibitors(15% to 38%) and aspirin (22% to 33%) during the timeperiod that they demonstrated lowered amputations.1Locally, we have shown a decrease in mean blood pressure(140/79mmHg to 137/75mmHg), HbA1c (8.1% to 7.5%)and serum cholesterol concentrations (5.0mmol/L to4.4mmol/L) across the diabetes population at a time whenamputations reduced.

The MDFC may be the central component of organ-ised diabetes foot care, such that patients with diabetes inthe community can gain rapid access to specialised serv-ices. Thus, organisation of community foot care and goodcommunication links with the centre may be important forquality foot care and amputation prevention.

Amputations are usually preceded by foot ulceration.Diabetic foot screening programmes have been devel-oped22–24 which integrate a number of known risk fac-tors,3,22 and have been demonstrated to successfully iden-tify patients at risk of foot ulceration in day-to-day clinical

settings.23,24 Lack of adequate health care resources is aproblem in most countries and is likely to get worse withthe current epidemic of diabetes. Identification of patientsat greatest risk of foot problems allows appropriate treat-ments to be directed towards those at greatest need.

Simple education programmes have been shown toprevent amputations in patients with diabetes,25 but thegeneralisability and sustainability of such programmesremain untested. Orthotic interventions26,27 have beenshown to reduce the rates of foot ulceration and,although it is likely that this will reduce amputation rates,this has not formally been demonstrated. One study of 70patients with diabetes demonstrated a reduction in majoramputations from 33% to 9% with the use of hyperbaricoxygen in patients with neuro-ischaemic foot ulcers.28

Further research is required to identify which treat-ments are most effective at reducing amputations.

Survival after amputationPatients with diabetes, who undergo major LEA, have atwo-year median mortality of up to 50%.29–32 After onemajor LEA, patients with diabetes are more likely toundergo a further amputation, and are more likely to suffer cardiac failure, than people without diabetes whohave had an LEA.29 Amputation is frequently a surrogatemarker of vascular disease.

In a recent study, staff who were providing routinefoot-ulcer care within an MDFC also focused on optimalmanagement of glycaemic control, blood pressure anddyslipidaemia, and promoting the use of ACE inhibitors.They demonstrated a five-year mortality rate decreasingfrom 48% to 27%.33 Attention to treating cardiovascularrisk factors appears to prolong survival in this group of patients.

SummaryThere are some encouraging data that, in areas wherediabetes foot services are well organised and integrated,the rate of amputations may be declining for patientswith diabetes. Although there is some evidence ofimprovement, a lot more can, and needs to be done asmany amputations are avoidable. Best practice needs tobe shared worldwide. The Scottish Government hasinvested in a ‘Foot Action Group’ and a two-year DiabetesNational Foot Co-ordinator with the aim to improve footcare in Scotland. The Scottish Foot Action Group is work-ing with Foot in Diabetes UK (FDUK) and works withDiabetes UK on various projects. These latter groups arealso working with the Joint British Diabetes SocietiesInpatient Care Working Group to provide guidance foracute foot problems. In addition, there are various initia-tives being undertaken across the rest of Europe andbeyond. Hopefully, all this should help to improve out-comes for patients with diabetes who have foot problemsin the future.

Graham P Leese, MD, FRCP, FRCPE, Consultant inDiabetes, Ninewells Hospital, Dundee, UK, andChairman of the Scottish Diabetes Foot Action GroupChristopher J Schofield, MB ChB, MRCP, Registrar inDiabetes, Ninewells Hospital, Dundee, UK

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CONFERENCE NOTICE

Association of British Clinical Diabetologists Autumn Meeting27–28 November 2008, Hotel Russell, London

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