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One of the major goals of our Limb Salvage and Wound Care program is to avoid amputation when we can—and our efforts and those of similar programs around the country are paying off. The Centers for Disease Control and Prevention reports a 65 percent decrease in diabetes-related amputations in the U.S. between 1998 and 2006.
But sometimes amputation is the best choice for a patient. This is particularly true when diabetic foot ulcers lead to multiple serious infections. Diabetes causes problems with sensation in the feet, which leaves patients susceptible to foot injuries that can go undetected long enough to become severely infected. These patients are in and out of the hospital constantly and sometimes face repeated surgeries. This cycle dramatically decreases their quality of life and disrupts their home, social and work lives.
Before we recommend amputation, we consider any other therapies that might work to treat a patient’s condition. In an effort to do this for more patients, we’ve created a special program to identify and provide proactive care for people at high risk for amputation.
LISTEN: Dr. Elmarsafi discusses diabetes-related amputation and risk reduction in the Medical Intel podcast.
How we identify people at high risk for amputation
We have a strong system of working closely with local primary care doctors. I regularly visit family medicine and internal medicine doctors to ensure that they know about our Limb Salvage and Wound Care program. Community doctors can refer their diabetic patients with foot complaints to us immediately, before a wound develops, so we can proactively manage their risks.
When we identify these patients early, we often can prevent wounds and neuropathy, or loss of nerve sensation in the feet, from developing. Neuropathy is one of the biggest risk factors for developing problems and infections in the feet that lead to amputation.
We tailor foot-care plans for high-risk patients based on several factors, including:
- Foot complaints
- Foot type
- Level of sensitivity in their feet
- How they walk
- How well their diabetes is controlled
These factors tell us how often a patient needs to be monitored for changes in their feet. We use a variety of methods to improve and maintain foot health, including general health coaching and even surgery to prevent recurring foot sores in certain patients.
Related reading: How negative-pressure wound therapy has changed diabetic foot care
When diabetes risks are addressed and managed early enough, we can avoid having to discuss amputation as a treatment option. Much of this depends on the patient’s ability and willingness to participate in their own care at home by following some basic self-care practices.
What patients can do to reduce their risk of amputation
I can’t emphasize enough the importance of checking the feet every day for redness or irritation. Whether a diabetic patient went jogging or simply walked around the house a bit, it’s important to examine the feet, because you might not feel a cut or blister if neuropathy has set in. These tiny injuries quickly can turn into serious infections if left untreated.
General good health also can reduce amputation risk. This includes keeping sugar levels under control and communicating regularly with the wound care team, primary care doctor and endocrinologist to improve overall health. If a wound does develop, we make sure the patient has the necessary dressings and medication, as well as training in how to use them.
What to expect if you do need an amputation
Diabetes-related amputation refers to many types of surgery, from removing part of a toe to removing a large portion of the leg, with the goal of saving a person’s life from complications of a wound or infection.
Regardless of the type of amputation a patient and doctor are considering, reasonable goal-setting should be an important part of the discussion. Each patient needs to understand how mobile they can expect to be after surgery. Healthier patients in their 20s to 50s who could walk before likely will be able to walk again after with a few months of rehabilitation and the use of prostheses, or artificial feet or legs.
Older patients and those who were sedentary before surgery tend to face greater challenges after amputation. However, focused physical rehabilitation and follow-up support can help patients overcome these barriers and more easily move from their bed or chair to the bathroom or kitchen.
In general, patients do well and can walk again for lower-extremity amputations at the level of the foot or toes. They tend to have the same level of balance as they had before surgery and can wear essentially the same shoes. Typically, the biggest issue they face is getting used to how the foot looks. Most patients find that they feel so much better after surgery that the aesthetic changes are worth it.
Making the choice to have an amputation
This change is a process, and each person goes through a different rate of acceptance. It’s not a decision to be taken lightly, and it’s important to seriously consider your doctor’s recommendations, even if you’re afraid of losing part of your foot or leg.
This was the situation I encountered with a patient I cared for during my residency. She’d had multiple foot infections due to diabetes and ultimately developed sepsis, a serious blood infection. Her doctors encouraged her to undergo a midfoot amputation, which is removal of the toes and the part of the foot just below them. She fought the recommendation until the surgeon told her she was going to die if she didn’t have the procedure. Finally, she decided to go through with it.
As soon as she came out of surgery, the patient already was feeling better. Over the next 12 hours, her health blossomed. She left the hospital within a few days, and when I saw her a couple weeks later in outpatient care, she was like a new person. The first thing she said was, “I wish I had taken the doctor’s advice a long time ago.”
Choosing to have an amputation can be an emotional journey. A wound care expert will not recommend amputation if there is another effective way to treat your condition. We want what’s best for you, and for some patients, amputation is the right choice.