Expired CME Article

Local Biological Factors that Influence Amputations in Diabetic Patients

Authors: Mitchell S. Wachtel, MD, Eldo E. Frezza, MD, MBA, FACS

Abstract

Lower extremity amputation is one of the worst complications of diabetes, as it usually has a life expectancy that is below that of most cancers. Four local biologic factors—ulcer, ischemia, neuropathy, and infection—have been shown to be related to amputation. These factors interact with one another, such that neuropathy has been shown to cause ulcers and ischemia and to prevent the healing of ulcers. In addition, ischemia and neuropathy are independent risk factors for infection. More coordinated efforts are needed to create better grading schemes and therapeutic protocols.


Key Points


* Most studies cite ulceration as the single most important local biologic factor affecting the risk of amputation.


* Neuropathy is the most important cause of ulceration.


* Ischemia is an important risk factor for patients with ulcers to undergo amputations; it is the most important principle cause of amputation in some studies.


* Infection, universally accepted as a consequence of ulceration, is often the direct cause of amputation.

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References

1. Global Lower Extremity Amputation Study Group. Epidemiology of lower extremity amputations in centres in Europe, North America, and East Asia. Br J Surg 2000;87:328–337.
 
2. Apelqvist J, Ragnarson Tennvall G, Persson U, et al. Diabetic foot ulcers in a multi-disciplinary setting: an economic analysis of primary healing and healing with amputation. J Intern Med 1994;235:463–471.
 
3. Kanade RV, van Deursen RWM, Price P, et al. Risk of planta ulceration in diabetic patients with single-leg amputation. Clin Biomech 2006;21:306–313.
 
4. Aulivola B, Hile CH, Hamden AD, et al. Major lower extremity amputation: outcome of a modern series. Arch Surg 2004;139:395–399.
 
5. Abbas ZG, Archibald LK. Epidemiology of the diabetic foot in Africa. Med Sci Monit 2005;11:RA262–RA270.
 
6. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care 1990;13:513–521.
 
7. Hennis AJ, Fraser HS, Jonnalagadda R, et al. Explanations for the high risk of diabetes-related amputation in a Caribbean population of Black African descent and potential for prevention. Diabetes Care 2004;27:2636–2641.View Full Text | PubMed | CrossRef
 
8. History of foot ulcer among persons with diabetes: United States, 2000–2002. MMWR Morb Mortal Wkly Rep 2003;53: 1098–1102.
 
9. Marston WA, Davies SW, Armstrong B, et al. Natural history of limbs with arterial insufficiency and chronic ulceration treated without revascularization. J Vasc Surg 2006;44:108–114.
 
10. Murray HJ, Young MJ, Hollis S, et al. The association between callus formation, high pressures and neuropathy in diabetic foot ulceration. Diabet Med 1996;13:979–982.
 
11. Rich P, Hare A. Onychomycosis in a special patient population: focus on the diabetic. Int J Dermatol 1999;38(suppl 2):17–19.
 
12. Tseng CH. Prevalence of lower-extremity amputation among patients with diabetes mellitus: is height a factor? CMAJ 2006:174:319–323.
 
13. Wu SC, Crews RT, Armstrong DG. The pivotal role of offloading in the management of neuropathic foot ulceration. Curr Diab Rep 2005;5:423–429.
 
14. Gregg EW, Sorlie P, Paulose-Ram R, et al. Prevalence of lower-extremity disease in the U.S. adult population ≥40 years of age with and without diabetes. Diabetes Care 2004;27:1591–1597.
 
15. Carmona GA, Hoffmeyer P, Herrmann FR, et al. Major limb amputations in the elderly observed over ten years: the role of diabetes and peripheral arterial disease. Diabetes Metab 2005;31:449–454.
 
16. Shearer A, Scuffham P, Gordois A, et al. Predicted costs and outcomes from reduced vibration detection in people with diabetes in the US. Diabetes Care 2003;26:2305–2310.
 
17. Gamba MA, Gotlieb SL, Bergamaschi DP, et al. Lower extremity amputations in diabetic patients: a case-control study. Rev Saude Publica 2004;38:399–404.
 
18. Jeffocoate WJ, Lipsky BA. Controversies in diagnosing and managing osteomyelitis of the foot in diabetes. Clin Infect Dis 2004;39:S115–S122.
 
19. Lipsky BA, Berendt AR, Deery HG, et al. Diagnosis and treatment of diabetic foot infections. Plast Reconstr Surg 2006:117(7 suppl):212S–238S.
 
20. Adam DJ, Raptis S, Fitridge RA. Trends in the presentation and surgical management of the acute diabetic foot. Eur J Vasc Endovasc Surg 2006;31:151–156.
 
21. Lipsky BA. A report from the international consensus on diagnosing and treating the infected diabetic foot. Diabetes Metab Res Rev 2004;20 (Suppl 1):S68–S77.
 
22. Slater RA, Lazarovitch T, Boldur I, et al. Swab cultures accurately identify bacterial pathogens in diabetic wounds not involving bone. Diabet Med 2004;21:705–709.
 
23. Tentolouris N, Petrikkos G, Vallioanou N, et al. Prevalence of methicillin-resistant Staphylococcus aureus in infected and uninfected diabetic foot ulcers. Clin Microbiol Infect 2006;12:186–189.
 
24. Kessler L, Piemont Y, Ortega F, et al. Comparison of microbiological results of needle puncture vs superficial swab in infected diabetic foot ulcer with osteromyelitis. Diabet Med 2006;23:99–102.
 
25. Dang CN, Prasad YD, Boulton AJ, et al. Methicillin-resistant Staphylococcus aureus in the diabetic foot clinic: a worsening problem. Diabet Med 2003;20:159–161.
 
26. Shone A, Burnside J, Chipchase S, et al. Probing the validity of the probe-to-bone test in the diagnosis of osteomyelitis of the foot in diabetes. Diabetes Care 2006;29:945.
 
27. McGill M, Molyneaux L, Yue DK. Which diabetic patients should receive podiatry care? Int Med J2005;35:451–456.
 
28. Shearer A, Scuffham P, Gordois A, et al. Predicted costs and outcomes from reduced vibration detection in people with diabetes in the US. Diabetes Care 2003;26:2305–2310.
 
29. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005;293:217–228.
 
30. Pound N, Chipchase S, Treece K, et al. Ulcer-free survival following management of foot ulcers in diabetes. Diabet Med 2005;22:1306–1309.
 
31. Vijay V, Narasimham DVL, Seena R, et al. Clinical profile of diabetic foot infections in south India: a retrospective study. Diabet Med 2000;17:215–218.
 
32. Peters EJ, Lavery LA, Armstrong DG. Diabetic lower extremity infection: influence of physical, psychological, and social factors. J Diabetes Complications 2005;19:107–112.