A new meta-analysis suggests that reamputation rates following a primary amputation in people with diabetes remain unchanged over the course of two decades.
The authors of the systematic review, which was recently published by BMJ Open Diabetes Research & Care, assessed data from 22 studies with exclusive enrollment of patients with diabetes who had primary amputations.1 Liu and colleagues looked at contralateral and ipsilateral reamputations in 21,145 patients, and assessed the risk of contralateral reamputations in 1,129 patients. At one year, the reamputation rate for all contralateral and ipsilateral reamputations was 19 percent, according to Liu and colleagues. At five years, researchers noted the reamputation rate was 37.1 percent. The study authors indicated that these reamputation rates have not changed in over 20 years.
In the study, the authors suggested that a number of factors may contribute to the lack of improvement in reamputation rates, including “challenges selecting the optimal level of index amputation.”1
Christine Miller, DPM, PhD, FACCWS concurs that this can be “very challenging” with less ideally being more in terms of limb salvage. However, the use of indocyanine green (ICG) fluorescence angiography has been a beneficial tool in determining amputation level in her practice as it allows one to assess tissue perfusion and the potential for necrosis, according to Dr. Miller, the Medical Director of Wound Care and Limb Salvage at the University of Florida College of Medicine.
David G. Armstrong, DPM, MD, PhD, a co-author of the study, says there may not be an optimal amputation level per se as patients age and their function changes.
“The key thing is to optimize the function of the patient at the time that you’re seeing him or her, understanding that it is always in flux,” notes Dr. Armstrong, the President of the American Limb Preservation Society (ALPS). “That is why having a team of excellent physicians, surgeons, prosthetists, dietitians, physical therapists (PTs), occupational therapy (OT) and behavioral health among others is the way forward.”
Post-op follow-up and surveillance may be other target areas for improvement as the study authors say poor post-op wound healing and rehabilitation are other possible factors contributing to high reamputation rates.1 Dr. Armstrong says technological advances can provide viable preventive information on pedal velocity, temperature and pressure.
“There are many available tools now, ranging from accelerometers to dermal thermometers to in-device pressure sensors,” points out Dr. Armstrong, a Professor of Surgery at the Keck School of Medicine at the University of Southern California.
Dr. Miller says the majority of patients in her practice do not have health insurance so socioeconomic factors may hamper scheduling of follow-up visits.
“Ensuring follow up is difficult, particularly if patients have no permanent residence,” adds Dr. Miller, Chair Elect of the American College of Clinical Wound Specialists. “Ideally, regular follow up with our service as well as primary medicine for systemic diabetes management would likely yield the best outcomes.”
The study authors also point to post-op gait deviation from the primary amputation as a potential trigger for the recurrence of diabetic foot ulcers.1 Drs. Armstrong and Miller advocate working with physical therapists to help mitigate this risk factor.
“We have changed our ‘toe and flow’ clinic into ‘toe, flow and go’ by adding physical therapists as partners,” adds Dr. Armstrong, the Director of the Southwestern Academic Limb Salvage Alliance (SALSA).
“A multidisciplinary approach is always best. We work closely with physical therapists to address biomechanical issues,” points out Dr. Miller. “However, not being able to acquire appropriate offloading devices due to the socioeconomics of our patient population is a major obstacle.”
Recognizing that wound recurrence and reamputation remain common in high-risk patients with diabetes who have had a primary amputation, Drs. Armstrong and Miller strongly emphasize a proactive preventative approach to post-op care.
“Patients are in remission after an amputation just as they are in remission after a DFU,” acknowledges Dr. Armstrong. “The goal continues to be ulcer-free, hospital-free and activity-rich days.”
“Prevention and early detection/intervention in DFUs offer the greatest likelihood for long-term success,” concurs Dr. Miller.
- Liu R, Petersen BJ, Rothenberg GM, Armstrong DG. Lower extremity reamputation in people with diabetes: a systematic review and meta-analysis. BMJ Open Diab Res Care. 2021;9:e002325. doi:10.1136/bmjdrc-2021-002325.