Picking up the pieces

Amputation is typically viewed as the final event in the management of diabetic foot ulceration. Over the years, the reduction of amputations has been regarded as the primary aim of multidisciplinary foot care teams and, despite a realisation that amputation can be a positive outcome for a patient racked by sepsis and debilitated by chronic ulceration, amputation is often seen as a failure.

Among the four articles summarised in this quarter’s digest are three related to amputation. The first, by Fedorko et al, is another nail in the coffin of hyperbaric oxygen therapy (HBOT) for managing foot ulceration. In a well-conducted randomised trial, the authors concluded that HBOT does not offer any additional advantage to comprehensive wound care in reducing the indication for amputation or facilitating wound healing in people with chronic diabetic foot ulceration.

The next two articles deal with the aftermath of amputation. Davie-Smith and colleagues used an amputation rehabilitation database to look at outcomes following major amputation in people with and without diabetes in Scotland. They confirmed that people with diabetes account for nearly half of all the major amputations performed, despite comprising only 4% of the Scottish population. In addition, people with diabetes were younger at amputation and were more likely to have a below-knee amputation. Despite this, prosthesis fitting rates were low in both groups, with under 40% of people receiving a prosthesis. We can expect 60% of our patients with a major amputation to be wheelchair-reliant for the rest of their lives.

As Wanivenhaus and colleagues report, even if initially amputated at the transtibial (below-knee) level, up to 25% of people with diabetes may require revision to more proximal levels within the year. Indeed, the authors suggest that primary selection of a more proximal level of amputation might actually be better in the long run, despite the negative impact on limb fitting as a result.

Sadly, as Walsh et al report, the increased mortality rate after foot ulceration – in this case, 42.2% at 5 years – persists. We are still no closer to preventing this toll in the wider diabetes foot community than we were 8 years ago (Young et al, 2008).

To read the article summaries, please download the PDF