Amputations in diabetic patients: a plea for footsparing surgery

Abstract

The authors observed a rather high rate of primary major amputation (above-knee or below-knee) performed for diabetic foot problems as well as an important revision rate for minor amputations (forefoot or toe) in diabetics. They reviewed their experience in order to compare it with more recent data from the literature, pleading for foot-sparing surgery. From 1993 to 1998, 186 amputations were performed on 146 diabetic patients. The cause of foot ulcers was neuropathy in 43 of them (51 episodes of diabetic foot problems) while in the remaining 103 patients (135 episodes of diabetic foot problems), diabetic macroangiopathy (absent ankle pulses) was on cause. For neuropathic foot problems, amputations were almost minor, resulting in a limb salvage rate of 90%. Only five of these patients (12%) had primary major limb amputation versus 43 of the dysvascular patients (42%). The reasons for major amputation by first intention were extensive tissue loss, intractable infection or non-reconstructible occlusive vessel disease, as judged by the surgeon. A foot-sparing surgery was attempted in 92 dysvascular cases. In only 44 of them, a preliminary vascular repair was performed. Twenty eight percent of the primary toe amputations and 24% of the forefoot amputations required secondary revision to a more proximal level. Minor amputations in case of diabetic neuropathy were characterized by a more favourable outcome: only 14% of the toe and 9% of the forefoot amputations failed. During follow-up, only 63% of the major amputations regained an autonomic walking capability with their prosthesis. Wound healing problems in diabetic foot are mainly due to infection and poor tissue perfusion. An aggressive control of the infection and distal revascularization of calf- or foot arteries, whenever possible, could improve the results of diabetic foot surgery. The poor functional recovery after major amputation (only 63% autonomic gait with limb prosthesis) argues for foot-sparing surgery whenever possible.