Title: Risk of Reamputation in Diabetic Patients Stratified by Limb and Level of Amputation
Authors: Izumi Y, Satterfield K, Lee S, Harkless L
Source: Diabetes Care, Volume 29, Number 3, March 2006
PODIATRIC RELEVANCE:
Unfortunately, foot amputations in diabetic patients are not an uncommon scenario. In fact, although the recognition, awareness, and treatment of diabetic wounds and complications has advanced significantly over the years, the number of amputations is still substantial. In this study, the aim was to illustrate the difference between reamputation risks for ipsilateral and contralateral limbs, and stratify the risk of reamputation by the original level of amputation. This could not only provide us with useful information as practitioners, in an attempt to prevent some of these future reampuations, but also to inform our patients of the severity and possible associated sequela.
METHODS:
This was a retrospective cohort study consisting of 277 diabetic patients with a first lower-extremity amputation performed between 1993 and 1997 at University Hospital in San Antonio, Texas. Subjects were divided into 4 groups according to the level of their original amputation: toe, ray, midfoot (TMA, LisFranc, Chopart) or major (Syme, transtibial, transfemoral, hip disarticulation). The median observational period was 5.2 years after the original amputation. Efforts were made to identify the vascular status of each patient, but no routine record of vascular studies was found before 1995. Therefore, only patients with a history of lower-extremity bypass surgery or those with an ICD code indicating Peripheral Arterial Disease were noted as having PAD. The cumulative reamputation rates for each limb and level were calculated from the cumulative incidence of reamputation at 1, 3, and 5 years.
RESULTS:
Ray amputations were the most frequent type of first LEA (41%), followed by major (23%), toe (22%), and midfoot (14%) amputations. Patients who had a major amputation as their first amputation were significantly older than those who had a midfoot or ray amputation. PAD was more common in toe and major amputations than in ray or midfoot amputations. By the end of the study period, 34% of the subjects had deceased. Those with major amputations were more likely than any other group to be deceased. The overall reamputation rates for all subjects at 1, 3, and 5 years were 27%, 48%, 61%, respectively. The rates for ipsilateral amputations at each level at 1, 3, and 5 years were as follows: toe: 23%, 40%, 52%; ray: 29%, 41%, 50%; midfoot: 19%, 33%, 43%; major: 5%, 12%, 13%. The rates for contralateral amputations for each level at 1, 3, and 5 years were as follows: toe: 3%, 19%, 29%; ray: 9%, 22%, 29%; midfoot: 9%, 18%, 33%; major: 12%, 44%, 53%. The major group had a higher reamputation risk to the contraleral limb than did the toe and ray amputation groups.
Limitations of the study include, the fact that neorological and vascular status are crucial variables in diabetic patients, and these were not accurately recorded.
COMMENTS:
Although there are a lot of statistics presented in this article, which can be difficult to follow, the major trends can easily be identified. The results show that once a diabetic patient has an initial amputation, there is a significant risk of reamputation. Furthermore, ipsilateral limbs had a significantly higher reamputation rate than contralateral limbs, especially in the first 6 months. Also, patients with more distal amputations had higher reamputation rates to the ipsilateral limb, than more proximal ones. Not to be ignored, is the fact that patients with major limb amputations have a significant mortality rate within the first 5 years, too. These statistics can not only help us inform our patients of the devastating consequences of an amputation, but also stress the importance of preventing the initial amputation.
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Disclaimer:
Scientific Abstract Monthly postings are submitted by podiatric surgical residents. The ideas presented are not the opinions of the American College of Foot and Ankle Surgeons (ACFAS), nor are they presented as facts. ACFAS presents this information without any warranty of any kind, expressed or implied, and is not liable for its accuracy nor for any loss or damage caused by the user's reliance on information obtained in these areas.