February 2012

Out on a limb: Amputation ups & downs

By Jordana Bieze Foster, Editor

Lower extremity practitioners who treat patients with diabetes are finally receiving their 15 minutes of fame. Enjoy it while it lasts.

The Centers for Disease Control and Prevention (CDC) finding that nontraumatic lower extremity amputation (NLEA) rates in patients with diabetes decreased by 67% between 1996 and 2008 (see “CDC reports dramatic 12-year drop in diabetic lower limb amputation”) is unquestionably good news.

There’s also no question that lower extremity practitioners deserve a lot of the credit for this achievement. The CDC findings can’t specify reasons for the decline, but you and I both know what’s involved in amputation prevention. Whether by revascularizing an ischemic limb, coaxing a wound into granulation, offloading areas of elevated plantar pressure, promoting the benefits of the Therapeutic Shoe Bill, or
convincing a patient to actually look at his or her feet on a regular basis—you’ve made a difference.

So go ahead and celebrate. You deserve it. But don’t overdo it on the champagne, because there’s still a lot of work left to be done.

Looking past the happy headlines and spirited sound bites, a number of details in the CDC report are cause for concern. Age-adjusted NLEA rates in patients with diabetes may have declined dramatically, but they are still eight times higher in the diabetic population than in nondiabetic patients. Amputation rates are disproportionately high in older patients and in blacks—and the CDC didn’t even look at Hispanic patients as a separate demographic subgroup. Their database also didn’t include Veterans Affairs patients or nursing home patients.

The most sobering of the cautionary statements in the report, however, is the authors’ reminder that the incidence of diabetes is soaring at a rate that could make it next to impossible for amputation prevention efforts to keep up. CDC data for 33 states published in 2008 indicated that the age-adjusted incidence of diabetes increased by 90% from 1995-1997 to 2005-2007. That makes a 67% improvement in amputation rates seem a little less impressive, doesn’t it?

In the current report, the authors warn:

…increased incidence may have resulted in a greater number of individuals with milder disease, detected earlier in the disease process, who have not had diabetes long enough to develop complications. Once these patients with new-onset, milder disease have had diabetes long enough, it is possible that the encouraging trends in diabetes-related NLEA will reverse.

The good news is that individuals with milder disease and no complications are those in whom preventive efforts like foot health education are most likely to be successful. Unfortunately, too many people still aren’t aware of the most basic foot care information. A New York City study (see “Foot-shoe mismatches leave patients at risk”) indicates that one-third of at-risk individuals may be wearing shoes that are at least one size too big or too small—which could easily send a patient with diabetic neuropathy on the slippery slope to amputation.

Amputation prevention efforts are working. The challenge going forward is to make sure they’re working for everyone.

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