April 2018

When considering amputation, consider the whole patient

It is likely that someone close to you has faced a major health decision. After the choices and medical advice have been considered, a very personal factor came into play, and the words were spoken: “I don’t want to be a burden.”

This situation often arises when a patient with diabetes is faced with a decision regarding limb salvage or amputation. Often, the decision is clear, as with ischemic limbs that are unsuitable for revascularization, or necrotizing fasciitis is present. The choice is less clear, however, in cases in which the outcome from limb-sparing partial foot amputation is uncertain. Although major amputation is associated with higher mortality and lower quality of life (QoL), we have seen minor amputations result in transfer lesions, and limb salvage often involves further procedures and is associated with high rates of reulceration and reamputa­tion.1-3 This is why we should listen when the patient says, “I don’t want to be a burden.”

As described in the article “Limb salvage vs amputation in the diabetic foot—the kindest cut,” on page XX, our decisions typically take into account clinical factors such as vascular status, infection, and previous amputations. Yet we often fail to adequately consider the patient’s mindset, ability to provide self-care, and perhaps most relevant, their QoL. Importantly, depression affects many patients with diabetes, and many patients with depression have some degree of functional impairment. Cognitive deterioration also may occur in patients who have diabetes, and a global cognitive deficit is more than 3 times as likely following amputation.4 Moreover, episodic memory loss is 4 times more likely after amputation and nearly 10 times more likely with microvascular diabetic foot complications.4 These cognitive deficits negatively affect adherence to foot care, and also decrease mobility and independence.5 A vicious cycle of depression and immobility can ensue, leading to nonhealing and recurrent ulcers.6,7 In such situations, it is QoL that cannot be saved.

Thus, our decisions regarding limb salvage and amputation must account not only for the standard clinical factors, but also the patient’s mental status, access to care, and family and community support. Which option will result in greater mobility, activity, and independence for the patient?  For one patient, that may be limb salvage, such as a transmetatarsal amputation rather than multiple digital amputations. In another patient, an appropriate definitive procedure may be major amputation, with the goal of improving QoL over a shortened life expectancy. We clinicians must also bear in mind that a good prosthesis following a below-knee amputation can help move the patient beyond the acute process. The shorter recovery period following a more definitive amputation also may reduce the number of subsequent surgeries, admissions, and outpatient provider visits.

Because physical QoL parameters positively correlate with overall QoL, and considering morbidity and mortality associated with procedures, limb salvage is preferred when a definitive procedure can return the patient to mobility and independence. It can break the vicious cycle, yet is not always the best choice for the patient. When limb salvage may require multiple surgeries, an extended convalescent period, and potential deterioration in behavioral health and QoL, it is time to consider minor or major amputation.

The integration of a behavioral health specialist and a prosthetist to the care team can be helpful in determining when limb salvage is best for the patient. This added clinical dimension can better assess a patient’s wishes, prior functional level, and community support, thus providing more personalized care, including choice of a prosthetic based on the patient’s functional needs rather than degree of amputation. Doing so may help us optimize the patient’s ability to re-establish mobility and independence, and be a burden to no one.

Dr. Labovitz is professor and assistant dean of clinical education and medical director of the Foot and Ankle Center at Western University of Health Sciences College of Podiatric Medicine in Pomona, California.

REFERENCES
  1. Yue-Jie Chu, Li XW, Wang PH, et al. Clinical outcomes of toe amputation in patients with Type 2 diabetes in Tianjin, China. Int Wound J. 2016;13:175-181.
  2. Borkosky SL, Roukis TS. Incidence of re-amputation following partial first ray amputation associated with diabetes mellitus and peripheral sensory neuropathy: a systematic review. Diabetic Foot Ankle. 2012;3:12169. Doi 10.3402/ dfa.v3i0.12169
  3. Thorud J, Jupiter DJ, Lorenza J, et al. Reoperation and reamputation after transmetatarsal amputation: A systematic review and meta-analysis. J Foot Ankle Surg. 2016;55:1007-1012.
  4. Marseglia A, Weili X, Rizzuto D, et al. Cognitive functioning among patients with diabetic foot. J Diabetes Complications. 2014;28:863-868.
  5. Tseng CL, Sambamoorthu U, Helmer D, et al. The association between mental health functioning and nontraumatic lower extremity amputations in veterans with diabetes. Gen Hosp Psych­i­atry. 2007;29:537-546.
  6. Williams LH, Miller DR, Fincke G, et al. Depression and incident lower limb amputation in veterans with diabetes. J Diabetes Complications. 2011;25:175-182.
  7. Monami M, Longo R, Desideri CM, et al. The diabetic person beyond a foot ulcer: Healing, recurrence and depressive symptoms. J Am Pod Med Assoc. 2008;98:130-146.
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