By Mark Hinkes, DPM
In a recent article in the Philadelphia Inquirer, reporter Stacey Burling wrote, “Amputation rates among people with diabetes in the United States dropped for about 15 years, but recent reports issued by the U.S. Centers for Disease Control and Prevention highlight a disturbing trend: Amputation rates have been rising in people under 65 with diabetes since 2009. The trend was particularly strong for so-called minor amputations of toes and feet, which rose by 62% between 2009 and 2015. But major amputations — those done above or just below the knee — were also up by 29%.”
I can understand the rationale for the increasing numbers of minor amputations of digits. It tells me that we are identifying diabetic foot pathology in its early stages and taking a proactive stance by amputation of a toe or part of a toe, typically due to osteomyelitis. These procedures are usually done on an outpatient basis, using local anesthesia and IV sedation and are usually very successful. Patients treated in this manner usually do not need post-op antibiotics and/or wound care and go on to heal uneventfully. Digital amputations prevent worse pathology that may necessitate an amputation at a higher level.
Burling goes on to say, “Because many amputations could be prevented with a healthy lifestyle and good medical care, experts say this recent rise in the last-ditch procedure is worrisome. It may reflect serious shortcomings in a health system — a country — beset by inequalities that affect access to doctors as well as the support needed to make major lifestyle changes and follow doctors’ orders precisely.”
I am a bit more skeptical about why major amputations have risen. In most cases, the culprit causing major amputations is vascular disease or peripheral arterial disease (PAD), which results in critical limb ischemia. Approximately 8 to 12 million people in the US suffer from PAD, which can be caused by smoking, high blood pressure, atherosclerosis, and diabetes. When confronted with amputation, often times patients are not offered vascular testing such as Ankle-Brachial Index, and/or CT angiogram to identify the location of a stenosed or occluded artery in the trunk or legs; this represents a missed opportunity to re-
establish the circulation and prevent the amputation. However, when identified, this pathology is now being repaired everyday by a technique called endovascular surgery. This minimally invasive technique is used to re-establish circulation to the area of an ulcer or infection, thus promoting healing and obviating the need for an amputation. Every patient who is facing a major lower extremity amputation MUST have a pre-operative vascular evaluation to see if the circulation can be re-established and the amputation can be prevented.
Diabetes Education For Patients and Providers
Clearly there are multiple and complex contributing factors to amputations. Most patients lack the education about how diabetes affects their body and fail to understand the consequences of chronically elevated blood sugars on their feet and legs. The services of Diabetes Educators and Nutritionists should be used for all new patients diagnosed with diabetes and for return visits as necessary. Many patients also fail to practice preventive foot health behaviors. Patients need to be responsible for the care that only they can provide for themselves.
Moreover, many providers lack the knowledge or fail to follow the accepted standards for diabetic foot health when treating a diabetic foot ulcer or infection. They may also fail to refer “at risk” patients to appropriate members of the multi-disciplinary team for appropriate care. Access to care can be an issue as well as social demographics. Regardless of the reason, the current standard of care for diabetic foot pathology is REACTIVE, that is, we only provide care AFTER pathology is noted. This must change.
I believe the time has come for the standard of care of diabetic foot pathology to be PROACTIVE and that change in philosophy embraces PREVENTION.
Prevention in the area of diabetic foot health works. It prevents much patient suffering and reduces the cost of healthcare. However, the success of any prevention effort will be determined by patients, providers, and payers becoming knowledgeable about what can be done to prevent foot ulcers which are the triggers to infections, hospitalizations, and amputations and a willingness to embrace and support, and practice prevention.
A larger discussion concerning prevention and the current paradigm of fee-for-service medicine should be left for another day, but it should be noted, that in the current system, there is no motivation for providers to embrace and promote prevention as it may negatively affect their income. The Accountable Care Organization (ACO) model of medicine will eventually change the current paradigm and promote prevention as it will encourage providers to embrace prevention as a method to increase their income.
Prevention as Treatment
Prevention as a treatment modality has been recognized in our medical lexicon for years. Women have Pap smears and mammograms, men have digital prostate exams and PSA tests. Yearly eye exams and dental exams that include cleanings and x-rays are universally accepted.
Why has a yearly preventative foot exam for people with diabetes not been included as an accepted form of evaluating foot health? Why should patients be evaluated yearly for their foot health? The reasons are in the numbers:
- 85% of all patients with diabetes will develop a foot ulcer in their lifetime;
- 85% of all lower extremity amputations in the diabetic population are proceeded by a foot ulcer;
- 38% of all diabetic patients who undergo lower extremity amputations will lose the other leg in 3 years; and
- 75% of diabetic patients who undergo lower extremity amputations will not survive 5 years.
The mortality of a lower extremity amputation for patients with diabetes is greater than all forms of cancer combined, excluding lung and pancreatic cancers.
We can and should do better for our diabetic patients.
Here are the three non-invasive and painless tests that can easily be done by any provider to identify those patients with diabetes who are at risk for lower extremity amputation.
- Evaluate patient’s vascular status. Palpate pedal pulses and ask for history of smoking, claudication or rest pain in the legs. If there is any question about the patient’s circulatory status, a referral to a vascular surgeon is appropriate.
- Examine patient’s neurological status for loss of protective sensation for pain (LOPS) by a Monofilament test. [Monofilaments may be purchased from most medical supply distributors or at https://medicalmonofilament.com/]. If the patient has LOPS, he/she should be evaluated for special foot gear, insoles, socks, and perhaps moisturizing lotion, and receive ongoing foot care with a yearly foot exam. Patient education about this finding is CRITICAL so patients can protect themselves from a triggering event of foot trauma that can result in a foot ulcer.
- Evaluate patient’s feet for deformities of the bones/joints that include hallux abducto valgus or bunions; digital deformities, such as hammer toes and tailor’s bunions (and Charcot foot deformity); soft tissue lesions that include keratosis, corns, and callouses; and thick or deformed toenails. If any local foot pathology is noted, the patient should be referred to a podiatrist or foot care specialist trained in the diabetic foot.
While today’s numbers concerning lower extremity amputations may be disheartening, the good news is that the 30 million patients with diabetes and the 84 million patients who are considered pre-diabetic in the United States and the providers who treat them have the power to prevent the suffering and health care costs associated with lower extremity amputations by embracing and practicing proactive foot health behaviors and prevention.
Mark Hinkes, DPM, is board certified in foot surgery by the American Board of Foot and Ankle Surgery and in wound care by the American Professional Wound Care Association. He is the Chief Executive Officer of Healthy Feet, LLC, in Nashville, Tennessee. Dr. Hinkes, an active speaker and consultant, has 40 years of experience in private practice and working with the Veterans Affairs Medical System. This article has been adapted from its original Linked In version, “Lower Extremity Amputations Are Increasing, Again.”