April 2012

Prevention pitfalls: Why amputation rates are still too high

In the moment: Diabetes

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By Jordana Bieze Foster

Essential to achieving the goal of prevent­ing amputation in patients with diabetes is recognizing barriers that stand in the way, according to a Swedish diabetic foot expert who spoke in March at the Diabetic Foot Global Conference (DFCon) in Los Angeles.

Barriers include vascular compromise and infection, both of which can easily be overlooked in patients with diabetic neuropathy because the classic symptom of pain is absent, said Jan Apelqvist, MD, PhD, senior consultant in the Department of Endocrinology at Skane University Hospital in Malmö, Sweden.

“Patients are actually very rational,” Apelqvist said. “They feel that if there is no pain, there is no problem. They don’t like to change, so they try to avoid the problem for as long as possible.”

He cited multiple studies suggesting a clear shift in the diabetic patient population, formerly characterized primarily by neuropathic foot ulcers but now more often by ulcers in feet that are not just neuropathic but also affected by varying degrees of limited vascular perfusion.

In the EURODIALE (European Study Group on Diabetes and the Lower Extremity) database, about half of the study population of more than 1000 patients with new diabetic foot ulcers also had peripheral arterial disease (PAD). A 2008 Diabetologia study based on EURODIALE data found healing rates were significantly lower in patients with PAD than those without, and that different factors predicted healing in the two groups. A 2009 Diabetologia study of 2511 patients from Apelqvist’s group found similar discrepancies in healing between neuropathic and neuroischemic ulcers.

“We have been so focused on classic clinical signs that we forget the risk related to perfusion,” Apelqvist said.

This means patients who could benefit from revascularization too often are not receiving it in a timely manner, he said. Research, including a 2011 Journal of Vascular Surgery study from the Malmö group, suggests percutaneous transluminal angioplasty and reconstructive vascular surgery significantly increase odds of diabetic foot ulcer healing without amputation.

“We know we have to go in much earlier,” Apelqvist said.

New guidelines from The International Working Group on the Diabetic Foot, published in the February issue of Diabetes Metabolism Research and Reviews, specifically address diagnosis and treatment of PAD in patients with diabetic foot ulcerations.

Similar challenges arise when neuropathic ulcers are complicated by infection: Timely intervention is critical, but diagnosis is often delayed because of the absence of pain.

“If you have a deep infection, you have to do surgery right away or you will lose the foot,” Apelqvist said.

In the EURODIALE database, 58% of patients with diabetic foot ulcers also presented with infection. Infection was a significant predictor of nonhealing in EURODIALE patients with PAD only, but, in a 2011 Diabetes Medicine study, was found to be a predictor of minor amputation in the larger EURODIALE cohort.

Upon realizing that 90% of patients with deep foot infections were already being treated with antibiotics, Apelqvist’s group instituted a structured antibiotic program. Under the new strategy, 10% of patients with deep infections have undergone major amputation and 86% required surgery to achieve healing. Meanwhile, economic costs of treatment have decreased by 28%.

Ultimately, Apelqvist said, the barriers to amputation prevention come down to a failure to consider the whole patient.

“Usually we start with one treatment, and we don’t develop a systematic understanding of the patient in terms of a multi­organ disease,” he said. “What we need to do to save the patient is coordinate all of our efforts into one package.”


Prompers L, Schaper N, Apelqvist J, et al. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE study. Diabetologia 2008;51(5):747-755.

Gershater MA, Londahl M, Nyberg P, et al. Complexity of factors related to outcome of neuropathic and neuro­ischaemic/ischaemic diabetic foot ulcers: a cohort study. Diabetologia 2009;52(3):398-407.

Schaper NC, Andros G, Apelqvist J, et al. Specific guidelines for the diagnosis and treatment of peripheral arterial disease in a patient with diabetes and ulceration of the foot 2011. Diabetes Metab Res Rev 2012;28(Suppl 1):236-237.

Van Battum P, Schaper N, Prompers L, et al. Differences in minor amputation rate in diabetic foot disease throughout Europe are in part explained by differences in disease severity at pre­sentation. Diabet Med 2011;28(2):199-205.

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