Limb Preservation and Why You Should Care

The mortality rates surrounding diabetic neuropathic foot ulcers, PAD and amputation are often compared to multiple forms of cancer, in part, to emphasize the gravity of the situation facing many diabetics.  While the diabetic population in the United States has reached an estimated 30 million, the CDC has estimated that the number of those afflicted with pre-diabetes adds an additional 70 million, while the American Diabetes Association estimates this number to be approximately 84 million.  Depending upon the source, this brings the total of both groups us to between 100-114 million.1,2

Advances in technology provided a temporary decline in amputation rates for the period between 2009 through 2015.  Nontraumatic lower extremity amputation rates declined by 43% for individuals between the age groups of 18-44 and 45 to 65, respectively, during that time.  Unfortunately, since 2015, the amputation rate has increased by over 50% among individuals in both groups.  The amputations include digital, trans-metatarsal, below and above knee.3

The events that lead to lower extremity amputation are often multiple and span over a significant time.  Regardless of the specifics surrounding each amputation, the loss of dignity to the patient is universal as are the ensuing associated issues.

Let’s examine then, at several key and varying reasons why lower extremity amputation is not a simple solution and often creates more problems for the patient. The goal here is solidifying your commitment to amputation prevention.

The Amputation Lottery

Statistics regarding lower extremity amputation are generally bleak.  Among the most disturbing pertains to the decision to amputate.  David Allie first presented data that revealed roughly 50% of non-traumatic lower extremity amputations performed in the United States are a first line of treatment.  What’s most disturbing is that these amputations are performed without any prior vascular testing, even something as simple as a cursory Doppler examination.   As shocking as this is to fully comprehend, the SAGE Group validated these findings.4,5,6,7,8

Where amputation is concerned in the USA, it is often based on subjective opinion versus objective findings.  Therefore, the chances of preserving a lower extremity in danger of amputation and the well being of the patient often rests in the hands of the provider managing the care.  If the provider is committed to lower extremity preservation, the patient has a better chance for a favorable outcome.Hence the term, “The Amputation Lottery” and all it implies.

Amputation rates among younger and middle-aged patients, including toe, foot, below and above knee have seen an increase between 2015 to present.  The increase in diabetes-related non-traumatic lower extremity amputation rates between 2009 and 2015 was driven by a 62% increase in the rate of minor amputations and a smaller, but also statistically significant, 29% increase in major NLEAs.

The increases in rates of total, major, and minor amputations were most pronounced in young (age 18–44 years) and middle-aged (age 45–64 years) adults and more pronounced in men than women. 3

From a purely financial perspective, the costs associated with amputation are greater compared to preserving a limb. 5%-10% of BK amputees die in the hospital. There is also a high rate of revision amputations, including 20% in BKAs and 12% in BKAs.   Additionally, 15%-20% AK die while hospitalized.  Endovascular mortality rates are between 1% and 3%.  One in-hospital death can cost $12,000 (2012 dollars).

All of these add to the total national bill for amputation, before you consider the adverse patient outcomes such as inability to walk (60%-80% never walk again with or without a prosthesis), depression, hospital readmissions for amputation related problems, and the necessity for long term care, etc.  Private insurance pays about 20% while Medicare and Medicaid pay 75% of the bill for PAD—in other words your tax dollars. No matter how you look at it whether from the viewpoint of the hospital, the economy or the patient, the costs of a major amputation are higher versus attempting to preserve a lower extremtiy!5,8

Conclusion:

Amputation is certainly warranted in cases where no other options remain, and the benefits of proceeding outweigh the reasons to attempt preservation.  That being stated, knowing who to consult with and the commitment of other members of the lower extremity preservation team should well established. 

Despite the discouraging tone of the statistics and information presented here, there is some encouraging news to consider.  

Ultimately, attempting to preserve an at-risk lower extremity is warranted and most often, it’s the right thing to do.

We have heard for some time now that the team approach to wound care and limb preservation are essential in everyday practice.  The emergence of endovascular technologies to restore or enhance perfusion to lower extremities with significant PAD has created a paradigm shift in thinking and approach to limb preservation.  “Toe and flow” has become as much a part of the lexicon and is synonymous with amputation prevention.

To further emphasize this concept and to end things on a positive note, a study at Duke University found that patients who are seen by a Podiatrist have a decreased chance of amputation.  Patients with severe lower extremity complications who only saw a podiatrist experienced a lower risk of amputation compared with patients who did not see a podiatrist.  Lastly, the multidisciplinary team approach that includes Podiatrists most effectively prevents complications from diabetes and reduces risks of amputations.9

Never doubt the difference you make!

  1. CDC.  National Diabetes Statistics Report, 2017. Estimates of Diabetes and Its Burden in the United States  http://www.cdc.gov/diabetes
  2. American Diabetes Association. The Staggering Costs of Diabetes. Diabetes.org/congress. 2018
  3. Geiss LS, Yanfeng L, et al.Diabetes Care 2019 Jan; 42(1): 50-54
  4. Allie, David E, MD. New Advances in Critical Limb Ischemia. “The Staggering Clinical and Economic Cost of CLI” Lecture. New Cardio Vascular Horizons. CLI Summit. Miami, FL. 2006.
  5.  Allie, David E, MD. Podiatry Today. Vol. 20. July 2007. “Emerging Vascular Approaches for Healing Diabetic Foot Ulcers”. 44-54.
  6. Allie DE, Hebert CJ, Lirtzman MD, et al. Critical limb ischemia: a global epidemic. A critical analysis of current treatment un- masks the clinical and economic costs of CLI. EuroIntervention. 2005;1(1):75-84
  7.  Goodney PP,Travis LL, Nallamothu BK, et al.Variation in the use of lower extremity vascular procedures for critical limb ischemia. Circ Cardiovasc Qual Outcomes. 2012;5(1):94-102
  8. The SAGE Group Estimates the Economic cost of Critical Limb Ischemia Costs at $25 Billion. The SAGE Group. Accessed on- line: http://www.businesswire.com/news/home/20140815005003/ en/correcting-replacing-sage-group-estimates-economic-cost.  Additional information, interview with Mary Yost, The SAGE Group.  The Save a Leg, Save a Life Radio Show.  WOKV, Jacksonville Florida 2012.
  9. F. A., Feinglos, M. N. and Grossman, D. S., RESEARCH ARTICLE: Receipt of Care and Reduction of Lower Extremity Amputations in a Nationally Representative Sample of U.S. Elderly, Health Services Research, no. doi: 10.1111/j.14756773.2010.01157.

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