Diabetic amputations. Diabetic Amputations. Indications for Major Amputation in Patients with DM

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1 When is Primary Amputation Better for the Patient UCSF Vascular Symposium 2015 Diabetic amputations One of the most feared complications of diabetes : Armstrong Int Wound J 2007 Dane K. Wukich MD UPMC Mercy Center for Healing and Amputation Prevention Professor of Orthopaedic Surgery University of Pittsburgh School of Medicine A catastrophic complication in individuals with diabetes : Tseng Gen Hosp Pysch 2007 More than 60% of non-traumatic amputations occur in patients with diabetes mellitus Diabetic Amputations Non-Traumatic LEA in Patients with Diabetes CDC: Diabetes Surveillance System 2007 Slide courtesy of Dr. Robert Frykberg 71, /1000 DM Indications for Major Amputation in Patients with DM Non- reconstructable Unstable, non braceable Unable to revascularize Acute life threatening infection with fulminant sepsis Infection that can t be eradicated Intractable pain Chronic wound that won t heal despite advanced techniques 1

2 Indications for Major Amputation in Patients with DM Non- ambulatory patients Severe proximal joint contractures Hip and knee flexion contractures Paraplegia If they could not walk preoperatively unlikely to walk postoperatively unless they have a severe non plantigrade foot that prevents ambulation Foot and Ankle Reconstructive Surgery in Patient with DM High rates of complications Surgical site infections Delayed wound healing Nonunion of fusions Hardware failure Why are amputations so bad? 30 Day Perioperative Cardiac Event Anesthesia and Analgesia 2005 (BI Deaconess) Anesthesia and Analgesia 2005 (BI Deaconess) 2

3 Long term survival of patients who undergo AKA or BKA is dismal Is the Amputation Truly the Culprit? 5 yr mortality of diabetic patients undergoing amputation: 47% 5 yr mortality of patients whose diabetic foot ulcers healed: 44% Moulik et al. Diabetes Care 2003 Subramanium et al. Anesth Analg 2005 Perhaps it is the patient! Limb Preservation at Georgetown Moulik et al. Diabetes Care 2003 Gazis et al. Diab Med 2004 Evans: J Diab Comp

4 What Do Our Patients Fear? 5 is greatest fear, 1 least fear Diabetic Foot vs. Diabetic Control Ambulation after Amputation Approximately 65% of patients who undergo BKA will ambulate with a prosthesis Only 33% of patients who undergo AKA will ambulate with a prosthesis Why??? Energy Expenditure 4

5 Vascular Amputees Walker Slower than Traumatic Amputees Quality of Life Studies Suggest that the negative impact on health related QOL in diabetic foot ulcer patients may be as severe or similar to patients who have undergone lower extremity amputation! Waters et al. JBJS 1976 Willrich et al. FAI 2005 Major Amputation and SF 36 (Higher score is better) Quality of Life DFU versus Amputation No difference between the two groups except that DFU patients had higher bodily pain Physical limitations were identical between transtibial amputees and DFU patients Physical limitations were less in minor amputees than DFU patients Median Scores were quite low for both groups Willrich et al. FAI 2005 Boutoille et al. FAI

6 Although amputation remains a drastic step in the story of a DFU, its influence on the quality of life is not worse than when the patient suffered from the ulcer No difference in emotional scores between amputation and DFU Tennvall and Apelqvist: J Diab Comp 2000 Peters et al: Diabetes Care 2000 Willrich et al: FAI 2005 Boutoille et al: FAI 2008 Vileikyte: Current Diabetes Reports 2008 Willrich et al. FAI 2005, Boutoille et al. FAI 2008 Study of Transtibial Amputations Minimum one year follow up Mean age 55 years 32 patients (21 males and 11 females) Mean duration of diabetes of 20 years 85% utilized insulin Type 1 DM 15% and Type 2 DM 85% Self reported outcome instruments were obtained in all patients pre and postoperatively SF 36 as a measure of overall health Foot and Ankle Ability Measure to assess LE function Outcomes of BKA (32 patients) SF 36 Subscales Preop Mean Postop Mean P value Physical Function * <0.001 Role Physical *< Bodily Pain * <0.001 General Health * <0.05 Vitality * <0.05 Social Function * <0.001 Role Emotional * <0.01 Mental Health * <0.05 6

7 Patients Overall Health Improved Lower Extremity Function Postop Preop Postop Preop Preop Postop P < Preop Major Amputation Well done BKA should not be viewed as a failure View it as the first step in the patients rehabilitation and recovery Conclusion Amputation is a drastic step in patients with diabetes Patients fear amputation more than anything except blindness The goal should be the most distal amputation possible that provides stable soft tissue coverage and function Decreased energy expenditure Higher likelihood of ambulation 7

8 29 Conclusion If you treat Charcot and/or Diabetic Foot Infections you will have patients who require a major amputation In select patients Transtibial Amputation may Permit faster rehabilitation Maintain if not improve quality of life Eradicate chronic sources of infection Consult with Physical Medicine and Rehabilation, Physical Therapy and Prosthetics preop well before the actual BKA 30 Conclusion Mobility in certain patients may be improved with a well fitted prosthesis compared to boots, casts and CROW Anecdotally I am amazed how much better chronically infected patients feel within hours after amputation by eliminating the bacterial load We do everything possible to avoid a Major Amputation 1920 PITTSBURGH