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Treatment of the diabetic foot – to amputate or not?
© Weledji and Fokam; licensee BioMed Central Ltd. 2014
Received: 2 February 2014
Accepted: 14 October 2014
Published: 24 October 2014
Diabetic foot infections are a frequent clinical problem. About 50% of patients with diabetic foot infections who have foot amputations die within five years. Properly managed most can be cured, but many patients needlessly undergo amputations because of improper diagnostic and therapeutic approaches.
The article debates the pros and cons of amputation of the diabetic foot. The thesis is that if the guidelines on the management of the diabetic foot are followed primary amputation is only necessary for the unsalvageable diabetic foot. This approach would reduce the incidence of lower limb amputations in diabetic patients.
We favour the argument that a structured clinical and vascular assessment would help clinical decision- making as to which patients to hospitalize, which to send for imaging, or for whom to recommend surgical interventions. Endovascular procedures are the future in the treatment of diabetic arterial disease and hence the diabetic foot.
KeywordsDiabetic foot Infection Neuropathy Ischaemia Treatment Amputation
The Wagner-Meggitt classification
deep ulcer to tendon, bone, or joint
deep ulcer with abscess or osteomyelitis
whole foot gangrene
Classification of diabetic foot infection 
No signs or symptoms of infection
Superficial, limited in size and depth
Deeper or more extensive
Systemic signs or metabolic pertubation
Summary of indications for conservative surgical approach or primary amputation
Good blood supply to foot but infected
wet gangrene (infection + ischaemia)
Small vessel disease and gangrenous toes
Successful surgical bypass
extensive muscle necrosis
Neuropathic foot with little arterial disease
revascularisation technically impossible, bed-ridden patients/functionally useless limb
Osteomyelitis with little arterial disease
Arguments for primary amputation
Natural history of disease
Assessment and treatment
The greatest immediate danger to these patients after successful revascularization is the ‘reperfusion syndrome’ caused by the release of toxic metabolites and oxygen free radicals into the systemic circulation from the ischaemic limb [16, 17]. This can cause a profound cardiovascular collapse and with renal and sometimes respiratory failure. For this reason revascularisation should not be used in patients with signs of muscle necrosis. Primary amputation is better. A graft should if possible prevent limb loss for at least 2 years if it is to be considered a success. The 2 year patency rate of distal vascular grafts for experienced vascular units should be in the region of 75% [16, 17]. There is evidence that failed bypasses result in a higher level of amputations and the combined mortality rate of a failed reconstruction followed by amputation may be higher than a primary amputation .
Arguments against primary amputation
Natural history of disease
Assessment and treatment
The diabetic patient presenting with a foot wound should be assessed at three levels- the patient as a whole, the affected limb and foot and the infected wound [1–4]. The affected limb and foot should be assessed for arterial ischaemia, venous insufficiency, presence of protective sensation, and biomechanical problems.There may be an obvious large wound or ulcer associated with erythema and pyrexia. The presence of any exposed bone and ulcer larger than 2 cm  increase the likelihood of osteomyelitis [1, 3]. It is suspected in a patient with an adequate blood supply to the affected foot that has a deep ulcer which would not heal after 6 weeks of appropriate wound care and off-loading . Some diabetic patients who develop neuropathies or osteomyelitis but with little arterial disease may often benefit from surgical debridement or excision and/or prolonged antibiotic therapy for at least 4 weeks, based on the culture and sensitivity of biopsied bone tissue or the curettage of deep tissues [3, 4, 26]. Swab specimens, especially of incompletely debrided wounds provide less accurate results [1, 27].
Diabetic foot infection
Diabetic foot infections typically begin in a neuropathic ulceration. An infected diabetic foot with good blood supply would respond to debridement . In neuropathic foot, severe infection is treated with intra-venous antibiotics in hospital and, antiseptics and dressings for ulcers. Necrotic tissue is removed and conservative digital amputations or filleting is sufficient.The surgical approach would optimize the likelihood for healing while attempting to preserve the integrity of the walking surface of the foot . Specialised footwear is used to reduce weight bearing [1, 4]. In ischaemic foot infection is treated by debridement (cleaning the wound, removing pus, dead necrotic tissue and infected bone) [1, 31].
While all wounds are colonized with microorganisms, the presence of infection is defined by findings of inflammation or purulence [1, 3]. There are usually complex polymicrobial infections, but aerobic gram positive cocci is a vital part of diabetic foot infection. A broad-spectrum intra- venous antibiotic and metronidazole for anaerobes are recommended. Antibiotics can usually be discontinued once the clinical signs and symptoms of infection have resolved usually 1–2 weeks for mild infection and 2–3 weeks for moderate to severe infection, and not until the wound has healed. This is to avoid resistance . If the wound is not easily debrided varidase dressing is used, and inadine or granuflex dressing would promote granulation [33, 34]. The use of topical antimicrobials for most clinically uninfected wounds is not advocated for lack of evidence substantiating the benefit over conventional wound care therapy [1, 4, 35]. Several recent systematic reviews have suggested that silver-containing dressings and topical silver were neither better nor worse than control dressings in preventing wound infection and prolong healing . New techniques for wound debridement include low frequency ultrasound therapy, hydrosurgery, monofilament polyester fibre pad and plasma-mediated bipolar radiofrequency ablation . Skin grafting when no infection is present may be required .
As diabetes is chronic and progressive, it makes sense to have a conservative surgical approach that include surgical revascularization . A successful surgical bypass of larger vessel disease may enable more conservative treatment of the diabetic foot. Revascularisation is, however, considered inappropriate in bedridden patients, in a functionally useless limb, in patients with life threatening sepsis, extensive muscle necrosis and where it is technically impossible. Primary amputation is better in these cases [3, 17].
A percutaneous transluminal angioplasty (PTA) and luminal stenting or arterial reconstruction to improve blood flow would aid healing . Because in most cases ischaemia is secondary to larger vessel artherosclerosis rather than to ‘small vessel disease’, vessels above the knee and below the ankle tend to be relatively spared. Thus lower extremity artherosclerosis can be amenable to angioplasty or vascular bypass . The indications for a PTA in diabetic peripheral arterial disease are classically for disabling claudication and critical limb ischaemia, Patients with non-critical ischaemia (ankle/brachial pressure index (ABPI- 0.4-0.9) can in some cases be successfully treated without a vascular procedure . Although the prevalence of ABI <0.9 in individuals with normal glucose tolerance was 7% and increased to 20.9% with diabetes, care should be taken when interpreting ABPI in diabetics . Arterial calcification of the vessel media renders the vessels incompressible and causes false ‘high’ readings. Toe pressure measurements may be of value. Revascularization by percutaneous transluminal angioplasty (PTA) of short segment disease was feasible in more than 96% of diabetics with critical limb ischaemia (ankle systolic pressure of less than 50 mmHg or the toe pressure of less than 30 mmHg) . Many centres have reported successful use of both aggressive endovascular interventions and distal bypass procedures for more severe vascular disease of the foot. The short-term effects are satisfactory with healing of the foot ulcers and thus diminishing the risk of amputation. However, follow-up is required to ascertain the long-term effects [10, 17, 38]. The feasibility with bypass prosthetic grafting (BPG) is lower but consistent . Studies strongly suggest that early recognition and aggressive surgical drainage of pedal sepsis followed by surgical revascularization is critical to achieving maximal limb salvage of 74% at 5 years in the high risk population . The risks of unsuccessful revascularization leading to limb loss must be weighed against the benefits and the patient informed. However, careful debridement of necrotic, infected diabetic foot wound should not be delayed while awaiting revascularization [3, 10].
Postoperative amputation pain and rehabilitation
Post- operative amputation pain is mostly due to phantom limb pain (54%) and phantom limb sensation (90-98%) . Phantom limb pain usually continues for more than six months whereas phantom limb sensation (except pain) usually disappears or decreases with time. The true mechanism is not known but many theories overlap a peripheral, spinal and central mechanism. The successful treatment of phantom limb pain is thus difficult and treatment is usually combined and multiple based on the person’s level of pain. These include biofeedback to relieve muscle tension, physical therapy, surgery to remove scar tissue entangling a nerve, transcutaneous electrical nerve stimulation (TENS) of the stump, neurostimulation techniques, medications such as analgesics, neuroleptics, anticonvulsants, antidepressants, beta -blockers and sodium channel blockers . The patient must therefore be properly prepared for surgery psychologically with time being spent on assessment by the physiotherapist and reassurance and encouragement being provided by the surgeons, ward nurses or a successful amputee. The patient should be encouraged to spend periods lying prone to help keep the knee straight post-operatively and avoid fixed flexion deformity. The level of amputation may have to be high enough to ensure adequate healing of the stump . Above Knee amputation (AKA) or ‘transfemoral amputation’ is associated with a much poorer outcome because these patients are more often unwell than those needing a below knee or ‘transtibial amputation’ (BKA). Although AKA is more likely to heal, rehabilitation is less successful . Most elderly patients are not psychologically prepared and rehabilitation is an up-hill task.
Many diabetic foot problems are avoidable. Good glycaemic control and patient’s education are essential. The main determinant of which patients with a diabetic foot infection need to be hospitalized is the clinical severity of the infection. With minimal surgical trauma and certain curative effect endovascular procedures is the future in the treatment of diabetic peripheral arterial disease and thence the diabetic foot. It is desirable that a vascular surgeon should assess the diabetic foot as the possibility of revascularization must always be considered and the correct sub-group selected for amputation. Guideline-based care for diabetic foot infections and the employment of multidisciplinary teams would help improve outcome and minimize amputations.
We confirm that informed consent for the publication of the image of the diabetic foot was obtained from the patient. Our gratitude to the diabetic foot patients at the Regional hospital Buea, Cameroon who rendered me the impetus to write about this major diabetic complication that incessantly appeared on the surgical ward.
- Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG, Deery HG, Embil JM, Joseph WS, Karchmer AW, Pinzur MS, Senneville E: Infectious diseases society of America. Clinical practice guidelines for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012, 54: 132-73.View ArticleGoogle Scholar
- Becks PJ, Mackaay AJ, de Neeling JN, de Vries H, Bouter LM, Heine RJ: Peripheral arterial disease in relation to glycaemic level in an elderly Caucacianpopulation : the Hoorn study. Diabetologia. 1995, 38 (1): 163-166.Google Scholar
- Schaper NC, Apelqvist J, Bakker K: The international consensus and practical guidelines on the management and prevention of the diabetic foot. Curr Diab Rep. 2003, 3: 475-9. 10.1007/s11892-003-0010-4.View ArticlePubMedGoogle Scholar
- Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Lew DP, Mader JT, Norden C, Tan JS: Diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2004, 39: 885-910. 10.1086/424846.View ArticlePubMedGoogle Scholar
- Prompers L, Huijberts M, Apelqvist J, Jude E, Piaggesi A, Bakker K, Edmonds M, Holstein P, Jirkovska A, Mauricio D, Ragnarson Tennvall G, Reike H, Spraul M, Uccioli L, Urbancic V, Van Acker K, van Baal J, van Merode F, Schape N: High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia. 2007, 50: 18-25. 10.1007/s00125-006-0491-1.View ArticlePubMedGoogle Scholar
- Oyibo SO, Jude EB, Tarawinch I, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJ: A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems. Diabetes Care. 2001, 24 (1): 84-88. 10.2337/diacare.24.1.84.View ArticlePubMedGoogle Scholar
- Schaper NC: Diabetic foot ulcer classification system for research purposes; a progress report on criteria for including patients in research studies. Diabetes Metab Res Rev. 2004, 20 (Supp1): 390-5.Google Scholar
- Singh N, Armstrong DG, Lipsky B: Preventing foot ulcers in patients with diabetes. JAMA. 2005, 293: 217-28. 10.1001/jama.293.2.217.View ArticlePubMedGoogle Scholar
- Callum KG: Below knee amputation. Curr Pract Surg. 1992, 4: 20-24.Google Scholar
- Hirsh AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, William RC, Murphy WR, Jeffrey W, Olin JW, Puschett JB, Kenneth A, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, John White J, White RA: ACC/AHA practice guidelines for the management of patients with peripheral arterial disease. Circulation. 2006, 113: e463-6.View ArticleGoogle Scholar
- Bargellini I, Piaggesi A, Cicorelli A, Rizzo L, Cervilli R, Iacopi E, Lunardi A, Cioni R: Predictive value of angiographic scores for the integrated management of the ischaemic diabetic foot. J Vasc Surg. 2013, 57: 1204-12. 10.1016/j.jvs.2012.10.104.View ArticlePubMedGoogle Scholar
- Pinzur MS, Pinto MA, Schon LC, Smith DG: Controversies in amputation surgery. Instr Course Lect. 2004, 52: 445-51. 39(Suppl 2):S123-8Google Scholar
- Sumpio BE, Lee T, Blummet A: Vascular evaluation and arterial reconstruction of the diabetic foot. Clin Podiatr Med Surg. 2003, 20: 689-708. 10.1016/S0891-8422(03)00088-0.View ArticlePubMedGoogle Scholar
- Khan NA, Rahim SA, Anand SS, Simel DL, Panju A: Does the clinical examination predict lower extremity peripheral arterial disease?. JAMA. 2006, 295: 536-46. 10.1001/jama.295.5.536.View ArticlePubMedGoogle Scholar
- van Battum P, Schaper N, Prompers L, Apelqvist J, Jude E, Piaggesi A, Bakker K, Edmonds M, Holstein P, Jirkovska A, Mauricio D, Ragnarson Tennvall G, Reike H, Spraul M, Uccioli L, Urbancic V, van Acker K, van Baal J, Ferreira I, Huijberts M: 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: 199-205. 10.1111/j.1464-5491.2010.03192.x.View ArticlePubMedGoogle Scholar
- Gibbons GW: Lower extremity bypass in patients with diabetic foot ulcers. Surg Clin North Am. 2003, 83: 659-69. 10.1016/S0039-6109(02)00199-8.View ArticlePubMedGoogle Scholar
- Faglia E, Clerici G, Losa S, Tavano D, Cammiti M, Miramonti M, Somalvico F, Airoldi F: Limb revascularization feasibility in diabetic patients with critical ischaemia: results from a cohort of 344 consecutive unselected diabetic patients evaluated in 2009. Diabetes Res Clin Pract. 2012, 95: 364-71. 10.1016/j.diabres.2011.10.033.View ArticlePubMedGoogle Scholar
- Armstrong DG, Wrobel J, Robbins JM: Guest editorial: are diabetes-related wounds and amputations worse than cancer?. Int Wound J. 2007, 4: 286-7. 10.1111/j.1742-481X.2007.00392.x.View ArticlePubMedGoogle Scholar
- Tan T, Shaw EJ, Siddiqui F, Kandaswamy P, Barry PW, Baker M: Inpatient management of diabetic foot problems: summary of NICE guidance. BMJ. 2011, 342: 1280-10.1136/bmj.d1280.View ArticleGoogle Scholar
- Richard JL, Lavigne JP, Got I, Hartemann A, Malgrange D, Tsirtsikolou D, Baleydier A, Senneville E: Management of patients hospitalized for diabetic foot infection: results of the French OPIDIA study. Diabetes Metab. 2010, 37: 208-15.View ArticlePubMedGoogle Scholar
- Pecorano RE, Reiber GE, Burgess EM: Pathways to diabetic limb amputation. Basis for prevention. Diabetic Care. 1990, 13 (5): 513-521. 10.2337/diacare.13.5.513.View ArticleGoogle Scholar
- Trautner C, Haastert B, Mauckner P, Gatcke LM, Giani G: Reduced incidence of lower-limb amputations in the diabetic population of a German city, 1990–2005: results of the Leverkusen Amputation Reduction Study (LARS). Diabetes Care. 2007, 30: 2633-7. 10.2337/dc07-0876.View ArticlePubMedGoogle Scholar
- Krishnan S, Nash F, Baker N, Fowler D, Rayman G: Reduction in diabetic amputations over 11 years in a defined U.K. population: benefits of multidisciplinary team work and continuous prospective audit. Diabetes Care. 2008, 31: 99-101.View ArticlePubMedGoogle Scholar
- Chaytor ER: Surgical treatment of the diabetic foot. Diabetes Metab Res Rev. 2000, 16 (Suppl 1): S66-9.View ArticleGoogle Scholar
- Lavery LA, Peters EJ, Armstrong DG, Wendel CS, Murdoch DP, Lipsky BA: Risk factors for developing osteomyelitis in patients with diabetic foot wounds. Diabetes Res Clin Pract. 2009, 83: 347-52. 10.1016/j.diabres.2008.11.030.View ArticlePubMedGoogle Scholar
- Goven MF, Karibiber A, Kaynak G, Oyet T: Conservative and surgical treatment of the chronic Charcot foot and ankle. Diabetic Foot Ankle. 2013, In pressGoogle Scholar
- Bridges RM, Deitch EA: Diabetic foot infections. Pathophysiology and treatment. Surg Clin North Am. 1994, 7 (4): 537-55.Google Scholar
- Prompers L, Schaper N, Apelqvist J, Edmonds F, Jude E, Mauricio D, Uccoli L, Urbanci V, Bakker K, Holstein B, Jirkovska A, Piaggesi A, Jirkovska A, Ragnaeson-Tennrall G, Reike H, Spraul M, VanAcker K, Van Baal J, Van Merode F, Ferriera I, Huijbets M: 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: 747-55. 10.1007/s00125-008-0940-0.View ArticlePubMedPubMed CentralGoogle Scholar
- Cheo JJ, Tan SB, Sivathasan C, Pavanni R, Tan SK: Vascular assessment in the neuropathic diabetic foot. Cln Orthop Relat Res. 1995, 320: 95-100.Google Scholar
- Piaggesi A, Schipani E, Campi F, Romanelli M, Baccetti F, Arvia C, Navalesi R: Conservative surgical approach versus non-surgical management for diabetic neuropathic foot ulcers: a randomized trial. Diabet Med. 1998, 15: 412-7. 10.1002/(SICI)1096-9136(199805)15:5<412::AID-DIA584>3.0.CO;2-1.View ArticlePubMedGoogle Scholar
- Shogalefard A, Khorgami Z, Mologen-Tehrain MR, Langam B: Large and deep diabetic heel ulcers need not lead to amputation. Foot Ankle Int. 2013, 34: 215-21. 10.1177/1071100712460228.View ArticleGoogle Scholar
- Lipsky BA, Sheehan P, Armstrong DG, Tice AD, Polis AB, Abramson MA: Clinical predictors of treatment failure for diabetic foot infections: data from a prospective trial. Int Wound J. 2007, 4: 30-8. 10.1111/j.1742-481X.2006.00274.x.View ArticlePubMedGoogle Scholar
- Vermeulen H, Ubbink D, Goossens A, de Vos R, Legemate D: Dressings and topical agents for surgical wounds healing by secondary intention. Cochrane Database Syst Rev. 2004, 2: CD003554-PubMedGoogle Scholar
- Weledji EP, Kamga HLF, Assob JC, Nsagha DS: A critical review of HIV/AIDS and wound care. Afr J Cln Exper Microbiol. 2012, 13 (2): 66-73.Google Scholar
- Nelson EA, O’Meara S, Golder S, Dalton J, Craig D, Iglesias C, DASIDU Steering Group: Systematic review of antimicrobial treatments for diabetic foot ulcers. Diabetic Med. 2006, 23 (4): 348-359. 10.1111/j.1464-5491.2006.01785.x.View ArticlePubMedGoogle Scholar
- Storm-Versloot MN, Vos CG, Ubbink DT, Vermeulen H: Topical silver for preventing wound infection. Cochrane database. Syst Rev. 2010, 17 (3): CD066478-Google Scholar
- Madhok BM, Vowden K, Vowden P: New techniques for wound debridement. Int Wound J. 2013, 10 (3): 247-51. 10.1111/iwj.12045.View ArticlePubMedGoogle Scholar
- Nian- Feng S, Ai-Ling T, Yu-Ling T, San-yuan H, Li X: The interventional therapy for diabetic peripheral artery disease. BMC Surg. 2013, 13: 32-10.1186/1471-2482-13-32.View ArticleGoogle Scholar
- Stone PA, Back MR, Armstrong PA, Flaherty SK, Keeling WB, Johnson BL, Shames ML, Bandyk DF: Midfoot amputations expand limb salvage rates for diabetic foot infections. Ann Vasc Surg. 2005, 19 (6): 805-11. 10.1007/s10016-005-7973-3.View ArticlePubMedGoogle Scholar
- Giummarra MJ, Gibson SJ, Georgion-Karistinis N, Bridshaw JC: Central mechanisms in phantom limb perception: the past, present and furure. Brain Res Rev. 2007, 54: 219-23. 10.1016/j.brainresrev.2007.01.009.View ArticlePubMedGoogle Scholar
- Ramachandran VS, Hirstein W: The perception of phantom limbs. ‘The D.O.Hebb Lecture”. Brain: J Neurol. 1998, 121 (9): 1603-1630. 10.1093/brain/121.9.1603.View ArticleGoogle Scholar
- Wrobel JS, Robbins J, Armstrong DG: The high-low amputation ratio: a deeper insight into diabetic foot care. J Foot Ankle Surg. 2006, 45: 375-9. 10.1053/j.jfas.2006.09.015.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/14/83/prepub
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