March 2012

Study: Amputation Rates Down In Patients With Diabetes Over 40

By Brian McCurdy, Senior Editor

The prevalence of diabetes has increased in recent years and is projected to keep rising. However, a recent study in Diabetes Care may offer a silver lining: Non-traumatic lower extremity amputation rates have fallen in patients with diabetes over the age of 40.

   Authors found the age-adjusted amputation discharge rate per 1,000 people with diabetes over the age of 40 decreased from 11.2 in 1996 to 3.9 in 2008 while amputation rates among people without diagnosed diabetes had changed little.

   Valerie Schade, DPM, AACFAS, notes that innovations in wound care may facilitate the preservation of functional limbs with a partial foot amputation instead of major amputation of the extremity.

   “With the vast array of advanced local wound care products and multiple negative pressure wound therapy devices currently available for use, reconstruction of an ulcerated foot is more of a reality then the prior days of amputation of the extremity,” notes Dr. Schade, the Chief of the Limb Preservation Service and Director of the Complex Lower Extremity Surgery and Research Fellowship at Madigan Healthcare System in Tacoma, Wash.

   Lee C. Rogers, DPM, concurs, citing advanced products such as VAC therapy (KCI), Regranex (Healthpoint Biotherapeutics), Apligraf (Organogenesis) and Dermagraft (Advanced BioHealing).

   Dr. Rogers, the Co-Director of the Amputation Prevention Center, Valley Presbyterian Hospital in Los Angeles, also cites “improved education, including several respected meetings and a virtual explosion in literature for preventing amputations” in explaining the decrease in amputations. Similarly, as more patients with diabetes are getting regular foot examinations from their primary care physicians and education about diabetic foot care, Monica Schweinberger, DPM, says this leads to earlier referral for specialty foot care in high-risk patients, which can help prevent amputation.

   Dr. Schweinberger notes that insurance coverage for extra depth shoes and orthotics for patients with diabetes can provide better accommodation for foot deformities. Dr. Rogers also cites the effectiveness of the Medicare Diabetic Shoe Bill.

Will The Amputation Trend Continue Or Reverse?

The study authors note that the increased incidence of diabetes “may have resulted in a greater number of individuals with milder disease, detected earlier in the disease process, who have not had diabetes long enough to develop complications. Once these patients with new-onset, milder disease have had diabetes long enough, it is possible that the encouraging trends in … amputations will reverse.”

   Although a longer duration of the disease can lead to a greater potential for complications to occur, with education and the development of specialized teams and centers to prevent lower extremity amputation, a continuing decrease in diabetic amputation “does not appear to be an unobtainable goal,” maintains Dr. Schade.

   Dr. Schweinberger concurs that a longer duration of diabetes leads to a greater likelihood of developing complications such as peripheral neuropathy and peripheral arterial disease, which could increase the risk of amputation.

   “However, with earlier diagnosis and treatment of diabetes, more frequent foot screening and foot care education, in addition to more aggressive management of patients with ulceration or at high risk for ulcer or amputation, I would hope that we would not see a significant increase in lower extremity amputation over time,” says Dr. Schweinberger, who is affiliated with the Cheyenne Veterans Affairs Medical Center in Cheyenne, Wyo.

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