dr. ramakath

1. AMPUTATIONS IN DIABETICAMPUTATIONS IN DIABETIC
FOOTFOOT

2. PROF. RAMA KANT
KING GEORGE MEDICAL UNIVERSITY
LUCKNOW
ramakantkgmc@rediffmail.com

3. • Diabetes mellitus increases risk of
amputation by 20-fold.
• Declining rate of foot amputations
parallels decrease in hospitalizations
for skin and soft tissue infections.
• This reflects better and effective
outpatient care for diabetic foot ulcers
and infections.

4. Do we waste time trying to saveDo we waste time trying to save
some feet ?????some feet ?????
Should we be aiming for local minimal
surgery at all costs, or is there a case for
primary radical amputation?
Technological advances and improvements in local
treatments for diabetic foot disease place clinicians
under ever increasing pressure to preserve the foot
(Watkins PJ, 2003; Smith J, 2003).

5. These are real
challenges for
decision……

7. CHANGE YOUR PERCEPTION
STILL THERE IS HOPE…………
CHANGE YOUR PERCEPTION
STILL THERE IS HOPE…………

8. Health-economic consequences ofHealth-economic consequences of
diabetic foot infectionsdiabetic foot infections
• Result in huge costs for society and individual.
• Costs of antibiotics also substantial… ..
• Total costs for topical treatment high .
• Total costs for healing of infected ulcers not
requiring amputation - $17,500
• Costs for lower-extremity
amputations are above $30,000

9. Often a successful outcome is followed by a rapid
recurrence necessitating further hospitalisation.
Clinicians should always consider
whether the best interests of the patient
might be served by primary amputation
or often prolonged, expensive and
failure bound local aggressive surgical
traetment ????

10. The aim of any treatment
is to deliver a fully mobile
patient back into the
community.

11. Levels of lower extremity amputations

12. MAJOR AMPUTATION-MAJOR AMPUTATION-
• Advantages
• No more surgery
• Shorter hospital stay
• Disadvantages
• Major procedure and risk
• Difficult & expensive rehabilitation
• Independence threatened

15. FOOT—REVISION-BELOW
KNEE---REVISION—ABOVE
KNEE---STILL NEEDS REVISION

16. NOW HEALED ABOVE KNEE
AMPUTATION

17. Indications for primary BKAIndications for primary BKA
instead of local amputationinstead of local amputation
Previous extensive hospitalisation
Limited life expectancy
Patient choice
Age
State of circulation
Effect of failed distal bypass
Failed conservative management.

18. • We should aim to minimise
the time spent in hospital as
these patients are often
towards the end of their
lives…….

19. Approximately 50% of
patients ended up with a
BKA
a very high proportion
indeed…..

20. • Major amputation should
be considered as an
option for every patient
with diabetic foot disease.

21. EFFORTS TO RESTORE
THIS FOOT TO NORMAL
MOST PROBABLY WILL
FAIL……
HE MAY BE BETTER
OFF WITH
AMPUTAION AND
PROSTHESIS

22. 50% of lower extremity amputations performed in50% of lower extremity amputations performed in
the United States are due to diabetes.the United States are due to diabetes.
9% foot,9% foot,
31% lower leg,31% lower leg,
30% above knee.30% above knee.
Ipsilateral higher amputations occur in 22% ofIpsilateral higher amputations occur in 22% of
cases.cases.
Contralateral amputations 10% per year.Contralateral amputations 10% per year.
After 5 years, amputees with diabetes have aAfter 5 years, amputees with diabetes have a
50% chance of bilateral amputation,50% chance of bilateral amputation,

23. Number of operations
• Diabetes
• Toe BKA AKA
• 282 (67%) 110 (49%) 39 (18%)

24. MINOR AMPUTATIONMINOR AMPUTATION

25. Advantages
• Limb preserved
• Reduced anaesthetic risk
• Independence preserved
Disadvantages
• Prolonged healing time
• Prolonged hospitalisation
• Prolonged re-mobilisation
• Risk of failure of healing
• Risk of further treatment

26. • Decisive factors in type of
treatment provided to
patients..
• They must participate

27. CENTRAL PLANTAR ABSCESS WITH
OSTEOMYELITIS

28. TOE AMPUTATION

34. WRONG DECISION FOR LEVEL OF
AMPUTATION

35. BILATERAL DEFORMED BUT
WALKABLE FOOT

36. FUNCTIONAL
BUT DEFORMED
FOOT
EVEN THIS IS
MUCH BETTER
THAN THE BEST
PROSTHESIS…
….This is also a
view

60. • Patient choice
• Patients should always be offered three
choices:
• No treatment
• Continued conservative management
involving minor amputation
• Major amputation.
• Surprisingly, patients often choose
the major amputation route.

61. Age
• Younger people adapt very well to BKA,
but are likely to have better circulation and
heal local amputations.
• However, young people are young
enough to return with further problems.
• Elderly people are less likely to adapt well
to major amputation, but are also less
likely to have good circulation and the
ability to heal locally within the foot.

62. State of circulationState of circulation
For local amputation in the foot to
heal, the circulation must be
adequate. In practice, this means
at least one patent artery to ankle
level.

63. Some patients may have been treated
for months in hospital clinics without
success.
In patient with neuropathic foot even
if healing is eventually achieved, there
is a very high risk of new ulceration
despite very careful attention to
footwear
Failed conservative treatment

64. Algorithm for management of
Patients
38% of patients have a foot
which is not salvageable and
these patients should have a
major amputation from the
outset.

65. • Circulation normal, foot is
salvageable, and patient is
young, then local
amputation is an option.
• However, 19% will fail their
local amputation and require
major amputation.

66. • What is life expectancy ?
• Previous treatment they have had
• Morphology of foot
• Circulation of foot.
• Mobility of patient
• Whether patient has a job and what
it is ?
• What is the family situation
?

67. Transmetatarsal AmputationTransmetatarsal Amputation
(TMA)(TMA)
• Gangrene must be limited to the toes and
should not involve the web space. Infection
should be controlled.
• Preserves the attachment of the dorsiflexors
and plantar flexors and their function.
• These amputations can be fitted with sole
stiffeners and toe fillers with minor apparent
loss of function during stance and walking on
level surfaces.

68. Other Foot AmputationsOther Foot Amputations
• Lisfranc amputation at the tarso-metatarsal
junction
• Chopart amputation is a midtarsal, talo-
navicular, calcaneo-cuboid amputation. Only
talus and calcaneus bones remain
• Pirogoff is a vertical calcaneal amputation (in
this amputation, the lower articular surfaces of
the tibia/fibula are sawn through)
• Boyd is a horizontal calcaneal amputation (all
tarsals removed except calcaneus/talus)

69. Syme's AmputationSyme's Amputation
• Indications: Trauma above the foot,
congenital anomalies, tumors, and
deformities that necessitate amputation.
• Disadvantages: healthy plantar heel
skin is necessary for weight bearing in
this area. The patient also must have
good perfusion in this area, thus
making it a difficult procedure for the
dysvascular patient.

70. Pros: Functionally, this procedure represents an
excellent level of amputation because:
It maintains the length of the limb
preservation of the heel pad,
excellent weight-bearing stump
Immediate fitting of prosthesis is possible
with excellent results
Stump weight bearing is possible almost
immediately after the procedure (~ within 24
hrs)
Cons: cosmesis (bulbous, bulky residual limb);
fitting for a prosthesis may be more difficult
than for other amputation levels.

71. Trans-metatarsal amputation ready for a split-
thickness skin graft.

72. Transmetatarsal
amputation with
a skin graft.

73. Trans-
metatarsal
amputation
with a plantar
flap.
Primary
closure by the
plantar flap
ideal due to
vast arterial
supply from
the plantar
artery.

74. MODIFIED SHOES AND AIDS
FOR WALKING AND OFF
LOADING…KEY TO
SUCCESS

77. Partial Foot AmputationsPartial Foot Amputations
• Small-toe amputations do not affect ambulation
• Usually require no replacement
• Partial foot prostheses are used to restore foot
function
• Amputation of the great toe reduces push-off
force, thus requiring a resilient toe filler and also
a molded insole with arch support to maintain
the alignment of the amputated foot.

78. Partial foot amputations involving the forefoot,
such as ray resections and trans-metatarsal
amputations, generally require only shoe fillers or
shoe modifications.
Will require stiff sole, the addition of a spring
steel shank extending to the metatarsal heads, a
rocker sole and/or padding of the tongue of the
shoe to help hold the hind foot firmly in the shoe.

79. Transtarsal amputationsTranstarsal amputations
As Chopart, Lisfranc, and Boyd will have
better functional results if there is an
active balanced dorsiflexion and plantar
flexion with normal skin and heel pad
present.
• The best prosthetic option for a hind foot
amputation - use of a custom prosthetic
foot with a self-suspending split socket

80. It should not be too difficult to
determine break points at which
effectiveness of treatment is
cost effective, or even cost
saving.

81. Conclusions
Major amputation should be
considered as an option for
every patient with diabetic
foot disease.

82. THANKS