Diabetic amputations When is Primary Amputation Better for the - - PowerPoint PPT Presentation

4/18/2015 1

When is Primary Amputation Better for the Patient UCSF Vascular Symposium 2015

Dane K. Wukich MD UPMC Mercy Center for Healing and Amputation Prevention Professor of Orthopaedic Surgery University of Pittsburgh School of Medicine

Diabetic amputations

“One of the most feared complications of diabetes”:

Armstrong Int Wound J 2007

“ A catastrophic complication in individuals with

diabetes”: Tseng Gen Hosp Pysch 2007

More than 60% of non-traumatic amputations

• ccur in patients with diabetes mellitus

Non-Traumatic LEA in Patients with Diabetes

Diabetic Amputations

CDC: Diabetes Surveillance System 2007 Slide courtesy of Dr. Robert Frykberg

71,000

4.4/1000 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

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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?

Anesthesia and Analgesia 2005 (BI Deaconess)

30 Day Perioperative Cardiac Event

Anesthesia and Analgesia 2005 (BI Deaconess)

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Long term survival of patients who undergo AKA or BKA is dismal

Subramanium et al. Anesth Analg 2005

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

Perhaps it is the patient!

Gazis et al. Diab Med 2004 Moulik et al. Diabetes Care 2003

Limb Preservation at Georgetown

Evans: J Diab Comp 2011

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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

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Vascular Amputees Walker Slower than Traumatic Amputees

Waters et al. JBJS 1976

Quality of Life Studies

Suggest that the negative

impact on health related QOL in diabetic foot ulcer patients may be as severe

• r similar to patients who

have undergone lower extremity amputation!

Willrich et al. FAI 2005

Major Amputation and SF 36

(Higher score is better)

Willrich et al. FAI 2005

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

Boutoille et al. FAI 2008

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Although amputation remains a drastic step in the story

• f a DFU, its influence on the quality of life is not

worse than when the patient suffered from the ulcer

Willrich et al. FAI 2005, Boutoille et al. FAI 2008

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

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 23.6 47.7 * <0.001 Role Physical 13.3 40.8 *< 0.001 Bodily Pain 38.1 63.7 * <0.001 General Health 41.6 53.9 * <0.05 Vitality 39.7 51.5 * <0.05 Social Function 46.1 75.0 * <0.001 Role Emotional 33.3 66.2 * <0.01 Mental Health 59 71.7 * <0.05

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Patients Overall Health Improved

P < 0.001 Postop Preop Preop

Lower Extremity Function

Preop Postop Preop Postop

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

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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

Conclusion

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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 48-72 hours after amputation by eliminating the bacterial load

We do everything possible to avoid a Major

Amputation

Conclusion

30

2014 1920

PITTSBURGH