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Editorial

Lower-limb amputation and diabetes: the key is prevention

Education in footcare and regular examination will reduce the burden of diabetes-related amputation

MJA 2000; 173: 341-342

  Diabetes-related foot problems result in significant social, medical and economic consequences, and constitute the most common reason for hospital admission for people with diabetes.1 Lower-limb amputation is one of the most feared complications of diabetes, but comprehensive Australian data for its current incidence and prevalence in people with diabetes have not been previously available. It is thus timely that the study by Payne is published in this issue of the Journal.2 By analysing the National Hospital Morbidity Database of all hospital separations for the ICD codes which shared diabetes and lower-limb amputation over the financial years 1995-96, 1996-97 and 1997-98, he found a mean of 2629 lower-limb amputations per year. This tragic figure is even more frightening as it most likely represents an underestimate, because of the under-reporting of diabetes on discharge summaries.

In all countries, diabetes is the major risk factor for amputation. Data from the United States National Hospital Discharge Survey found an annual average of 110 000 amputations for the period 1989-1992. Of these, 32% were for amputation of toe, 10% foot/ankle, 23% below-knee, and 16% above-knee amputations.3 Of all discharges listing lower-limb amputation, about 51% also listed diabetes, even though people with diabetes represented only 3% of the total US population. The age-adjusted amputation rate calculated for people with diabetes is about 15 to 40 times higher than that for people without diabetes.

What are the other risk factors for amputation in people with diabetes? As in Payne's Australian study, the amputation rates in the US are 1.4 and 2.4 times higher for individuals aged 65-74 and aged 75 years and over, respectively, compared with those aged under 65 years.4 Apart from sex, the other major risk factors described are race or ethnic background: a number of US studies have shown higher rates of amputation for black and Hispanic people than for non-Hispanic white people.4 It is unfortunate that Payne was unable to determine this type of demographic data for the Australian population. Other major risk factors include the presence of peripheral neuropathy and lower-limb arterial disease.5,6 In turn, many factors contribute to the development of peripheral vascular disease, including hypertension, smoking and hyperlipidaemia. Finally, duration of diabetes and glycaemic control have been documented as risk factors for amputation and clearly contribute to both peripheral neuropathy and vascular disease.5-8

So, the profile of patients with diabetes at increased risk of amputation is well known. How can we reduce the risk of amputation in people with diabetes? The categorisation of risk of developing diabetes-related foot disease is relatively easily achieved in most people by basic clinical history and examination (Box 1).

Self-reported preventive practices in patients have been linked to decreased risk of lower-limb complications.3 However, among individuals with diabetes identified in the 1989 US National Heath Interview Survey, 22% stated they never checked their feet, and 52% checked their feet at least daily. In addition, 53% of patients reported no foot examination by a healthcare professional within the past six months.3 These behaviours need to be changed (Box 2).

High-risk foot clinics are also very successful both in healing ulcers and in reducing amputations in patients who have had foot ulcers.11 These multidisciplinary clinics involve specialists from vascular surgery, orthopaedic surgery, endocrinology, infectious diseases, orthotics, and podiatry. Recent advances in prosthetic and orthotic materials, design and manufacturing have improved the ability of clinicians to prevent ulceration in the at-risk foot. Furthermore, advances in orthopaedic techniques now enable the reconstruction of many feet previously considered beyond salvage.

What approaches are we taking in Australia to reducing diabetes-related foot problems? The National Diabetes Strategy, published in 1998, identified foot care as a major issue in the National Diabetic Foot Disease Management Program.12 Among the goals set was a 50% reduction in lower-limb amputation by the year 2005, and an 80% level of screening for diabetic foot disease risk factors each year. In addition, an increased availability of podiatry services and specialist foot clinics to provide these services was advocated. Guidelines for non-medical healthcare professionals have been formulated by the Australian Diabetes Educators Association and the Australian Podiatry Council, and Diabetes Australia has produced the Australian Podiatric Guidelines. Most States have established footcare guidelines for doctors, and national guidelines will soon be available. Furthermore, the Australian Diabetes Society position statement on the lower limb in people with diabetes is also published in this issue of the Journal.13 The position statement summarises the major issues and makes recommendations to reduce lower-limb problems for Australians with diabetes.

The overriding priorities are to ensure all people with diabetes practise appropriate self-care and that healthcare professionals examine the feet of all people with diabetes regularly to identify people at high risk for ulcer and amputation. Finally, appropriate funding is required to ensure that people at risk are provided with regular podiatry care and education and that people with active foot problems are provided with multidisciplinary foot care. Only when these are achieved will we start to make progress towards reducing this tragic and feared complication of diabetes.

Peter G Colman
Clinical Associate Professor, and Director
Department of Diabetes and Endocrinology
Royal Melbourne Hospital, Melbourne, VIC

Andrew D Beischer
Senior Lecturer
Department of Orthopaedic Surgery
Royal Melbourne Hospital, Melbourne, VIC

  1. Young MJ, Veves A, Boulton AJM. The diabetic foot: aetiopathogenesis and management. Diab Metab Rev 1993; 9: 109-127.
  2. Payne CB. Diabetes-related lower-limb amputations in Australia. Med J Aust 2000; 173: 352.
  3. Reiber GE, Boyko EJ, Smith DG. Lower extremity foot ulcers and amputations in diabetes. In: Diabetes in America. 2nd ed. Bethesda, Md: National Diabetes Data Group, National Institute of Diabetes and Digestive and Kidney Diseases, 1995; 409-427.
  4. Centers for Disease Control and Prevention. Diabetes Surveillance, 1993. Atlanta, GA: US Department of Health and Human Services, 1993; 87-93.
  5. Reiber GE, Pecoraro RE, Koepsell TD. Risk factors for amputation in patients with diabetes mellitus. A case-control study. Ann Intern Med 1992; 117: 97-105.
  6. Nelson RG, Gohdes DM, Everhart JE, et al. Lower extremity amputations in NIDDM: 12-yr follow-up study in Pima Indians. Diabetes Care 1988; 11: 8-16.
  7. Lee JS, Lu M, Lee VS, et al. Lower extremity amputation. Incidence, risk factors, and mortality in the Oklahoma Indian Diabetes Study. Diabetes 1993; 42: 876-882.
  8. Klein R. Hyperglycemia and microvascular and macrovascular disease in diabetes. Kelly West Lecture, 1994. Diabetes Care 1995; 18: 258-268.
  9. Litzelman DK, Slemenda CW, Langefeld CD, Hays LM. Reduction of lower extremity clinical abnormalities in patients with non-insulin dependent diabetes. Ann Intern Med 1993; 119: 36-41.
  10. Malone JM, Snyder M, Anderson G, Bernhard VM. Prevention of amputation by diabetic education. Am J Surg 1989; 158: 520-524.
  11. Edmonds ME, Blundell MP, Morris ME, Thomas EM. Improved survival of the diabetic foot: the role of a specialized foot clinic. QJM 1986; 60: 763-771.
  12. Colagiuri S, Colagiuri R, Ward J. National Diabetes Strategy and Implementation Plan. Canberra: Diabetes Australia, 1998.
  13. Campbell LV, Graham AR, Kidd RM, et al. The lower limb in people with diabetes. Position statement of the Australian Diabetes Society. Med J Aust 2000; 173: 369-372.

©MJA 2000
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1: Assessing the risk of diabetic foot disease

History
Look for a history of:

  • non-traumatic partial or total foot amputation,
  • a diabetic foot ulcer, or
  • admission to hospital for a diabetes-related foot infection.

Examination
It is not unreasonable to expect these procedures to be performed by medical and non-medical healthcare professionals in the primary care setting:

  • Both feet should be inspected for the presence of obvious deformity and for trophic skin changes.
  • A careful examination should be made for callosities, which may herald incipient ulceration, particularly if present on the plantar aspect of the foot.
  • Peripheral neuropathy, with a loss of protective sensation, can be identified using a 10g Semmes-Weinstein monofilament.
  • Peripheral vascular disease can be detected by palpation of the pedal pulses.
  • Shoes should also be inspected to ensure proper fit and also for unusual wear that may be the result of deformity.
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2: Interventions to improve footcare among people with diabetes

  • A 12-month randomised trial evaluated the effectiveness of comprehensive patient, healthcare provider, and system interventions on risk factors for amputation in 352 patients with type 2 diabetes.9 Patients were randomised to a foot-care group that provided education, and telephone and postcard prompts. Physicians assigned to intervention patients received practice guidelines, information on amputation risk factors and footcare practice and prompts. As a result, physicians detected ulcers in the intervention group more frequently. Similarly, foot self-care behaviours were reported more frequently by intervention patients.
  • A similar prospective randomised study used an intervention in which patients attended a one-hour class and were given written instructions for footcare.10 Clinical care for both groups was identical. After one year of follow-up, there was a threefold excess for both foot amputations and ulcers in the group receiving no education. A case-control study reported the same findings.5 Interestingly, patient education provided at the time of diabetes diagnosis and in hospital settings did not show the same benefit as formal outpatient diabetes education nearer to amputation.
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