amputation the answer

1. Dr. Johny KannampillyDr. Johny Kannampilly
Consultant Diabetologist & Diabetic foot specialist,Consultant Diabetologist & Diabetic foot specialist,
Diabetes centre &Diabetes centre &
Diabetes LEAP (Lower Extremity Amputation Prevention) CentreDiabetes LEAP (Lower Extremity Amputation Prevention) Centre
Lakeshore Hospital & Research Centre, KochiLakeshore Hospital & Research Centre, Kochi
DFSI
mumbai
2006

2. IS AMPUTATION THE ANSWERIS AMPUTATION THE ANSWER
TO DIABETIC FOOT PROBLEMSTO DIABETIC FOOT PROBLEMS
??DFSI
mumbai
2006

3.  1 Amputation in every 10th minute
 45000 India Every Year
 85% Of Amputations Are Due To Untreated
And/Or Inadequately Treated Diabetic Foot
Ulcers
BURDEN
DFSI
mumbai
2006

4. BURDEN OF DIABETIC FOOTBURDEN OF DIABETIC FOOT
 Majority Of Diabetic Foot Ulcers In India AreMajority Of Diabetic Foot Ulcers In India Are
Neuropathic InfectiveNeuropathic Infective
 15% Lesions Have Associated Vasculopathy15% Lesions Have Associated Vasculopathy
 Prevention Is Easy And Treatment Is CostPrevention Is Easy And Treatment Is Cost
EffectiveEffective
DFSI
mumbai
2006

5. WHY FOOT NEEDS TO BEWHY FOOT NEEDS TO BE
SAVED IN DIABETES ?SAVED IN DIABETES ?
 Bk Amputation Requires 40% MoreBk Amputation Requires 40% More
Kcal/MinKcal/Min
 Net Oxygen Consumption IncreasesNet Oxygen Consumption Increases
 Needs 5 -10 % Extra Cardiac ReserveNeeds 5 -10 % Extra Cardiac Reserve
 85% Mortality At The End Of 5 Years85% Mortality At The End Of 5 Years
DFSI
mumbai
2006

6. Krauts et al. Foot 1997
Boyko et al. Diabetic Med. 1996
MORTALITY FOLLOWING
AMPUTATION
1 year - 11-41%
3 years - 20-50%
5 years - 39-68%
DFSI
mumbai
2006

7. Relation of lower-extremity amputation to all-Relation of lower-extremity amputation to all-
cause and cardiovascular disease mortality incause and cardiovascular disease mortality in
American Indians: the Strong Heart StudyAmerican Indians: the Strong Heart Study..
..
Diabetes Care. 2004 Jun;27(6):1286-93Diabetes Care. 2004 Jun;27(6):1286-93
OBJECTIVE: compare risk of all-cause and cardiovascular disease
(CVD) mortality in people with a lower-extremity amputation (LEA)
attributable to diabetes and people without an LEA.
RESEARCH DESIGN AND METHODS: study of CVD and its risk
factors in 13 American-Indian communities. LEA was ascertained at
baseline by direct examination of the legs and feet. Mortality
surveillance is complete through 2000.
RESULTS: 2,108 participants with diabetes
134 participants (6.4%) had an LEA.
Abnormal ankle-brachial index (53%), albuminuria (87%),

8. Diabetes Duration
Diabetic participants without LEA- 11.9 years
Toe amputation -18.6years
Below-the-knee amputations -21.1 years
Diabetic subjects with LEA - 19.8 years
During 8.7 (+/-2.9) years of follow-up
102 of the participants with LEA (76%) died from all causes
35 (26%) died from CVD
1,974 diabetic participants without LEA at baseline,
604 (31%) died from all causes and 206 (10%) died from CVD.
CONCLUSIONS: LEA is a potent predictor of all-cause and
CVD mortality in diabetic American Indians.

9. 6-30 % within 1-3 years
12 % at 1 year
28-51 % at 5 years
SECOND LEG AMPUTATION
Diabetic Med. 1992
DFSI
mumbai
2006

10. Risk of contralateral limbRisk of contralateral limb
Extra weight –bearing load on contralateral foot
increase-risk for ulceration-progress to amputation
Work of walking –energy expeniture increase
DFSI
mumbai
2006

11. Deformed Foot With GoodDeformed Foot With Good
Foowear Is Preferable ToFoowear Is Preferable To
Amputed Leg With SophisticatedAmputed Leg With Sophisticated
ProsthesisProsthesis
DFSI
mumbai
2006

12. DEFORMED BUT “WALKABLE”
DIABETIC FOOT
DFSI
mumbai
2006

13. NEWER TECHNOLOGIESNEWER TECHNOLOGIES

14. Syme ankle disarticulation inSyme ankle disarticulation in
patients with diabetes.patients with diabetes.
J Bone Joint Surg Am. 2003 Sep;85-A(9):1667-72J Bone Joint Surg Am. 2003 Sep;85-A(9):1667-72METHODS: Ninety-seven adult patients with diabetes mellitus who
underwent Syme ankle disarticulation because of a neuropathic foot
with an infection or gangrene, or both, during an eleven-year period
were studied retrospectively
RESULTS: Eighty-two patients (84.5%) achieved wound-healing. At a
minimum follow-up of two years, all but two patients were able to walk
with a prosthesis. Thirty of the ninety-seven patients died at an average
of 57.1 months following surgery.
CONCLUSIONS:. This function-sparing amputation can be
successfully performed with a reasonable risk. Patients managed with a
Syme ankle disarticulation appeared to remain able to walk better and to
survive longer than similar patients who had a transtibial amputation
and served as historical controls.

15. Mobility outcome following unilateralMobility outcome following unilateral
lower limb amputation.lower limb amputation.
Prosthet Orthot Int. 2003 Dec;27(3):186-90Prosthet Orthot Int. 2003 Dec;27(3):186-90
Study concludes that mobility rates one year after
prosthetic provision for unilateral trans-tibial and
trans-femoral amputees worsen with increasing
age at amputation and a higher level of
amputation.
DFSI
mumbai
2006

16. DIABETIC FOOT AMPUTATIONDIABETIC FOOT AMPUTATION
IN 19IN 19THTH
CENTURYCENTURY
DFSI
mumbai
2006

17. ““I Marvel A Society Which Is ReadyI Marvel A Society Which Is Ready
To Pay A Surgeon A Large AmountTo Pay A Surgeon A Large Amount
Of Money To Amputate A Leg ButOf Money To Amputate A Leg But
Nothing To Save It “Nothing To Save It “
George Bernad ShawGeorge Bernad Shaw

18.  Amputation is the easy choice for the treating doctorAmputation is the easy choice for the treating doctor
and also quick remedy for the patientand also quick remedy for the patient
 Conservative foot salvage is time consuming for theConservative foot salvage is time consuming for the
doctor and patient. It needs skill and perservence by thedoctor and patient. It needs skill and perservence by the
doctor and patience by the patientsdoctor and patience by the patients
 But conservative foot salvage has better long termBut conservative foot salvage has better long term
outcome in terms of mortality and morbidityoutcome in terms of mortality and morbidity
 Long term financial cost is the same for both amputatedLong term financial cost is the same for both amputated
patients and conservative foot salvage patientspatients and conservative foot salvage patients
CONSCLUSION
DFSI
mumbai
2006

19. An ancient Sanskrit saying.
“ The one who walks, his good fortune
also marches ahead. ”
PRESERVE & PROTECT THEMDFSI
mumbai
2006

20. THANK YOUTHANK YOU
DFSI
mumbai
2006