Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Everything that you are ever going to want to know about running shoes: Running Shoes Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
  2. Have you considered the Critical Thinking and Skeptical Boot Camp, for taking it to the next level? See here for more.
    Dismiss Notice
  3. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

No incidence of amputation

Discussion in 'Diabetic Foot & Wound Management' started by David Smith, Oct 19, 2012.

  1. David Smith

    David Smith Well-Known Member

    Members do not see these Ads. Sign Up.
    Hi all

    Yesterday we went to the Foot in Diabetes UK Conference at Ibis Earls Court London. Many seminars focusing on Wound care, prevention and management and management of diabetic foot care service. I run a busy High street private practice seeing up to 80 customers a week. It kind of dawned on me at some point that despite have quite a high percentage of patients with diabetes type one and two, I have never had a single patient who has ever required surgical amputation of a limb, not even a toe. I see all types of risk classification but none presenting with wounds requiring surgery or extensive debridement because those types of cases are usually referred directly to the NHS podiatry dept.

    Now the obvious reply to that is that I don't see the high risk cases with severe pathology so that those I see wouldn't have the sequela of limb loss.
    But high risk cases are not a start point they are an end result and what I don't see are cases progressing to that end result that then require referral to a Multi Disciplinary Team for instance. It was interesting and surprising to note that there was a new term introduced " Foot Attack" and foot attack require rapid appropriate treatment on the premise that if some one with diabetes had presented with 3 of the following - neuro ischaemia, PAD, non palpable pulses, infection, ulceration, then they had a higher 5 year mortality rate than those suffering heart attack or CVA.

    Now, if memory serves, the statistic given yesterday was something like that 60-70% of those with diabetes would progress to neuropathic limbs and if more sensitive tests were done it would more likely be close to 90%. Of those about 50% would have severe degeneration and amputation due to neuro-ischaemia and 20% would lose their life within 5 years and much more than this if they did not receive early well managed treatment programs.

    So, why don't I see that sort of progression in my diabetic patient demographic?
    Maybe they escape out of my care without noticing and are taken up by the NHS but I think that is unlikely since other patient groups that go to NHS care for other reasons usually return with their history noted and recorded. Even if they did not return as is more likely to be the case with high risk diabetics there would still be the trail of disease progression and referral for many patient but that is not seen.

    I wonder if you would care to comment on why that might be? Also is this normal experience for other private clinics?

    Regards Dave Smith
    Last edited: Oct 19, 2012
  2. David Smith

    David Smith Well-Known Member


    So I seemed to have answered my own question:

    Last night reading up on research it would appear that total amputation rates are somewhat lower than expressed at the conference at about 0.25% of the diabetic population. So maybe I heard wrong or didn't understand correctly or there was some exaggeration or misinterpretation or the mainstream research is wrong!!?? Having said that reports also suggest that there can be a wide regional variation by a factor of 10 so reported results may depend on where the population sample is taken.

    Diabetes UK report 2012 says - "Around one in twenty people with diabetes will develop a foot ulcer in one year.62 More than one in ten foot ulcers result in the amputation of a foot or a leg." (but that's not including minor loss like toes but still equates to 1/200 or >0.5%)

    and "Up to 70 per cent of people die within five years of having an amputation as a result of diabetes." (0.35% total Diabetes population)

    Anyway the major research shows that total amputation rates minor and major including toes is around 2.5/1000 people with diabetes or 0.25% of the diabetic population. ( I only read summaries so I don't know SD) So anyway, over 13 years I have seen about 4800 individual people. around 30% of those report Diabetes, which is around 1600 and so one might expect only 4 of those to have amputations. Therefore it might be quite reasonable that those 4 might have moved out of my area or of my list or even that the amputation rate in that particular population by chance turned out to be much lower than 0.25-0.5%

    Regards Dave Smith
  3. Jonix

    Jonix Active Member

    I was there too, and I heard your comment. "That you know of", was my silent reply!!

    However, I do think that any patient who is MOTIVATED enough to see a private practitioner is giving them selves a big helping hand in preventing progression to ulceration and amputation. I think motivation is the key here, and it is more frequently found in patients who seek private care, or maybe its is also germinated by regular contact with someone who appears to care about them on a practical level.

    I have a number of very high risk patients (previous ulcer or amputation) who attend this clinic regularly in the hope of preventing or postponing future amputation. I think the motivation of these patients is what has kept them sound thus far. Though it is ongoing, ongoing, ongoing. And along the way there have been emergency trips to hospital not necessarily just for feet.. but for leg wounds and injuries that they were otherwise neglecting.

    However, it is also not extremely unusual to have new patients book for nail care who in addition happen to have stinking infected foot wounds, who I send off to A&E actually in the hope of oral ABs or even some level of amputation. In this case, it is frequently a family member or friend who suddenly becomes aware of a problem, when the patient themselves was not.
  4. Tkemp

    Tkemp Active Member

    While working in public health I treated many foot ulcers.
    Amputation generally occured in patients with uncontrolled BGLs, other related complications eg. kidney failure, chronic limb ischaemia, or continued non-complicance with the wound care regime eg. as noted when swabbing of wounds revealed fecael matter and dog hairs, or their removing the dressings and applying meths to the wounds- old wives cure.

    However, some unfortuante patients presented with MRSA or biofilm in their wounds which did not respond to less invasive surgery, leaving surgical debridement/ amputation as the only option.

    As Jo mentioned, if you take medical complications out of the equation, motivation is a large factor in the prevention of ulceration. That combined with self-care education. We need to empower our patients with the knowledge and skills to help them reduce their risk of ulceration and amputation.
    Obviously in your practise David you are doing this, and all kudos to you for this!

Share This Page