The Diabetic Foot Amputation Decision-Making Process.

NewsBot · Aug 24, 2018

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The Diabetic Foot Amputation Decision-Making Process.
Wang SY et al
Adv Skin Wound Care. 2018 Sep;31(9):413-420.

OBJECTIVE:
Diabetes has been the fourth leading cause of death in Taiwan since 2002 and is one of the top four most prevalent chronic diseases worldwide. Patients who have diabetic foot, as well as their families, are faced with the burden of possible limb amputation. The aim of this study was to explore the amputation decision-making process with patients with diabetic foot and their families.

METHODS:
Grounded theory was used in this study. Data from 16 participants at a regional hospital in Taiwan were collected using purposive sampling. The data analysis was conducted through open coding, axial coding, selective coding, and memo writing.

RESULTS:
The study revealed that the core factor in the decision-making process was "amputation in order to survive." Patients and families additionally considered "the devastation of experiencing multiple diseases," "treatment of poorly healing wounds," and "facing the decision of whether to undergo amputation."

CONCLUSIONS:
After understanding the patients' decision-making process regarding amputation, healthcare providers should be encouraged to empathize with such patients. Further, providers should respect the patients' and families' decision and provide them with necessary care. Future research should explore professional perspective and family members' care process for amputees to understand the decision-making process of patients who require amputation.
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NewsBot · May 31, 2020

The Correlation of the Trans-Atlantic Inter-Society Consensus Classification to Outcomes of Pedal Amputations
Matthew D. Doyle et al
JFAS: May 28, 2020

In an attempt at limb salvage for patients with peripheral arterial disease, revascularization is often performed prior to pedal amputation. The purpose of this study was to evaluate the association between proximal arterial lesions, based on Trans-Atlantic Inter-Society Consensus aortoiliac, femoropopliteal, and infrapopliteal classifications, and healing pedal amputations post endovascular revascularization. Patients with revascularization up to 90 days prior to pedal amputation with a minimum of 12 months post-operative follow-up were included. Each level of proximal disease was subdivided into Trans-Atlantic Inter-Society Consensus Classifications A through D, which range in severity from a single short stenosis or occlusion to more complex stenoses and chronic total occlusion. For comparison, we categorized A/B lesions into Group 1 and C/D lesions into Group 2. The frequency of proximal lesions was recorded as either isolated, bi-level, or multi-level disease. Chi-square and Fisher's exact tests were used to compare categorical variables. Of the 310 patients, there were a total of 68 aortoiliac, 256 femoropopliteal, and 172 infrapopliteal lesions; 140 patients had isolated lesions, 154 had bi-level disease, and 16 had multi-level disease. Although not statistically significant, patients in Group 1 (A/B lesions) had higher proportion of failed amputation compared to Group 2 (C/D lesions) in either aortoiliac (84.4% vs 15.6%, p=0.17), femoropopliteal (61.2% vs 38.8%, p=0.72), or infrapopliteal (57.3% vs 42.7%, p=0.44). Bi-level disease showed a higher proportion of failure (50.6%) compared to isolated lesions (43.8%) and multi-level disease (5.6%), (p=0.86). To our knowledge, this is the first study to evaluate the association between Trans-Atlantic Inter-Society Consensus arterial lesions and incisional healing of pedal amputations. Despite our belief, there was no correlation between patients with simple, isolated lesions compared to either complex arterial lesions or multi-level disease in healing pedal amputations.
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NewsBot · Nov 26, 2022

Surgical amputation for patients with diabetic foot ulcers: A Chinese expert panel consensus treatment guide
Xuan Liao et al
Front Surg. 2022 Nov 8;9:1003339

Background: Diabetic foot disease is a serious complication of diabetes mellitus. Patients with diabetes mellitus have a 25% lifetime risk for developing a foot ulcer, and between 14% and 24% of patients require a major or minor lower limb amputation due to severe gangrene. However, decisions concerning whether to amputate or whether to perform a major or minor lower limb amputation, and how best to determine the amputation plane remain unclear.

Methods: To consolidate the current literature with expert opinion to make recommendations that will guide surgical amputation for patients with diabetic foot ulcers. A total of 23 experts experienced in surgical treatment of patients with diabetic foot ulcers formed an expert consensus panel, and presented the relevant evidence, discussed clinical experiences, and derived consensus statements on surgical amputation for patients with diabetic foot ulcers. Each statement was discussed and revised until a unanimous consensus was achieved.

Results: A total of 16 recommendations for surgical amputation for patients with diabetic foot ulcers were formulated. The experts believe that determination of the amputation plane should be comprehensively evaluated according to a patient's general health status, the degree of injury, and the severity of lower limb vasculopathy. The Wagner grading system and the severity of diabetic lower extremity artery disease are important criteria when determining the degree of amputation. The severity of both diabetic foot infection and systemic underlying diseases are important factors when considering appropriate treatment. Moreover, consideration should also be given to a patient's socioeconomic status. Given the complexities of treating the diabetic foot, relevant issues in which consensus could not be reached will be discussed and revised in future.

Conclusion: This expert consensus could be used to guide doctors in clinical practice, and help patients with diabetic foot ulcers gain access to appropriate amputation treatment.
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NewsBot · Jan 18, 2023

Timing of minor and major amputation in patients with diabetes-related foot ulceration admitted to two public tertiary referral hospitals in Australia
Sarah M Manewell et al
ANZ J Surg. 2022 Dec 28

Background: There is limited information regarding the number of patients with diabetes-related foot ulceration (DFU) who receive minor or major amputation, and how quickly these amputations occur. This study aimed to identify the incidence of index minor and major amputation among inpatients with DFU over 4 years, and where amputation occurred during the patient's index DFU-related admission, investigate prognostic factors.

Methods: The incidence of index minor and major amputation, and the admission sequence during which amputation occurred were identified from DFU-related admissions to two public hospitals during 2014-2018. Where minor or major amputation occurred during the patient's index DFU-related admission, prognostic factors were investigated using logistic regression.

Results: DFU-related hospital admissions were required by 564 patients. The incidence of minor amputation over 4 years was 34% (n = 193). The incidence of minor amputation during the patient's index DFU-related admission was 28% (n = 155), which was associated with requiring revascularisation (odds ratio [OR] 2.33, 95% CI 1.53-3.55, P < 0.001). The incidence of major amputation over 4 years was 8% (n = 45). The incidence of major amputation during the patient's index DFU-related admission was 6% (n = 31), which was associated with having more comorbidities (OR 1.58, 95% CI 1.10-2.26, P = 0.01) and receiving care for a mental health condition (OR 3.85, 95% CI 1.48-10.01, P = 0.006).

Conclusion: Most amputations occurred during the patient's index DFU-related hospital admission. Major amputation during a patient's index admission was associated with more comorbidities and mental health conditions.
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NewsBot · Feb 26, 2024

Decision-making processes for non-emergency diabetes-related lower extremity amputations: A scoping review
Emilee Kim Ming Ong et al
Diabetes Res Clin Pract. 2023 Dec:

Living with a diabetes-related foot ulcer has significant lifestyle impacts. Whilst often considered a last resort, amputation can overcome the burden of ulcer management, for an improved quality of life. However, limited research has been conducted to understand how the decision to amputate is made for people with a chronic ulcer when amputation is not required as a medical emergency. Therefore, the aim was to identify and map key concepts in the literature which describe the decision-making for diabetes-related amputations. This review followed Arksey and O'Malley's PRISMA scoping review framework. Five electronic databases and grey literature were searched for papers which described clinical reasoning and/or decision-making processes for diabetes-related amputation. Data were extracted and mapped to corresponding domains of the World Health Organisation's International Classification of functioning, Disability and Health (ICF) framework. Ninety-four papers were included. Personal factors including emotional wellbeing, quality of life, and treatment goals are key considerations for an elective amputation. It is important to consider an individual's lifestyle and personal circumstances, as well as the pathology when deciding between amputation or conservative management. This highlights the importance of a holistic and shared decision-making process for amputation which includes assessment of a person's lifestyle and function.
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NewsBot · Apr 19, 2024

Development and content validation of a financial and functional outcomes tool for diabetes-related foot disease in patients undergoing major lower limb amputation: a prospective observational study from Pakistan
Nadeem Ahmed Siddiqui et al
BMJ Open. 2024 Mar 29;14(3):

Objective: To develop and content validate a questionnaire to assess the financial and functional impact of major lower limb amputation in patients with diabetes-related foot disease.

Design: Prospective observational study.

Setting: This study was conducted at a tertiary care centre in Pakistan.

Participants: We conducted a thorough literature review and a group interview with 10 participants, resulting in domain identification and item generation. The group included seven patients with diabetes-related foot disease who underwent major lower limb amputation and three caregivers. Subsequently, a focused group discussion was held to assess overlap and duplication among the items, and two rounds of content validation were carried out by five content and five lay experts in both English and Urdu. Question items with a Content Validity Index (CVI) score of >0.79 were retained, items with a CVI score between 0.70 and 0.79 were revised and items with a CVI score of <0.70 were excluded.

Results: The initial literature review and group interview resulted in 61 items in the financial and functional domains. After the focused group discussion, the questionnaire was reduced to 37 items. Following two rounds of content validation, the English questionnaire achieved the Scale-Content Validity Index/Average (S-CVI/Ave) of 0.92 and 0.89 on relevance and clarity, respectively. Similarly, the Urdu questionnaire achieved the S-CVI-Ave of 0.92 and 0.95, respectively.

Conclusion: A 37-item multidimensional questionnaire was developed and rigorously content-validated to assess the financial and functional impact of major lower limb amputation in patients with diabetes-related foot disease. The questionnaire used in this study has shown robust content validity specifically for our population.
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