Dr. Johny KannampillyDr. Johny KannampillyConsultant Diabetologist & Diabetic foot specialist,Consultant Diabetologist & Diabetic foot specialist,

Diabetes centre &Diabetes centre & Diabetes LEAP (Lower Extremity Amputation Prevention) Centre Diabetes LEAP (Lower Extremity Amputation Prevention) Centre

Lakeshore Hospital & Research Centre, KochiLakeshore Hospital & Research Centre, Kochi

DFSI mumbai 2006

IS AMPUTATION THE ANSWERIS AMPUTATION THE ANSWER

TO DIABETIC FOOT PROBLEMS TO DIABETIC FOOT PROBLEMS

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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

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BURDEN OF DIABETIC FOOTBURDEN OF DIABETIC FOOT Majority Of Diabetic Foot Ulcers In Majority Of Diabetic Foot Ulcers In

India Are Neuropathic InfectiveIndia Are Neuropathic Infective 15% Lesions Have Associated 15% Lesions Have Associated

VasculopathyVasculopathy Prevention Is Easy And Treatment Is Prevention Is Easy And Treatment Is

Cost EffectiveCost Effective

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WHY FOOT NEEDS TO BE WHY FOOT NEEDS TO BE SAVED IN DIABETES ?SAVED IN DIABETES ?

Bk Amputation Requires 40% More Bk Amputation Requires 40% More Kcal/MinKcal/Min

Net Oxygen Consumption IncreasesNet Oxygen Consumption Increases Needs 5 -10 % Extra Cardiac Needs 5 -10 % Extra Cardiac

ReserveReserve 85% Mortality At The End Of 5 Years85% Mortality At The End Of 5 Years

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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%

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Relation of lower-extremity amputation to all-Relation of lower-extremity amputation to all-cause and cardiovascular disease mortality in cause 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%),

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.

6-30 % within 1-3 years

12 % at 1 year

28-51 % at 5 years

SECOND LEG AMPUTATION

Diabetic Med. 1992

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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

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Deformed Foot With Good Deformed Foot With Good Foowear Is Preferable To Foowear Is Preferable To

Amputed Leg With Sophisticated Amputed Leg With Sophisticated ProsthesisProsthesis

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DEFORMED BUT “WALKABLE” DIABETIC FOOT

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NEWER TECHNOLOGIESNEWER TECHNOLOGIES

Syme ankle disarticulation in Syme 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):1667-72 METHODS: 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.

Mobility outcome following unilateral Mobility outcome following unilateral lower limb amputation.lower limb amputation.

Prosthet Orthot Int. 2003 Dec;27(3):186-90 Prosthet 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.

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DIABETIC FOOT AMPUTATIONDIABETIC FOOT AMPUTATION IN 19 IN 19THTH CENTURY CENTURY

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““I Marvel A Society Which Is Ready I Marvel A Society Which Is Ready To Pay A Surgeon A Large Amount To Pay A Surgeon A Large Amount Of Money To Amputate A Leg But Of Money To Amputate A Leg But

Nothing To Save It “Nothing To Save It “

George Bernad ShawGeorge Bernad Shaw

Amputation is the easy choice for the treating Amputation is the easy choice for the treating doctor and also quick remedy for the patientdoctor and also quick remedy for the patient

Conservative foot salvage is time consuming for the Conservative foot salvage is time consuming for the

doctor and patient. It needs skill and perservence doctor and patient. It needs skill and perservence by the doctor and patience by the patientsby the doctor and patience by the patients

But conservative foot salvage has better long term But 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 Long term financial cost is the same for both amputated patients and conservative foot salvage amputated patients and conservative foot salvage patientspatients

CONSCLUSION

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An ancient Sanskrit saying.“ The one who walks, his good fortune

also marches ahead. ”

PRESERVE & PROTECT THEM

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THANK YOUTHANK YOU

DFSI mumbai 2006