Foot or Leg Amputation and Diabetes

Foot or Leg Amputation and Diabetes

Also called: Lower Limb Amputation, Lower Extremity Amputation

Summary

Foot or leg amputation refers to surgical removal of a lower limb, often because of poor circulation or an uncontrolled infection that has destroyed skin, muscle and other tissue. It is one of the most traumatic yet preventable complications of diabetes.

Diabetes is the leading cause of foot or leg amputation in the United States. Interventions such as control of glucose (blood sugar), proper shoes, patient education and a program of daily foot care could prevent most of these amputations, according to the U.S. Centers for Disease Control and Prevention. Rates of diabetic amputations have fallen in recent years.

Foot or leg amputation caused by diabetes often results from a minor injury such as a blister that goes untreated and escalates into an infection or ulcer. For example, a person with diabetes often has nerve damage (diabetic neuropathy) that reduces sensation. This impairment makes it harder to notice and treat minor injuries such as blisters and skin cracks. Infections can enter these wounds and spread. Common complications of diabetes such as peripheral arterial disease (clogged blood vessels in the arteries, usually in the leg or foot) and hyperglycemia (high blood glucose) make healing more difficult. Infections can worsen and kill skin, muscle and even bone. By that point, amputation may be the only way to stop the infection.

Foot or leg amputation is performed by a surgeon in a hospital under general or regional anesthesia. Recovery is an extensive process of outpatient and usually inpatient care. Treatment involves wound care, stump care, physical therapy, prosthetic training and counseling.

About foot or leg amputation

A foot or leg amputation caused by the complications of diabetes is an operation in which some or most of a lower limb is removed. This is typically an inpatient procedure performed in a hospital by a surgeon using general or regional anesthesia.

Along with blindness and chronic kidney failure, amputation is one of the most devastating consequences of poorly controlled diabetes. Most of these amputations originate as a sore on the foot and could have been prevented.

People with diabetes account for 7 percent of the U.S. population but more than 60 percent of nontraumatic lower limb amputations, according to the U.S. Centers for Disease Control and Prevention (CDC). The incidence of diabetic amputation is higher among elders, men and members of racial and ethnic minorities.

Annual rates of lower limb amputations have declined in recent years from a peak of nearly 10 for every 1,000 diabetic Americans in the mid-1990s to 5.2 per 1,000 in 2003, the latest year for which data are available, the CDC reported in 2007. The percentage for 2003 is similar to those of the early 1980s. An estimated 75,000 diabetic amputations were performed on Americans in 2003.

Diabetic complications that may lead to the need for amputation include:

  • Impaired circulation caused by peripheral arterial disease (PAD) and atherosclerosis. Unhealthy amounts of cholesterol in the blood increase the risk of atherosclerosis and PAD.
  • Suppression of the immune system due to impaired circulation, which hinders infection-fighting white blood cells.
  • Reduced sensation and increased risk of injury due to neuropathy (nerve damage).
  • Dry skin that results from neuropathy and decreased circulation. It can crack and allow infection to enter.
  • High blood pressure, which can worsen the above risk factors.

Diabetic foot or leg amputation often begins with a seemingly minor injury. The following scenario is typical:

  • Poorly fitting shoes cause a blister.
  • Unnoticed and untreated, the blister opens.
  • A common bacterial, fungal or other microbial infection enters the sore.
  • Poor circulation limits the body’s ability to fight the infection.
  • The ulcer deepens and damages muscle tissue.
  • The infection spreads to bone (osteomyelitis).
  • The infection kills tissues (gangrene).
  • Antibiotics and wound care fail to cure the infection.
  • Amputation becomes the only way to keep gangrene from spreading.

One amputation is a risk factor for a second foot or leg amputation. Prevention, then, remains a major concern for amputees as well as potential amputees, such as persons with diabetes who have a foot deformity, nerve damage or poor circulation.

According to the NIH, ill-fitting footwear and failure to treat minor foot injuries early are the most common and avoidable causes of diabetic foot or leg amputation. It is essential for people with diabetes to:

  • Wear proper shoes and socks
  • Clean and inspect the feet daily
  • Get prompt medical attention for any foot problems
  • Have a comprehensive foot exam at least once a year by a physician

In addition, quitting smoking can benefit the blood vessels and reduce the risk of foot problems that may lead to amputation.

Most amputations in developed countries are intentional surgical procedures required because of complications from diabetes. In rare cases, spontaneous amputation may occur when a toe, finger or other body part falls off. Complications of diseases including diabetes and leprosy can cause this.

Before the foot or leg amputation

Sometimes a foot or leg amputation is an emergency procedure with little time to prepare, such as a longtime infection that has suddenly worsened. Often, however, the patient and healthcare team will have advance notice of the need for amputation. This time will allow for several types of preparation:

  • Medical. The surgeon will perform tests to determine the optimal level of amputation. An ideal site offers enough blood flow to promote healing and enough of a stump to accommodate a prosthetic limb. These tests are generally painless and noninvasive. The tests may include:

    • Monitoring of blood pressure at various sites on the leg or foot
    • Doppler ultrasound to measure blood flow in the arteries
    • Fluorescent measurement of the small blood vessels in the skin
    • Infrared measurement of skin temperature
    • Transcutaneous oxygen measurement. Use of electrodes to detect the amount of oxygen passing through the skin.

  • Physical. Exercises to strengthen the upper and lower body will speed recovery from the surgery and make it easier to use assistive devices such as crutches and prosthetics. The physician may refer a patient to a physical therapist, exercise physiologist or other health professional who can devise and monitor a strengthening and endurance program. A dietitian may be consulted if recovery is at risk because of malnourishment.
  • Mental and emotional. The physician will give the patient details of the procedure and receive a signed consent form. Knowing what to expect before the surgery can help prepare the patient and family. Loss of a limb often affects a person’s self-image. Counseling may be necessary (and should be planned) to restore a person’s self-confidence and self-esteem.
  • Environmental. The physician might order a home evaluation in advance by a physical therapist, occupational therapist or both. These professionals will note safety issues and the need for any modifications of the home, such as installation of a stair railing or removal of rugs. Alternately, a home evaluation might be ordered shortly before the amputee returns home.

Insurance may cover some of the physical, mental and environmental preparations for amputation.

Amputation ranges from removal of a toe to the entire leg. It is natural to hope for the least invasive intervention possible. The patient should understand that the extent of the surgery depends on factors the individual cannot control.

An above-the-knee amputation (AKA) may be necessary if circulation in the foot and lower leg is insufficient to promote healing. The site of amputation needs to be free of infection but ideally will have adequate limb length to accommodate a prosthetic.

In some cases, such as a below-knee amputation (BKA), a midlength stump may work better with an artificial limb than a longer stump. An AKA with a long stump may be preferable to a BKA with a stump too short to allow for a prosthesis.

During the foot or leg amputation

An amputation is performed in a hospital’s operating room by a general or orthopedic surgeon. Regional or general anesthesia is used. Antibiotics may be administered as well before surgery. Amputation of a lower limb usually requires hospitalization for several days, but less extensive surgery such as toe amputation might not require an overnight stay.

The surgery has two goals:

  • To remove the unhealthy tissue
  • To create a cone-shaped stump that will heal and accept an artificial limb (for more extensive amputations)

Surgical procedures vary according to the type of amputation. A general description of what may take place during an amputation of the lower extremity includes:

  • Tourniquets may be used to reduce bleeding but might be avoided with patients who have impaired circulation.
  • The site of incision is cleaned with antiseptic. 
  • Generally the preferred site for amputation is at a joint to avoid the added complication of cutting a bone in half.
  • The incision is made through the skin. Two flaps of skin and underlying tissue are created. As much skin as possible is kept and will be used later in the surgery to cover the stump. The muscle is cut, and the blood vessels are exposed.
  • The main arteries and veins are cut. They are reconnected to restore circulation.
  • The nerves are pulled down, tied above the site of amputation and cut. Severing them above the amputation site helps keep the patient from later experiencing pain in the stump (phantom limb pain).
  • If bone is to be bisected, it is cut with a surgical saw. Bony prominences near the amputation site are filed.
  • Muscle is extended over the amputation site and sutured over bone. The skin flaps are gathered over the site and sewed together.
  • Sterile wound dressings are applied. These will be changed frequently during recovery. In some cases a rigid dressing, splint or cast is applied at the end of the surgery. These may be removed within a week or two. The stitches may be removed after two to four weeks.
  • The patient is wheeled into a surgery recovery room for monitoring while the anesthetic wears off. Medications such as antibiotics and painkillers may be given.

After the foot or leg amputation

What to expect during recovery from a foot or leg amputation depends on how much of the limb was removed. Recovery for the different types of amputation includes:

  • Toes or forefoot. Unlike the more involved amputations, this type may not require an overnight hospital stay. Outpatient physical therapy can begin a day or two after discharge. The splint may be removed within the first week. The physician may allow the patient to bear weight on the involved leg after four to six weeks, or when the wound heals. During healing the wound granulates, forming small bumps of tissue. The wound requires sterile dressings until healing is complete. A custom shoe may be the only prosthetic device required.
  • Below the knee. A temporary splint may be used to protect the sutured incision. It will also help keep the knee from bending. A flexion contracture (muscle disuse causes the knee to be stuck in a bent position) is a risk of a below-knee amputation (BKA). One focus of therapy will be on avoiding this complication, which would prevent use of a prosthetic limb.
  • Above the knee. The incision is closed with sutures or staples. The stump is wrapped in an elastic bandage or stocking to reduce swelling (edema). An above-knee amputation may require a longer hospital stay than a BKA, perhaps several days in an acute-care hospital, inpatient rehabilitation center or both. Weeks of outpatient rehab may follow. The wound must be kept dry for several weeks until the stitches or staples are removed. Sponge baths may be necessary to prevent moisture from reaching the wound.

Recovery from leg or foot amputation focuses on several areas. These issues may vary depending on the type of amputation as described above. Concerns include:

  • Wound care and stump care. Wound care begins right after surgery, and routine stump hygiene and care needs are continual. Skin grafting may be used to help close the wound. The physician or other health professional will give specific instructions on caring for the incision site and residual limb. Typical aspects involved include:
    • Guarding against infection. The incision site should be kept sterile, clean and dry. Symptoms of infection, such as fever or nausea, should be reported.
    • Shaping a leg stump and controlling swelling. A conical shape is desired to fit an artificial limb. Elastic bandages are wrapped more tightly at the bottom, more loosely at the top to help form this shape. Elastic wrap may be worn continually at first, with rewrapping several times a day, to control swelling until the prosthesis can be worn. Keeping the stump wrapped and elevated enhances circulation and healing.
    • Hygiene. Typically, the site should be washed nightly with antibacterial soap after the removal of stitches. A prescription cleanser may be used. Bathing at night instead of in the morning helps prevent moisture and risk of infection in the socket of an artificial leg. Other aspects of hygiene include:
      • Drying well after washing
      • Letting scabs and dead skin fall off on their own
      • Leaving pimples alone to prevent infection
  • Prevention of contractures. A physician, physical therapist, nurse or other health professional will advise how to keep the joints moving so they do not get stuck in one position. The most common contracture after amputation is flexion (bending) of the knee. Stretching exercises to extend (straighten) the joint are used, while avoiding damage to stitches.
    • Desensitization. Gently and carefully rubbing and massaging the stump, including the end after removal of stitches, reduces skin hypersensitivity.

  • Physical rehabilitation. Physical therapy usually begins a day or two after the surgery, before a prosthetic is used. It intensifies after the artificial limb is introduced. Outpatient treatments may continue for weeks after discharge. The physician might order occupational therapy in the hospital to offer instruction in self-care such as bathing and toileting with assistive devices such as a shower bench or commode chair. Physical therapy involves:
    • Transfer training (e.g., from bed to chair, chair to standing)
    • Standing tolerance, increasing the length of time the patient can stand up
    • Gait training (walking), including:
      • Progression from parallel bars to walker to crutches to cane to ambulation with no assistive device, if possible
      • Progression from smooth surfaces to irregular terrain and obstacles such as thresholds and curbs

    • Stair climbing
    • Balance training, to adjust for the change in the body’s center of gravity
    • Learning how to land safely in case of a fall, and how to get back up
    • Range-of-motion exercises to keep joints from contracting
    • Strengthening to enhance recovery and the ability to use crutches
    • Desensitization
    • Instruction in wound care and stump care
    • Instruction in daily foot care and skin care to help avoid another amputation
    • Prosthetic fitting and training. A medical specialist called a prosthetist supplies and fits the artificial limb, custom shoe or other orthotic device needed. Sometimes a temporary prosthetic limb is used shortly after the amputation, with the permanent prosthesis introduced later. Artificial limbs are not appropriate for some amputees. Someone with a toe amputation, for example, will not need one. Sometimes there is not enough of a stump to accommodate one. Other complications including infection, mental confusion or physical frailty can rule out this option.

  • Avoidance of further amputation. Many amputees with diabetes undergo further amputation of the involved leg or an amputation of the other leg. Prevention is crucial and includes:
    • Patient and family education on diabetes care and management
    • Foot and skin care
    • Protection of the stump
    • Control of the risk factors of diabetes such as high glucose (blood sugar), high blood pressure and abnormal levels of cholesterol

Psychosocial issues. A foot or leg amputation involves a profound psychological and social adjustment. The following resources can help:

  • Counseling addresses common reactions such as depression, grief, mourning, fear, altered body image, impaired self-esteem and family stress.
  • Support groups such as the Amputee Coalition of America supply solidarity and advice.
  • A social worker can provide details about financial assistance and other resources.

Potential benefits and risks of amputation

Amputation is a drastic measure that patients and physicians want to avoid if at all possible. However, it may be the only way to control a severe infection that could require a more traumatic amputation later or that could otherwise prove fatal. After undergoing an amputation, patients may experience improved general health because a severe infection has been resolved.

Amputation might not be an option is if the individual has uncontrolled diabetes, has heart failure, has a blood-clotting disorder or is too frail to tolerate the anesthesia and surgery.

Foot or leg amputation involves the general risks of major surgery. These include:

  • Blood loss
  • Stroke or other complications of blood clots
  • Allergic reaction to the anesthetic
  • Overdose of anesthetic
  • A new hospital-acquired infection

Amputations also carry their own unique risks and side effects. These include:

  • Phantom limb pain
  • Stump pain and swelling (edema)
  • Joint contractures, especially flexion (bending) of the knee
  • Opening and infection of the amputation site after surgery
  • The need for further amputation because of improper healing
  • Unsteady gait (way of walking) that increases risk of falls

Lifestyle considerations with amputation

Foot or leg amputation will alter many aspects of a person’s life. The individual must cope with adjusting to the amputation while striving to prevent complications. Concerns include:

  • Pain. Phantom limb sensation is the feeling that the amputated part is still there. It may involve tingling or numbness. It is common after amputation. Phantom limb pain is the term used when this sensation is painful. In addition there may be stump pain, which is discomfort at the surgical site. Phantom limb pain can be troublesome and last for years. Treatments for phantom limb pain include:
    • Painkillers, ranging from nonprescription drugs to opioids
    • Anticonvulsant medications
    • Antidepressants
    • Electrical stimulation
    • Biofeedback
    • Acupuncture
    • Psychological counseling

  • Psychological adjustment. Normal reactions to loss of a limb include depression, grief and impaired self-esteem. Individual and family counseling and support groups may be helpful.
  • Smoking. Amputees who smoke have extra incentive to quit. Smoking impairs blood flow and thus impedes healing. It also is a risk factor in diabetes. Nonsmokers have lower risk of stump infection and further amputation.
  • Hyperthermia (heat exhaustion). Skin helps cool the body through sweating. With a more involved amputation, the reduction in surface area can be enough to impede the body’s ability to cool itself. Prevention of hyperthermia includes drinking enough water to prevent dehydration, avoiding midday heat, using a hat and staying in a shady or cool place. Symptoms include headache, nausea and fatigue after exposure to heat. Extreme hyperthermia, called heat stroke, is life-threatening and requires immediate medical attention. Indications include confusion, rapid pulse, flushed skin, lack of sweating, dizziness, staggering and aggression.

Questions for your doctor on amputation

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about foot or leg amputation:

  1. If I am at risk of amputation, can anything be done to avoid the need for this surgery?
  2. What are the benefits and risks of the surgery for me?
  3. What risks would delaying surgery pose for me?
  4. What level of amputation is recommended for me?
  5. What should I expect before, during and after the operation?
  6. How will my pain be controlled?
  7. What kinds of rehabilitation programs are available to me?
  8. What will my rehabilitation involve?
  9. Will I be a candidate for a prosthesis?
  10. Will I need an assistive device for ambulation? Will I eventually be able to walk unassisted?
  11. Will I need any adaptive equipment at home, such as a shower bench or commode chair?
  12. Could I benefit from support groups or counseling?
  13. What can I do to help prevent additional amputations?
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