Diabetic Amputation: Prevention for At-Risk Patients

Diabetes is on the rise both domestically and internationally, making diabetic amputation an ever-increasing concern. About 580 million people globally and 37 million people in the United States have diabetes, and these numbers are expected to rise by an estimated 46% jump by 2050. 90% of these cases are Type 2 diabetes, which is directly linked to an aging population, a decrease in physical activity, and obesity.

Diabetic foot ulcers are a major, and incredibly common, side effect. Unfortunately, because these wounds aren’t often caught early, they can result in amputation. As diagnosis numbers continue to climb, so does the necessity for diabetic amputations. Outcomes for those who require a lower limb amputation are poor, which suggests we try to create a sea change in the way we identify, treat, and prevent ulcers and other skin damage that can lead to amputations.

What Is the Cause of Diabetic Amputations?

The high blood sugar levels associated with diabetes also cause narrowing of blood vessels, poor circulation, and nerve damage. These factors can lead to damage of the limbs that eventually create the need for amputations. While the exact cause of amputation can vary, the underlying condition often remains diabetes and uncontrolled blood sugar levels.

Common conditions resulting from diabetes that lead to amputations include:

• Nerve damage. When nerves in the feet are damaged, the patient experiences numbness. Often, they don’t even realize that they have cuts, blisters, or broken skin that need to be cared for, or infections that require treatment. Without attention, these cuts can turn into deep wounds that do not heal.
• Narrow arteries. Diabetes causes a narrowing of the arteries, which reduces blood flow and restricts oxygen and other nutrients that need to travel to the extremities. This leaves the body vulnerable to infection, unable to protect itself as it normally would, and more likely to develop severe wounds.
• Poor circulation. Wounds that do not receive the blood flow necessary to heal can spread to the bone or cause tissue death. This severe state requires an amputation to prevent the infection from spreading to other parts of the body.
• Ineffective white blood cells. High blood sugar reduces the effectiveness of white blood cells. These bring healing nutrients throughout the body, but high blood sugar levels impair their ability to deliver healing agents.

How Common Are Amputations?

In the United States, of the 38 million people who have diabetes, 160,000 will experience amputations each year. Only 20% of lower limb amputations performed annually are the result of trauma, rather than diabetic foot ulcers and complications from diabetes. Some research indicates that the risk of amputation is higher for those with Type 1 Diabetes compared to those with Type 2.

Unfortunately, outcomes remain poor for amputees. 37% of patients who have one lower limb amputation will have a second within five years; 19% will have a second amputation within one year. The five-year survival rate following a diabetic lower limb amputation is shockingly only 64%.

Risk Factors for Diabetic Amputations

Lower limb amputation occurs any time a toe, foot, or the lower portion of the leg is removed. Those who have already been identified as having decreased circulation (diagnosed with Peripheral Artery Disease), nerve damage (diagnosed with neuropathy), or existing foot ulcers are at higher risk for lower limb amputations.

There are a few other factors that can increase the risk for diabetic amputations like:

• Kidney disease
• Uncontrolled high blood sugar/poor follow-through on a treatment regimen
• Being male
• History of smoking
• Vision problems
• High blood pressure
• Obesity
• Advanced age
• Wearing unsupportive footwear
• Cardiovascular disease
• Lack or low levels of physical activity

In addition, socioeconomic factors play a role in the risk for diabetic amputation. Ethnic minorities, include Black, Hispanic, and Native Americans, are at greater risk and experience lower limb amputations at a greater rate than the general population. Patients residing in rural areas, lower-income neighborhoods, or who are on Medicaid are also more likely to experience amputations. Research indicates that minorities and economically disadvantaged patients wait longer to seek treatment, have less access to necessary services, and have fewer visits with specialists that support better outcomes.

How Can We Prevent Lower Limb Amputations?

If you work in a wound care facility, a high priority is to communicate clearly to patients their risk for diabetic amputations and what steps they should take to decrease their risk. Monitoring risk factors, checking the feet for wounds, and supporting patients in lifestyle changes should all be part of your regular interactions with patients.

Here are some of the best ways you and your patients can mitigate risks for lower limb amputations.

• Manage chronic diseases: While this is primarily about managing blood sugar levels, taking steps to manage conditions like high blood pressure and cholesterol will also lower risk factors for diabetic amputations.
• Take care of the feet: Patients should avoid walking barefoot and wear supportive footwear to prevent cuts or blisters that could turn into more serious wounds. Providers should check a patient’s feet at every appointment and teach them how to monitor the condition of their own feet. Teach them the steps that specifically help reduce amputation risk, like washing between each toe, ensuring that the feet are dry after washing, moisturizing the feet regularly, and keeping toenails trimmed neatly. If any wounds are observed, make immediate referrals to a podiatrist or wound care specialist for effective treatment.
• Create an exercise regime: Help patients develop an exercise routine that includes cardio, strength, balance, and flexibility that is easy to follow and appropriate for their physical fitness level.
• Refer to smoking cessation support: Support patients in reducing their amputation risk by having a smoking cessation support program you trust available to refer to them.

Interventions for Foot Wounds

Even with careful care, because of the damage diabetes can do to the body, wounds may still appear and need treatment. The earlier treatment starts, the better the outcome. When a diagnosis is made and treatment is started within four weeks, healing rates are 55%. However, when treatment is delayed for four to 12 weeks, healing rates drop to 17%, and if treatment is delayed longer than 12 weeks, healing rates are at zero.

Proven interventions that providers can take to improve wound healing include:

• Antibiotics. Bacterial infections often respond to antibiotics that prevent the bacterial from reproducing. Mild infections respond to oral antibiotics while more serve infections will require IV antibiotics. Since 61% of diabetic ulcers become infected, antibiotics play an important role in healing and preventing amputation.
• Wound dressing. Dressing creates the moist environment that is optimal for wound healing. They protect the wound from the outside environment that can cause additional damage and introduce infection-causing bacteria. The dressing absorbs drainage and prevents further breakdown of the skin. Modern dressing options can also deliver healing agents like silver, iodine, and antimicrobials.
• Debridement. Removing dead and infected skin stops infection from spreading, manages pain, and creates a better environment for healing of the affected tissue. This can be accomplished by cutting away affected skin, using a chemical agent, adding substances to dressings that will remove the skin, using waterjets, or employing medical-grade maggot therapy.
• Hyperbaric Oxygen Therapy. Using a hyperbaric chamber increases pressure and allows the blood to carry more oxygen than normal. Facilitating high levels of oxygen in the body improves the performance of white blood cells and healing. It improves circulation, builds better capillaries, and reduces the body’s inflammation response.
• Physical therapy. Physical therapists often use targeted exercises, electrotherapy, and specialized off-loading devices to support patients with diabetic foot ulcers. Those who work with a physical therapist only have a 10% rate of wound recurrence, compared to 27% for those who do not.
• Nutrition. Support for changing their diets also shows an impact on the healing of lower limb wounds in diabetic patients. 56% of those with diabetic foot ulcers are deficient in Vitamin D, 73% are deficient in Vitamin C, and 27% are deficient in zinc. Partnering with a registered dietician for nutrition support can improve bodily function and speed healing.

What New Therapies Are Currently Being Researched?

Patients with peripheral artery disease and diabetes cost the healthcare system between $84 and $380 billion annually in the United States. Plus, those in high-risk groups are seeing rates of amputation increase, despite new technologies and treatment methods being introduced. This creates an immediate need to improve detection and early intervention to prevent wounds from deterioration and requiring amputation.

New research shows a significant difference in wound healing and amputation rates depending on the facility where care is provided. A study found that the odds of major leg amputation were almost two times higher between two facilities for an average patient within the US Veterans Affairs system. While this study only considered Veterans Affairs facilities, variation exists across healthcare systems and facilities across the US. When the quality of care varies this greatly, standardization of care is crucial to ensure that all patients, regardless of where they live, have access to well-trained providers and the medical devices and materials that give them the best chance for healing.

Semaglutides, like Ozempic, improve blood flow and have shown some signs of improving healing. Taking the drug once per week increased patients’ stamina when walking and overall quality of life, in addition to improving blood sugar levels.

New “smart” and AI technology has given providers and diabetic patients additional tools to monitor wounds and increase the chance for early intervention. Mats, socks, shoes, and bandages can sense foot pressure, temperature, inflammation, and gait changes. The devices collect and store this information, making it available to both the patient and the provider.

Alerts can even bring attention to problem areas before wounds form and proactively address risk factors that can not be observed through an in-office visit. AI’s ability to continuously monitor the skin, compare personal data to large data sets, and autonomously alert wound care specialists will greatly improve care delivery.

Multidisciplinary Care Is the Gold Standard to Prevent Diabetic Amputation

In order to effectively address the wide range of factors that can lead to diabetic amputations, a multidisciplinary team approach is recommended. This team should include medical professionals, surgical professionals, endocrinologists, dieticians, pharmacists, and mental health professionals. They should also have an established referral system that includes cardiologists, ophthalmologists, podiatrists, physical therapists, fitness experts, and social workers.

In 94% of studies on multidisciplinary teams for diabetes care, this approach reduced the need for amputations. Teams focused on glycemic control, wound management, vascular disease treatment, and identifying infection. Telemedicine provides new opportunities for patients in rural areas where, in the past, it was difficult to establish a team of diverse medical professionals.

New technologies and research-backed methods for early intervention and treatment support teams that include medical professionals, social support systems, and caregivers. Establishing these practices for your patients leads to better outcomes and decreases the risk of diabetic amputations and poor long-term prognosis.