Our primary focus is to educate and provide health-related information about diabetes management and prevention. However, during the past several months, we have received more than the usual number of phone calls and emails about being people losing their toe or leg due to diabetic complications.
During these phone calls, most of the callers tell us that they wished they had heard about our diabetes management and prevention program sooner. They all admitted that they didn't think they would ever face an amputation.
For those who were told that they would have to lose a toe, foot or leg, they called us looking for a miracle. But, we had to tell them that there is no miracle -- in fact, there is very little that we can do to prevent person from losing their toe, foot or leg once the doctor has identified the need for amputation.
For those who were told that they would have to lose a toe, foot or leg, they called us looking for a miracle. But, we had to tell them that there is no miracle -- in fact, there is very little that we can do to prevent person from losing their toe, foot or leg once the doctor has identified the need for amputation.
High blood glucose levels are responsible for the biological processes that impair the neurological, vascular, and immune systems, leading to damaged nerves, damaged blood vessels and a weakened immune system. Damaged nerves and blood vessels lead to circulatory problems in the feet and legs, which leads to sores, ulcers and deformed feet. A compromised circulatory system fails to bring enough fresh oxygenated blood, nutrients, and antibiotics to a traumatic wound, and the (weakened) immune system cannot resolve an infection by fighting bacteria and cleansing the wound site on a cellular level.
More than 80% of diabetics will develop one or more of the major diabetic complications (amputation, blindness, kidney failure, heart attack, or stroke) -- if they live long enough and fail to change their diet and lifestyle while relying solely on diabetic medications. Approximately 67% of people with diabetes will develop a mild to severe form of nervous system damage, which can lead to a toe, foot or lower leg amputation. Worldwide, there are more than 1 million amputation procedures performed each year, at the rate of one every 30 seconds.
The most common reason for an amputation is poor circulation. The lack of circulation is caused by narrowing of the arteries or damage to the arteries from diseases such as diabetes and atherosclerosis. When the blood vessels become damaged and the blood flow is impaired to the extremities, the tissue starts to die and may become infected.
Another reason for an amputation is the damage to the foot’s sensory nerves due to diabetic neuropathy. This contributes to foot deformities and/or ulcers that increase the chance of lower-extremity amputations unless treated.
Factors that predict the need for lower extremity amputation in patients with extremity ischemia include tissue loss, end-stage renal disease, poor functional status and diabetes mellitus. Patients with diabetes have a 10-fold increased risk for lower extremity amputation compared with those who do not have diabetes.
Foot ulcers and nerve disease caused by Type 2 diabetes is the leading cause of amputation of feet, toes, legs, hands and arms among diabetes sufferers. Collectively, the disorders which cause these amputations are called Diabetic Neuropathies. Neuropathies lead to numbness and sometimes pain and weakness in the hands, arms, feet, and legs. Problems may also occur in other areas of the body, including the digestive tract, heart, and sex organs. However, complications with the feet and legs are more common.
Treatments for leg and foot ulcers vary depending on the severity of the wound. In general, the treatment employs methods to remove dead tissues or debris, keep the wound clean, and promote healing. But, if the diabetic fails to change their eating habits and lifestyle, healing will either occur very slowly or will not occur at all.
When the condition results in a severe loss of tissue or a life-threatening infection, an amputation is usually the only option. Unfortunately, when a doctor identifies the need for a (diabetic) amputation because the toe (or leg) is "dead", there is very little that the patient can do -- especially, if there is an infection that could spread leading to further damage and possible death.
For a foot or toe to be considered dead, the blood supply must be so completely impeded that infarction and necrosis (dead tissue) develop. Infarction results in dry gangrene, with nonviable tissue becoming dry and black in color (because of the presence of iron sulfide, a product of the hemoglobin released by lysed erythrocytes).
The method of toe amputation (disarticulation versus osteotomy) and the level of amputation (partial or whole phalanx versus whole digit versus ray) depend on numerous circumstances but are mainly determined by the extent of disease and the anatomy.
A surgeon removes the damaged tissue and preserves as much healthy tissue as possible. After surgery, the patient will be monitored in the hospital for a number of days. It may take four to eight weeks for the wound to heal completely.
Possible Complications After an Amputation
Patients with diabetes, heart disease, or infection have a higher risk of complications from amputation than persons without these conditions. In addition, persons receiving above-knee amputations are more likely to be in poor health; therefore, these surgeries can be riskier than below-knee amputations.
As with any surgical procedure, complications can occur. Some possible complications that can occur specifically from an amputation procedure include a joint deformity, a hematoma (a bruised area with blood that collects underneath the skin), infection, wound opening, or necrosis (death of the skin flaps).
A stroke, heart attack, or a pulmonary embolism (due to deep vein thrombosis (DVT)) are additional health problems that pose a risk after an amputation primarily due to blood clots, heart muscle strain, or prolonged immobilization after surgery.
If you have this operation under general anesthetic, there is a risk of complications related to your heart and lungs. The tests that you have before the operation will ensure that you have the operation in the safest possible way to reduce the chances of such complications.
As with any surgical procedure, complications can occur. Some possible complications that can occur specifically from an amputation procedure include a joint deformity, a hematoma (a bruised area with blood that collects underneath the skin), infection, wound opening, or necrosis (death of the skin flaps).
A stroke, heart attack, or a pulmonary embolism (due to deep vein thrombosis (DVT)) are additional health problems that pose a risk after an amputation primarily due to blood clots, heart muscle strain, or prolonged immobilization after surgery.
If you have this operation under general anesthetic, there is a risk of complications related to your heart and lungs. The tests that you have before the operation will ensure that you have the operation in the safest possible way to reduce the chances of such complications.
The chances for heart or lung complications are higher for elderly people with other health problems such as diabetes, or disease of the arteries that feed the heart with blood.
Usually, it is important to have the operation as soon as possible. If you delay things then the condition of your toe will get worse and it might get infected and become necrotic. This can make you very ill and significantly increase the chances of complications because of the anesthetic or the operation.
If you have an anesthetic injection in the back, there is a very small chance of a blood clot forming on top of your spine. This can cause a feeling of numbness or pins and needles in your legs. The clot usually dissolves on its own and this solves the problem. Extremely rarely the injections can cause permanent damage to your spine.
Chest infections may arise, particularly in smokers or obese patients. Do not smoke. Being as mobile as possible and cooperating with the physiotherapists to clear the air passages is important in preventing a chest infection.
Another possible complication is the formation of clots in the deep veins (draining pipes for the blood) of your legs (deep vein thrombosis). Although this complication happens more frequently when the leg is amputated either above or below the knee, it can also happen after a toe amputation, especially if you stay in the hospital longer than expected and you are not particularly mobile.
A piece of one of these clots can get detached and travel to your lungs. There it can cause partial or complete obstruction of the blood vessels in the lungs, which can be lethal. Consequently, you will be given injections of blood thinners (heparin) after the operation to prevent a DVT.
In addition, being as mobile as possible and co-operating with the nurses and physiotherapists after the operation are very important in preventing a DVT.
Slow healing is a possibility and this will be apparent within the first week or two. The doctors will discuss this with you. Studies show that the chances of complete healing after a toe amputation are 40 to 60 per cent.
If complete healing doesn’t happen, you might need another operation to clean any dying (necrotic) tissue or tissue that is not healing. You might also need to have the leg amputated higher up.
Infection sometimes happens. This is usually localized in the wound area and very rarely spreads into your blood stream. You will be given antibiotics to prevent this and you will be given more if an infection actually occurs. The antibiotics take care of the problem in most cases, but there is a chance that you will need another operation to clean the infected tissues.
At the beginning, some patients feel that the leg or toe is still there (phantom leg/toe). It is also not uncommon for patients to also feel pain in the amputated area (phantom pain). This is usually mild to moderate and rarely severe pain and will usually get better over time. In some cases the pain can last for a long time. If this happens your doctors will discuss the problem with you.
Aches and twinges in the wound may be felt for six months or more but will usually settle down.
Occasionally there are numb patches in the skin around the wound that get better after two to three months.
Trouble with your circulation or diabetes causing the toe to be diseased needs to be watched very carefully.
Note: Because of a weakened immune system, you may be susceptible to other risks depending on your age, lifestyle, and specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.
Note: Because of a weakened immune system, you may be susceptible to other risks depending on your age, lifestyle, and specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.
Any Alternatives to an Amputation?
If you leave things as they are, your toe (or foot) will certainly get worse. Infection may spread to your other toes and foot. An operation to bypass or core out your leg arteries to improve the blood supply to the toe will not work in your case. Laser treatment and X-ray guided stretching of the arteries will not work for you. Injecting the nerve to your blood vessels will not work. Antibiotics are not enough by themselves.
An alternative to a toe amputation is an amputation higher up. This may help the healing process at the cost of loss of part of your limb. Unfortunately, most amputations through the foot do not heal very much better than toe amputations, but an amputation just below your knee would heal very well. Overall, usually your best plan is a toe amputation unless your doctor says otherwise.
Problems with the lower extremities respond best when treated by a multidisciplinary team of medical specialists. These specialists may include: endocrinologists, neurologists, diabetes educators, diabetes health coaches. vascular surgeons, orthopedic surgeons, podiatrists, nurses, pharmacists, infectious disease specialists, wound care specialists, nutritionists, and specialists in prosthetic and orthotic services, physical medicine and rehabilitation. Comprehensive foot care programs can reduce amputation rates by 45% to 85%.
The direct cost of an amputation associated with the diabetic foot is estimated to be between $30,000 and $60,000. Three years of subsequent care for individuals whose ulcer has healed without the need for amputation has been estimated to cost between $16,000 and $27,000. The corresponding cost for someone who eventually needs an amputation ranges from $43,000 to $63,000, mainly due to the increased need for home care and social services.
The mortality rate after amputations is about 40% at one year and 80% at five years. Five-year mortality rates after new-onset diabetic ulceration are between 43% and 55% and up to 74% for patients with lower-extremity amputation. These rates are higher than those for several types of cancer including prostate, breast, colon, and Hodgkin’s disease.
An alternative to a toe amputation is an amputation higher up. This may help the healing process at the cost of loss of part of your limb. Unfortunately, most amputations through the foot do not heal very much better than toe amputations, but an amputation just below your knee would heal very well. Overall, usually your best plan is a toe amputation unless your doctor says otherwise.
Problems with the lower extremities respond best when treated by a multidisciplinary team of medical specialists. These specialists may include: endocrinologists, neurologists, diabetes educators, diabetes health coaches. vascular surgeons, orthopedic surgeons, podiatrists, nurses, pharmacists, infectious disease specialists, wound care specialists, nutritionists, and specialists in prosthetic and orthotic services, physical medicine and rehabilitation. Comprehensive foot care programs can reduce amputation rates by 45% to 85%.
The direct cost of an amputation associated with the diabetic foot is estimated to be between $30,000 and $60,000. Three years of subsequent care for individuals whose ulcer has healed without the need for amputation has been estimated to cost between $16,000 and $27,000. The corresponding cost for someone who eventually needs an amputation ranges from $43,000 to $63,000, mainly due to the increased need for home care and social services.
The mortality rate after amputations is about 40% at one year and 80% at five years. Five-year mortality rates after new-onset diabetic ulceration are between 43% and 55% and up to 74% for patients with lower-extremity amputation. These rates are higher than those for several types of cancer including prostate, breast, colon, and Hodgkin’s disease.
Next Steps After an Amputation
It is critical that you see a podiatrist, podiatric surgeon, or foot surgeon specializing in diabetic limb salvage if you start to get any open sore or wounds on your feet. Do not wait until it is infected! With these simple interventions you can keep prevent more amputations.
It is also critical that the patient make some serious changes to his diet and lifestyle to better manage one's blood glucose level and strengthen the immune system. Otherwise, further amputations and other diabetic complications will occur such as infections, blindness, kidney dialysis, heart attack and/or stroke.
It is also critical that the patient make some serious changes to his diet and lifestyle to better manage one's blood glucose level and strengthen the immune system. Otherwise, further amputations and other diabetic complications will occur such as infections, blindness, kidney dialysis, heart attack and/or stroke.
Prevention and early detection of future disease should be discussed with the patient. Education on pressure-area pathogenesis is useful for engaging patients. Efforts should be made to encourage regular visits with a podiatrist, who can assist with provision of well-fitted enclosed shoes. Thick cotton socks act as a barrier to both pressure areas and foreign bodies. Daily self-inspection of feet should be promoted. Informed content must be obtained.
Appropriate preventive care includes professional foot care for timely debridment of the keratosis, padding, accommodative insoles, or biomechanical orthotics with accommodations to offload the pressure sites. Shoe modifications, diabetic shoes or custom molded shoes may also be considered. Prophylactic surgical care to eliminate the bony pressure point is also an accepted method of care.
Too often, toenails are overlooked. The nails can become thick and deformed due to mold, yeast and fungal infections Shoe pressure against these deformed toenails can cause a subungual abscess. Additionally, a long, thick or deformed nail can lacerate an adjacent digit, which can trigger the process of infection that can lead to amputation.
Topical antifungal medications are not FDA approved and are ineffective against this type of nail infection. Oral terbinafine or itraconazole are effective against this type of infection, but patient selection is critical for the safe and effective use of these medications. Confirmation of mycotic nail infection before prescribing medication is essential to minimize costs and potential drug-related complications. Testing for nail mold, yeast or fungal infections should be done before prescribing an oral antifungal medication. Foot care specialists should consider nail debridement and ongoing foot care to decrease the risk of a triggering event, such as a digital laceration during self nail care, that could lead to amputation.
Appropriate preventive care includes professional foot care for timely debridment of the keratosis, padding, accommodative insoles, or biomechanical orthotics with accommodations to offload the pressure sites. Shoe modifications, diabetic shoes or custom molded shoes may also be considered. Prophylactic surgical care to eliminate the bony pressure point is also an accepted method of care.
Too often, toenails are overlooked. The nails can become thick and deformed due to mold, yeast and fungal infections Shoe pressure against these deformed toenails can cause a subungual abscess. Additionally, a long, thick or deformed nail can lacerate an adjacent digit, which can trigger the process of infection that can lead to amputation.
Topical antifungal medications are not FDA approved and are ineffective against this type of nail infection. Oral terbinafine or itraconazole are effective against this type of infection, but patient selection is critical for the safe and effective use of these medications. Confirmation of mycotic nail infection before prescribing medication is essential to minimize costs and potential drug-related complications. Testing for nail mold, yeast or fungal infections should be done before prescribing an oral antifungal medication. Foot care specialists should consider nail debridement and ongoing foot care to decrease the risk of a triggering event, such as a digital laceration during self nail care, that could lead to amputation.
Psychological Impact of an Amputation
Loss of a limb can have a considerable psychological impact. Many people who have had an amputation report feeling emotions such as grief and bereavement, similar to experiencing the death of a loved one.
Coming to terms with the psychological impact of an amputation is therefore often as important as coping with the physical demands.
Having an amputation can have an intense psychological impact for three main reasons:
- You have to cope with the loss of sensation from your amputated limb
- You have to cope with the loss of function from your amputated limb
- Your sense of body image, and other people’s perception of your body image, has changed
It is common to experience negative thoughts and emotions after an amputation. This is especially true in people who had an emergency amputation, as they did not have time to mentally prepare themselves for the effects of surgery.
Common negative emotions and thoughts experienced by people after an amputation include:
- depression
- anxiety
- anger
- denial (refusing to accept they need to make changes, such as having physiotherapy, to adapt to life with an amputation)
- grief (a profound sense of loss and bereavement)
- feeling suicidal
Talk to your care team about your thoughts and feelings, especially if you are feeling depressed or suicidal. You may require additional treatment, such as antidepressants or counseling, to improve your ability to cope with living with an amputation.
People who have had an amputation have an increased risk of more amputations. Within one year after a diabetic foot amputation, 26.7% will have another amputation. Three years after the first diabetic amputation, 48.3% will have another amputation. Within 5 years of a diabetes related amputation, 60.7% will have another amputation.
If that isn't bad enough, diabetics with amputations don’t live very long. Approximately 50% of all diabetics with an amputation are dead 3 years after the amputation. About 65% of all of those with a diabetic amputation are dead within 5 years.
But, in spite of this, there is hope... most are preventable. Start eating healthier (i.e. vegetables, juicing) to better control your blood glucose level and to help heal your body. Check your feet every day and see a podiatrist, podiatric surgeon, or foot surgeon specializing in diabetic limb salvage if you start to get any open sore or wounds on your feet. Do not wait until it is infected! With these simple interventions you can keep prevent more amputations.
If that isn't bad enough, diabetics with amputations don’t live very long. Approximately 50% of all diabetics with an amputation are dead 3 years after the amputation. About 65% of all of those with a diabetic amputation are dead within 5 years.
But, in spite of this, there is hope... most are preventable. Start eating healthier (i.e. vegetables, juicing) to better control your blood glucose level and to help heal your body. Check your feet every day and see a podiatrist, podiatric surgeon, or foot surgeon specializing in diabetic limb salvage if you start to get any open sore or wounds on your feet. Do not wait until it is infected! With these simple interventions you can keep prevent more amputations.
Note: We hope this information is of some help and encourages you to take action before it's too late. If you have any queries or problems after surgery, please talk with your podiatrist, other doctors, and the other members of your healthcare team.
Note: If you haven't had an amputation, refer to our blog post about preventing diabetic amputations.
Warning!! Don't think this can't happen to you! It can ... and, it will -- especially if you don't change ...
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