AMPUTATIONS IN DIABETIC FOOT

1. AMPUTATIONS IN DIABETIC FOOT

2. PROF. RAMA KANT KING GEORGE MEDICAL UNIVERSITY LUCKNOW ramakantkgmc@rediffmail.com

3. Diabetes mellitus increases risk of amputation by 20-fold. • Declining rate of foot amputations parallels decrease in hospitalizations for skin and soft tissue infections. • This reflects better and effective outpatient care for diabetic foot ulcers and infections.

4. Do we waste time trying to save some feet ????? Should we be aiming for local minimal surgery at all costs, or is there a case for primary radical amputation? Technological advances and improvements in local treatments for diabetic foot disease place clinicians under ever increasing pressure to preserve the foot (Watkins PJ, 2003; Smith J, 2003).

5. These are real challenges for decision……

7. CHANGE YOUR PERCEPTION STILL THERE IS HOPE…………

8. Health-economic consequences of diabetic foot infections • Result in huge costs for society and individual. • Costs of antibiotics also substantial… .. • Total costs for topical treatment high . • Total costs for healing of infected ulcers not requiring amputation - $17,500 • Costs for lower-extremity amputations are above $30,000

9. Often a successful outcome is followed by a rapid recurrence necessitating further hospitalisation. Clinicians should always consider whether the best interests of the patient might be served by primary amputation or often prolonged, expensive and failure bound local aggressive surgical traetment ????

10. The aim of any treatment is to deliver a fully mobile patient back into the community.

11. Levels of lower extremity amputations

12. MAJOR AMPUTATION- • Advantages • No more surgery • Shorter hospital stay • Disadvantages • Major procedure and risk • Difficult & expensive rehabilitation • Independence threatened

15. FOOT—REVISION-BELOW KNEE---REVISION—ABOVE KNEE---STILL NEEDS REVISION

16. NOW HEALED ABOVE KNEE AMPUTATION

17. Indications for primary BKA instead of local amputation Previous extensive hospitalisation Limited life expectancy Patient choice Age State of circulation Effect of failed distal bypass Failed conservative management.

18. We should aim to minimise the time spent in hospital as these patients are often towards the end of their lives…….

19. Approximately 50% of patients ended up with a BKA a very high proportion indeed…..

20. Major amputation should be considered as an option for every patient with diabetic foot disease.

21. EFFORTS TO RESTORE THIS FOOT TO NORMAL MOST PROBABLY WILL FAIL…… HE MAY BE BETTER OFF WITH AMPUTAION AND PROSTHESIS

22. 50% of lower extremity amputations performed in the United States are due to diabetes. 9% foot, 31% lower leg, 30% above knee. Ipsilateral higher amputations occur in 22% of cases. Contralateral amputations 10% per year. After 5 years, amputees with diabetes have a 50% chance of bilateral amputation,

23. Number of operations • Diabetes • Toe BKA AKA • 282 (67%) 110 (49%) 39 (18%)

24. MINOR AMPUTATION

25. Advantages • Limb preserved • Reduced anaesthetic risk • Independence preserved Disadvantages • Prolonged healing time • Prolonged hospitalisation • Prolonged re-mobilisation • Risk of failure of healing • Risk of further treatment

26. Decisive factors in type of treatment provided to patients.. • They must participate

27. CENTRAL PLANTAR ABSCESS WITH OSTEOMYELITIS

28. TOE AMPUTATION

34. WRONG DECISION FOR LEVEL OF AMPUTATION

35. BILATERAL DEFORMED BUT WALKABLE FOOT

36. FUNCTIONAL BUT DEFORMED FOOT EVEN THIS IS MUCH BETTER THAN THE BEST PROSTHESIS…….This is also a view