Supporting the Educational Efforts of the Amputation Prevention Alliance

It’s no secret that diabetes can cause circulation issues, including in the feet and lower extremities. As podiatrists often experience, many patients don’t realize that seeking treatment for a non-healing wound or bone deformity may lower their risk for lower limb amputations.

Losing a foot or lower leg is a traumatic experience, with potential for hospitalizations, isolation, a higher risk for additional amputations, and death. The American Diabetes Association (ADA) reports that an individual who has had an amputation has a worse chance of 5-year survival than someone with coronary artery disease, breast cancer, and colorectal cancer.¹

Seeking to raise awareness that amputations are preventable, the American Society of Podiatric Surgeons (ASPS) has joined with the Amputation Prevention Alliance.¹ Formed by the ADA, the alliance aims to increase awareness amongst patients, caregivers, and health care providers about alternatives to amputation through education and legislative efforts to drive necessary policy changes.

ASPS physician leaders chose to join this alliance because they recognize the vital need for educational resources for the above-mentioned groups. Alternatives to amputations do exist—patients and caregivers just need to know about them. Programs such as those focused on nutrition or the role of revascularization, as well as those directed at high-risk communities, could have a major impact on the skyrocketing costs of amputation. An amputation is not simply removing a limb, as most providers are well aware.

“As podiatrists, we are sometimes the first line of care for patients with lower extremity wounds such as diabetic foot ulcers, venous leg ulcers, etc.” said Leon Shingledecker, DPM, FASPS, FACFAS, a Board Member of ASPS. “Therefore, patient awareness is one factor I believe is important for ASPS. Prevention of amputations can promote the longevity of the patient.”

A Closer Look at Educational Efforts to Prevent Amputation

Data from the ADA shows that more than 54,000 diabetes-related amputations occur annually in the United States, with 85% of procedures being preventable.¹  

How are these amputations preventable? Education is key. Patients must understand the importance of foot care, as well as the impact of nutrition, smoking, or a lack of regular health care monitoring.

“Diet plays a huge part in the prevalence of amputations,” said David Yeager, DPM, FASPS, FACFAS, the Chair of the ASPS Education Committee. “Good food is often financially unavailable, which leads to poor diets. Poor diets may lead to diabetes, which can lead to ulceration, which can lead to amputation. This cascade of events is not only unfortunate but is also preventable with a better diet. The alliance can help to educate people who may not understand the importance of taking better care of themselves through exercise, diet, and other factors such as smoking cessation and weight management.”

These educational efforts must bring together a range of specialties, including podiatry, to best care for patients with diabetes. No single specialty can heal every ulcer or lower every patient’s amputation risk.

Treating Wounds and Bone Deformities

Podiatrists all too commonly find that patients with diabetes are unaware of the importance of daily foot inspections and regular podiatric care, both crucial steps to lower amputation risk.

Dr. Shingledecker pointed to a lack of awareness amongst patients about wound care. He said patients assume that wounds will heal on their own, but that comorbidities such as peripheral artery disease or cardiovascular disease can severely impact the body’s ability to heal without medical intervention. Many patients with diabetes are also immunocompromised, putting them at greater risk for complications as wounds fail to heal.

“Patients need to understand that the amputation needs to be their last amputation,” said Dr. Yeager. “Too many times, I see patients with diabetes return to clinic with an ulceration even though they promised me they would return if they noticed any problems with their feet. These amputations can be preventable.”

Some patients may think that revascularization too risky, too expensive or simply unavailable. But providers know its importance.

“Re-establishing proper flood flow is essential in healing,” said Dr. Shingledecker. “Without blood flow healing will not occur, or it will be a long healing process. Revascularization can ultimately heal wounds and prevent any type of amputation.”

Biomechanics also plays a role.

“I think that we, as podiatrists, sometimes fail to understand the biomechanics of the ulceration, but once we do, we can surgically address the biomechanical etiology of the ulceration and prevent amputations,” said Dr. Yeager.

A bunion or other bone deformity may not sound alarm bells for a patient with diabetes, but the podiatric surgical community knows otherwise. Podiatrists can consider offloading techniques, gait analysis, or even corrective surgical procedures to minimize pathologic mechanics that can lead to ulceration, infection, or amputation.

Vascular screening prior to undergoing a procedure can also be a vital step for patients with diabetes. Surgeons may benefit from including this as part of their preoperative risk assessment, and early identification of PAD could truly be limb-preserving.

While amputation is never the goal, surgeons may find that removal of a diseased toe or part of a foot may also be a reasonable preventative measure, or a lower-risk option to more complex reconstruction. 

Reaching at-Risk Populations

Minorities and low-income individuals often face greater challenges when it comes to seeking health care. This could be due to insurance costs, lack of transportation or a myriad of other factors. In turn, the occurrence of amputations within these populations is much higher.

The ADA alliance seeks to target these communities with educational programs. Data shows that African Americans are up to 4 times as likely to suffer an amputation than non-Hispanic whites.¹ 

Taking a Team Approach to Amputation Prevention

Simply put, patients and providers should exhaust all other options before proceeding with amputation. But often, even some health care providers are not aware that alternatives exist, nor what steps should be taken to help save a patient’s limb. The Amputation Prevention Alliance’s website contains information on resources, policies, and educational outreach for both providers and patients.¹

“It is a gamut of individuals practicing as a cohesive unit to prevent amputations,” said Dr. Yeager. “The multidisciplinary approach to patient care for diabetes provides patients with a well-rounded circle of care. Each provider has their own unique ability of treating diabetes and through close collaboration, we are able to provide the utmost care for our patients.”

Created in partnership with the American Society of Podiatric Surgeons.

Editor’s note: For further reading on amputation, see “Important Insights from a Unique Limb Preservation Center,” “Preparing to Repair in Diabetic Wound Care: Insights from an Expert” or “Updates in PAD Diagnosis and Treatment.”

For additional articles, podcasts and videos, check out Podiatry Today’s Limb Salvage Resource Center.

Reference
1.    American Diabetes Association. Amputation Prevention Alliance.