The Compassionate Amputation: Think Outside The Limb

Faced with the challenges of non-healing diabetic ulcerations, a patient’s realization of progressively declining health, the burden of expansive health costs and the unrelenting frequency of doctor appointments, can cumulatively lead to a heavy emotional toll and state of despair. In dealing with high-risk patients, how we navigate the nuances of these aforementioned complexities may define our role in the lives we impact. While mental health consequences of chronic disease are well-documented, I feel there is no louder or stronger a case than the fragile cohort of those plagued with diabetes at the critical point where discussion about amputation becomes essential.

Not to mention, these very same patients often suffer from multiple comorbidities and may experience health delivery inadequacies, food insecurity or demonstrate poor health literacy. While diabetes does not discriminate by social stratification, there is concern about those at highest risk having poor outcomes and thus, by extrapolation, they may be the same patients at highest risk for limb loss. Therefore, the discussion about amputation is one not to take lightly.

What is profoundly interesting, as elucidated by Wukich and colleagues¹, is that patients with diabetes and lower extremity complications were 136 percent more in fear of an amputation than of death. This data comes from a level II, case-controlled, prospective study of 461 patients, emphasizing the importance of patient-related outcome perceptions. Another poignant large prospective study concludes that increased mortality exists for patients with concomitant diabetes and depression compared to those without depression.² The greatest risks for this mortality included advanced age, insulin use, lower extremity amputation and heart failure in this 3,923 patient study.²

So, what then of the patients with drawn-out courses of multiple remissions and relapses of diabetes-related lower extremity infections, who carry the weight of their pathology heavily on their hearts and minds? While major lower extremity amputation can resolve certain issues, all too often I’ve seen doctors tout previous patients who wish they had undergone such a procedure sooner, citing the notion of a life that is ulcer-free, with less-frequent doctor appointments and dressing changes. This is a mistaken and myopic view of a larger reality.

Regardless of possible short-term “compassionate” upsides, mortality rates for patients with diabetes and a major lower extremity amputation are 27.3 percent within one year, and 63.2 percent within five years in a recent systematic review and meta-analysis of 61 studies including 36,037 patients.³ Additionally, a recent study analyzing function after 256 major lower extremity amputations indicates that only 46.1 percent of these amputees are ambulatory at one year.⁴

For those who remain non-ambulatory, they exchange one set of problems for many others. It is naive to assume that the non-ambulatory patient becomes free of underlying depression or will not have additional wounds. Below-knee amputation stump ulcerations and sacral decubitus ulcers are very real possibilities, and for those with underlying cardiomyopathy, de-conditioning is another grave concern. The limb may be gone, but the underlying disease processes will remain, as will the mind’s hatchets and torches.

When we think major lower extremity amputation may offer compassion, we ought to consider all possible health and functional outcomes. Even for already bedridden patients, a major lower extremity amputation is not a simple or uncumbersome solution. One must consider the possible degree of required services, continued risk of falls and likelihood of loss of independence. The next time you lay down, try to turn over without using your leg. Even simply turning to prevent decubitus ulcers or lifting to place a bed pan becomes nearly impossible.

I submit, this is not an argument against major amputations. In fact, I strongly propose that a well-performed amputation at any level, for the right patient, under the right circumstances can lead to excellent, predictable and functional outcomes. If not for the diligent evidence-based care we provide, our patients would be far worse off. Rather, this is a provocation of thought to think outside the limb, outside the clinics and hospitals, outside the here and now and further outside our current way of practice. While we have gained much success, indeed, there is no doubt more work is necessary.

Returning to the patient who is at the precipice of a possible amputation, I would argue that a compassionate amputation is not the promise that a patient will benefit from eradication of frequent doctor visits, costs and emotional tolls. Rather, the most compassionate amputation is one offered to a patient properly educated, counseled and prepared for the entire spectrum in the journey after a diabetes-related lower extremity complication. The most compassionate amputation is one where a multidisciplinary group of specialists includes behavioral health, social workers and many other essential health care providers in addition to the medical and surgical teams; which these patients may need in perpetuum.

Dr. Elmarsafi is a fellowship-trained foot and ankle surgeon in private practice in Woodbridge and Chantilly, Va

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1. Wukich DK, Raspovic KM, Suder NC. Patients with diabetic foot disease fear major lower-extremity amputation more than death. Foot Ankle Spec. 2018;11(1):17-21.

2. Salinero-Fort MA, Gómez-Campelo P, Cárdenas-Valladolid J, et al. “Effect of depression on mortality in type 2 diabetes mellitus after 8 years of follow-up. the DIADEMA study.” Diabetes Res Clin Prac. 2021;172:108863.

3. Meshkin DH, Zolper EG, Chang K, et al. Long term mortality after nontraumatic major lower extremity amputation: a systematic review and meta-analysis. J Foot Ankle Surg. 2020;60(3):567-576.

4. Chopra A, Azarbal AF, Jung E, et al. Ambulation and functional outcome after major lower extremity amputation. J Vasc Surg. 2018;67(5):1521- 1529.