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Treatment of the diabetic foot – to amputate or not?
© Weledji and Fokam; licensee BioMed Central Ltd. 2014
Received: 2 February 2014
Accepted: 14 October 2014
Published: 24 October 2014
Diabetic foot infections are a frequent clinical problem. About 50% of patients with diabetic foot infections who have foot amputations die within five years. Properly managed most can be cured, but many patients needlessly undergo amputations because of improper diagnostic and therapeutic approaches.
The article debates the pros and cons of amputation of the diabetic foot. The thesis is that if the guidelines on the management of the diabetic foot are followed primary amputation is only necessary for the unsalvageable diabetic foot. This approach would reduce the incidence of lower limb amputations in diabetic patients.
We favour the argument that a structured clinical and vascular assessment would help clinical decision- making as to which patients to hospitalize, which to send for imaging, or for whom to recommend surgical interventions. Endovascular procedures are the future in the treatment of diabetic arterial disease and hence the diabetic foot.
The Wagner-Meggitt classification
deep ulcer to tendon, bone, or joint
deep ulcer with abscess or osteomyelitis
whole foot gangrene
Classification of diabetic foot infection 
No signs or symptoms of infection
Superficial, limited in size and depth
Deeper or more extensive
Systemic signs or metabolic pertubation
Summary of indications for conservative surgical approach or primary amputation
Good blood supply to foot but infected
wet gangrene (infection + ischaemia)
Small vessel disease and gangrenous toes
Successful surgical bypass
extensive muscle necrosis
Neuropathic foot with little arterial disease
revascularisation technically impossible, bed-ridden patients/functionally useless limb
Osteomyelitis with little arterial disease
Arguments for primary amputation
Natural history of disease
Assessment and treatment
The greatest immediate danger to these patients after successful revascularization is the ‘reperfusion syndrome’ caused by the release of toxic metabolites and oxygen free radicals into the systemic circulation from the ischaemic limb [16, 17]. This can cause a profound cardiovascular collapse and with renal and sometimes respiratory failure. For this reason revascularisation should not be used in patients with signs of muscle necrosis. Primary amputation is better. A graft should if possible prevent limb loss for at least 2 years if it is to be considered a success. The 2 year patency rate of distal vascular grafts for experienced vascular units should be in the region of 75% [16, 17]. There is evidence that failed bypasses result in a higher level of amputations and the combined mortality rate of a failed reconstruction followed by amputation may be higher than a primary amputation .
Arguments against primary amputation
Natural history of disease
Assessment and treatment
The diabetic patient presenting with a foot wound should be assessed at three levels- the patient as a whole, the affected limb and foot and the infected wound [1–4]. The affected limb and foot should be assessed for arterial ischaemia, venous insufficiency, presence of protective sensation, and biomechanical problems.There may be an obvious large wound or ulcer associated with erythema and pyrexia. The presence of any exposed bone and ulcer larger than 2 cm  increase the likelihood of osteomyelitis [1, 3]. It is suspected in a patient with an adequate blood supply to the affected foot that has a deep ulcer which would not heal after 6 weeks of appropriate wound care and off-loading . Some diabetic patients who develop neuropathies or osteomyelitis but with little arterial disease may often benefit from surgical debridement or excision and/or prolonged antibiotic therapy for at least 4 weeks, based on the culture and sensitivity of biopsied bone tissue or the curettage of deep tissues [3, 4, 26]. Swab specimens, especially of incompletely debrided wounds provide less accurate results [1, 27].
Diabetic foot infection
Diabetic foot infections typically begin in a neuropathic ulceration. An infected diabetic foot with good blood supply would respond to debridement . In neuropathic foot, severe infection is treated with intra-venous antibiotics in hospital and, antiseptics and dressings for ulcers. Necrotic tissue is removed and conservative digital amputations or filleting is sufficient.The surgical approach would optimize the likelihood for healing while attempting to preserve the integrity of the walking surface of the foot . Specialised footwear is used to reduce weight bearing [1, 4]. In ischaemic foot infection is treated by debridement (cleaning the wound, removing pus, dead necrotic tissue and infected bone) [1, 31].
While all wounds are colonized with microorganisms, the presence of infection is defined by findings of inflammation or purulence [1, 3]. There are usually complex polymicrobial infections, but aerobic gram positive cocci is a vital part of diabetic foot infection. A broad-spectrum intra- venous antibiotic and metronidazole for anaerobes are recommended. Antibiotics can usually be discontinued once the clinical signs and symptoms of infection have resolved usually 1–2 weeks for mild infection and 2–3 weeks for moderate to severe infection, and not until the wound has healed. This is to avoid resistance . If the wound is not easily debrided varidase dressing is used, and inadine or granuflex dressing would promote granulation [33, 34]. The use of topical antimicrobials for most clinically uninfected wounds is not advocated for lack of evidence substantiating the benefit over conventional wound care therapy [1, 4, 35]. Several recent systematic reviews have suggested that silver-containing dressings and topical silver were neither better nor worse than control dressings in preventing wound infection and prolong healing . New techniques for wound debridement include low frequency ultrasound therapy, hydrosurgery, monofilament polyester fibre pad and plasma-mediated bipolar radiofrequency ablation . Skin grafting when no infection is present may be required .
As diabetes is chronic and progressive, it makes sense to have a conservative surgical approach that include surgical revascularization . A successful surgical bypass of larger vessel disease may enable more conservative treatment of the diabetic foot. Revascularisation is, however, considered inappropriate in bedridden patients, in a functionally useless limb, in patients with life threatening sepsis, extensive muscle necrosis and where it is technically impossible. Primary amputation is better in these cases [3, 17].
A percutaneous transluminal angioplasty (PTA) and luminal stenting or arterial reconstruction to improve blood flow would aid healing . Because in most cases ischaemia is secondary to larger vessel artherosclerosis rather than to ‘small vessel disease’, vessels above the knee and below the ankle tend to be relatively spared. Thus lower extremity artherosclerosis can be amenable to angioplasty or vascular bypass . The indications for a PTA in diabetic peripheral arterial disease are classically for disabling claudication and critical limb ischaemia, Patients with non-critical ischaemia (ankle/brachial pressure index (ABPI- 0.4-0.9) can in some cases be successfully treated without a vascular procedure . Although the prevalence of ABI <0.9 in individuals with normal glucose tolerance was 7% and increased to 20.9% with diabetes, care should be taken when interpreting ABPI in diabetics . Arterial calcification of the vessel media renders the vessels incompressible and causes false ‘high’ readings. Toe pressure measurements may be of value. Revascularization by percutaneous transluminal angioplasty (PTA) of short segment disease was feasible in more than 96% of diabetics with critical limb ischaemia (ankle systolic pressure of less than 50 mmHg or the toe pressure of less than 30 mmHg) . Many centres have reported successful use of both aggressive endovascular interventions and distal bypass procedures for more severe vascular disease of the foot. The short-term effects are satisfactory with healing of the foot ulcers and thus diminishing the risk of amputation. However, follow-up is required to ascertain the long-term effects [10, 17, 38]. The feasibility with bypass prosthetic grafting (BPG) is lower but consistent . Studies strongly suggest that early recognition and aggressive surgical drainage of pedal sepsis followed by surgical revascularization is critical to achieving maximal limb salvage of 74% at 5 years in the high risk population . The risks of unsuccessful revascularization leading to limb loss must be weighed against the benefits and the patient informed. However, careful debridement of necrotic, infected diabetic foot wound should not be delayed while awaiting revascularization [3, 10].
Postoperative amputation pain and rehabilitation
Post- operative amputation pain is mostly due to phantom limb pain (54%) and phantom limb sensation (90-98%) . Phantom limb pain usually continues for more than six months whereas phantom limb sensation (except pain) usually disappears or decreases with time. The true mechanism is not known but many theories overlap a peripheral, spinal and central mechanism. The successful treatment of phantom limb pain is thus difficult and treatment is usually combined and multiple based on the person’s level of pain. These include biofeedback to relieve muscle tension, physical therapy, surgery to remove scar tissue entangling a nerve, transcutaneous electrical nerve stimulation (TENS) of the stump, neurostimulation techniques, medications such as analgesics, neuroleptics, anticonvulsants, antidepressants, beta -blockers and sodium channel blockers . The patient must therefore be properly prepared for surgery psychologically with time being spent on assessment by the physiotherapist and reassurance and encouragement being provided by the surgeons, ward nurses or a successful amputee. The patient should be encouraged to spend periods lying prone to help keep the knee straight post-operatively and avoid fixed flexion deformity. The level of amputation may have to be high enough to ensure adequate healing of the stump . Above Knee amputation (AKA) or ‘transfemoral amputation’ is associated with a much poorer outcome because these patients are more often unwell than those needing a below knee or ‘transtibial amputation’ (BKA). Although AKA is more likely to heal, rehabilitation is less successful . Most elderly patients are not psychologically prepared and rehabilitation is an up-hill task.
Many diabetic foot problems are avoidable. Good glycaemic control and patient’s education are essential. The main determinant of which patients with a diabetic foot infection need to be hospitalized is the clinical severity of the infection. With minimal surgical trauma and certain curative effect endovascular procedures is the future in the treatment of diabetic peripheral arterial disease and thence the diabetic foot. It is desirable that a vascular surgeon should assess the diabetic foot as the possibility of revascularization must always be considered and the correct sub-group selected for amputation. Guideline-based care for diabetic foot infections and the employment of multidisciplinary teams would help improve outcome and minimize amputations.
We confirm that informed consent for the publication of the image of the diabetic foot was obtained from the patient. Our gratitude to the diabetic foot patients at the Regional hospital Buea, Cameroon who rendered me the impetus to write about this major diabetic complication that incessantly appeared on the surgical ward.
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