Lower-extremity amputations in patients with diabetes: pre- and post-surgical decisions related to successful rehabilitation.

Background: Peripheral vascular disease and diabetes account for the majority of lower-extremity amputations in the adult population. Whenever a patient presents to a surgeon regarding a diseased limb, the initial basic decision is to determine whether to attempt limb salvage or proceed with an amputation. Unfortunately, limb salvage is not an option for many of these patients. Once amputation is chosen as a treatment option, the optimal level of amputation has to be determined by the surgeon, who is then faced with selecting the optimal level of amputation compatible with wound healing and subsequent prosthetic fitting.

Methods: Methods for objectively determining optimal amputation level include vascular evaluations, assessing the level of cellulites or osteomyelitis, or intra-operatively, by looking at the amount of bleeding in skin flaps.

Results: The net outcome is that there is currently no universally accepted method for determining the level of amputation for successful wound healing or for preventing subsequent higher amputations.

Conclusions: What is generally recognized is that there are disparities in the rates of amputation for type 1 versus type 2 diabetic patients, for different ethnic groups and for patients with multiple co-morbidities. However, with advances in surgical techniques and with modern prosthetics, all categories of patients are benefiting from surgeries in which a longer residual limb can be kept (within surgical constraints related to proper wound healing), and where appropriate biomechanical considerations are taken into account.