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Amputations in the diabetic patient:Med Media:"amputation should be considered for any diabetic patient w/ advanced changes (Charcot joints, multiple ulcers,vascular pathology) who has undergone a surgical debridement which could not logically leave the patient w/ a functional foot;- vascular considerations:- exam:- it is essential to distinguish between proximal and distal vascular lesions, since distal vascular lesions are not generally amenable to arterial bypass (this statement is restricted to the diabetic patient w/ ischemic ulcerations or osteomyelitis);- if there is an iliac pulse but no popliteal pulse (proximal lesion) then the patient should under go a formal vascular work up (since vascular bypass may be possible);- if there is a popliteal pulse but no DP or PT pulse (distal lesion), then it is unlikely that a vascular bypass will be successful);- these patients do not require a formal vascular work up;- doppler ABI:- in most cases, serves no useful role in the management of diabetic feet;- the loss of compliance of the diabetic vessels will falsely elevate ABI readings, (which may falsely indicate that the diabetic foot is well perfused)"
http://www.medmedia.com/ortho1/9745.htm

Risk of foot amputation may be double for diabetes patients :ahcpr.gov:"Patients with diabetes often develop blisters and cuts that do not heal, leading to infection and sometimes an amputation. The American Diabetes Association recommends a yearly foot exam for patients with diabetes to prevent the complications of foot ulcers and amputation, but there is little research to support this recommendation. Robert G. Nelson, M.D., Ph.D., who was with the National Institute of Diabetes and Digestive and Kidney Disease at the time of this research, and his colleagues undertook a population-based, retrospective case-control evaluation to assess the value of foot exams. The study was supported by the Agency for Healthcare Research and Quality and conducted with the Pima Indians, a group in which the prevalence of diabetes and diabetes-associated amputation is among the highest in the world."
http://www.ahcpr.gov/research/oct00/1000RA5.htm

Leg Amputation Averted in Elderly Diabetic Lady:circulatorboot:"This 76 year old diabetic Florida lady had had an excisional arthroplasty of the second and third toes and a Mitchell bunionectomy of the first metatarsal performed September 30th, 1987. Her toes became infected and gangrenous. Her physicians prescribed topical oxygen, systemic antibiotics and whirlpool treatments to no avail. Her foot x-ray showed a transverse fracture through the distal shaft of the first metatarsal, the site of her bunionectomy. She developed a C-Difficile diarrhea. The possibility of leg amputation was raised. Distressed, she transferred from the Florida hospital to Bryn Mawr"
http://www.circulatorboot.com/casehistory/case102.html

Lower extremity amputation in patients with diabetes:Southern Foot surgery, Inc. and Center for specialized diabetes foot services of Mississippi:"1989-1992 there was approximately 51,605 amputation annually leading cause was nonhealing foot ulceration and its complication 85% of lower extremity amputation are preceded by foot ulcers peripheral neuropathy, peripheral vascular disease, infection help facilitate ulcer. "
http://www.mcdfs.com/

Surgical Morbidity and the Risk of Amputation Due to Infected Puncture Wounds :sma.org:"The primary etiologic factors of foot ulcerations are peripheral neuropathy, pressure, and time. Peripheral sensory neuropathy provides a permissive environment for skin breakdown. In the insensate extremity, the three major extrinsic mechanisms that precipitate the development of neuropathic ulcerations are linked by the common thread of mechanical stress.8 The most common mechanism in the development of chronic foot wounds involves repetitive moderate stress over a long period.9-11 This mechanism most commonly produces wounds on the sole of the foot (eg, beneath a prominent metatarsal head) due to forces imparted while walking. The second mechanism involves constant low pressure over a prolonged period, causing ischemic necrosis of tissue. This is most commonly seen in areas of bony prominences (eg, bunion deformity, hammer toe deformity) that are exposed to extrinsic pressure from tight shoes.12,13 The third mechanism is puncture wound injury, which is commonly seen on the plantar aspect of the foot. Although puncture wounds are relatively common, there is little information in the medical literature about outcomes of these injuries in diabetic or nondiabetic adults."
http://www.sma.org/smj/97apr4.htm

Effective Factors in Diabetic Foot Development and Prognosis:ams.cu.edu.tr:"The most important reason for non-traumatic lower extremity amputation is diabetic foot ulcer8. It has been reported that in U.S.A., diabetic foot ulcer developed in 25% of diabetics and that in 1/15 of them require foot amputation. The most important reasons causing amputation are known to be peripheral vascular diseases and osteomyelitis10,11. In the literature, the infections accompanying diabetic foot ulcer are polymicrobial, and aerobic and anaerobic microorganisms may coexist12,13. Infection may cover all the tissues from the skin to the bone and it may even cause sepsis and death when it systematically spreads. In the management of diabetic foot infections, hospitalization, consistant blood sugar regulation, systematic antibiotic therapy, debridement of the tissue and local dressing all have importance14,15,16. The presence of osteomyelitis requires a longer treatment17"
http://ams.cu.edu.tr/September2000Vol9No3/yuksel.html

Diabetic foot ulcers leading cause of lower extremity amputation:American Family Physician:"Risk Factors for Lower Extremity Amputation in the Diabetic Foot-Absence of protective sensation due to peripheral neuropathy, Arterial insufficiency, Foot deformity and callus formation resulting in focal areas of high pressure, Autonomic neuropathy causing decreased sweating and dry, fissured skin, Limited joint mobility, Obesity, Impaired vision, Poor glucose control leading to impaired wound healing, Poor footwear that causes skin breakdown or inadequately protects the skin from high pressure and shear forces, History of foot ulcer or lower extremity amputation"
http://home.aafp.org/afp/980315ap/armstron.html

Amputation from diabetic foot complications- includes information on these complications:emedicine:"Any discussion of the diabetic foot requires introduction of the concept of function-preserving amputation surgery. Partial and whole foot amputations frequently are necessary as treatment for infection or gangrene. The goal of treatment is preservation of function, not just preservation of tissue. Amputation surgery should be the first step in the rehabilitation of the patient. Because most of these individuals are ambulatory, direct surgical planning at creating a terminal end organ of load-bearing that can interface most easily with accommodative footwear, prosthesis, or a combination of both (ie, prosthosis). Employ the principles that direct construction of a residual limb for weightbearing with a prosthesis when performing debridement or partial foot amputation."
http://www.emedicine.com/orthoped/topic387.htm

How is an amputation performed?:Discovery Health:"There are many different ways to perform an amputation. A single finger or toe may be removed, or an entire arm or leg. The surgeon will usually try to remove as little of the limb as needed to treat the condition. An amputation is done in an operating room. In many cases, general anesthesia is used to put the person completely to sleep with medications. Regional anesthesia may also be used. In this case, a person is awake but has no sensation of pain. The area of skin where the incision will be made is cleaned. The surgeon then cuts into and through the skin. In most cases, the surgeon will remove the limb or part of the limb at a point where there is a joint. For instance, the entire leg below the knee may be removed. The knee area is chosen partly because this is where the shinbone, or tibia, meets the thighbone, or femur. Removing the part or whole limb at a joint prevents the need to break one of the bones."
http://health.discovery.com/encyclopedias/illnesses.html?article=3284&page=1

The Amputee Coalition of America:amputee-coalition:"The Amputee Coalition of America (ACA) is a national, non-profit amputee consumer educational organization representing people who have experienced amputation or are born with limb differences. The ACA includes individual amputees, amputee education and support groups for amputees, professionals, family members and friends of amputees, amputation or limb loss related agencies, and organizations.The National Limb Loss Information Center (NLLIC), provides comprehensive resources for people with limb loss, as well as their families, friends, and the health care professionals involved in their lives. NLLIC is operated by the Amputee Coalition of America (ACA), a national, nonprofit organization representing amputees, their families and healthcare providers. Programs and services of the NLLIC include national hotline, a Web site, health care provider education (HCP), the Youth Activities Program (YAP), the National Peer Network (NPN), Limb Loss Education and Awareness Program (LLEAP), publications, and the Library."
1-888-AMP-KNOW (267-5669)
900 East Hill Ave., Suite 285
Knoxville, TN 37915
NLLICinfo@amputee-coalition.org
http://www.amputee-coalition.org/nllic_about.html



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Last updated by Andrew Lopez, RN on Wednesday, September 29, 2010


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