Study Suggests High Rates Of Reamputation In Patients With Diabetes

A recent study published in BMJ Open Diabetes Research & Care suggests that the rate of reamputation in patients with diabetes remains very high, and has not changed significantly over the past two decades.¹

In this systematic review and meta-analysis conducted by Liu and colleagues, the authors examined over 200 peer-reviewed articles looking at data on reamputations.¹ Of the articles reviewed, 22 studies that focused on patients with diabetes were included in the meta-analysis.  Notably, the researchers found that following an initial lower extremity amputation secondary to diabetes, the reamputation rate (involving either the contralateral or ipsilateral limb) was 19 percent at one year, and 37.1 percent at five years. When considering reamputations involving only the opposite limb, the reamputation rate at five years was 20.5 percent. Furthermore, reamputation-free survival decreased as the follow up period increased.¹

This is rather surprising considering some of the recent advances in wound care dressings and cellular and/or tissue products (CTPs) for the treatment of chronic diabetic foot ulcers, as well as an increased focus on establishing a standardized “toe and flow” model for multidisciplinary care of the diabetic foot. So where do we go from here? Remote temperature monitoring may offer one such solution.

In a study published last year, we assessed the impact of a diabetic foot ulcer prevention program that incorporated once-daily remote temperature monitoring and found a 91 percent reduction in severe DFUs (greater than University of Texas classification 1A) and a 71 percent reduction in diabetic amputations.² Patients with a history of a healed diabetic foot ulcer or minor amputation were enrolled in the year-long study with Kaiser Permanente, and asked to stand on a telemedicine foot temperature monitoring mat for 20 seconds per day. In addition to the reductions in severe DFUs and amputations, there was a 52 percent decrease in all-cause inpatient admissions, 40 percent reduction in emergency department visits, and 27 percent reduction in all-cause outpatient visits. In fact, for every three study participants, one hospital admission was avoided.²

I can personally attest that the vast majority of patients enrolled in the above referenced study were excited, engaged and educated about utilizing remote monitoring technology to prevent ulcer recurrence and avoid further diabeitc foot complications. We must find a better way to address the diabetic foot patient in remission. And, we must accept the limitations of treating this high risk population with the same old conventional approach. By simply having these patients follow up in the office or clinic every six, eight, or 12 weeks, we may be missing key opportunities to debride that callus before it progresses to an ulceration, or remove that ingrown nail before it becomes infected, or offload that “hot spot” before it leads to significant tissue loss.  Whether it is a smart mat, sock or insole, the technology has arrived and in many ways surpassed our wildest expectations. Now is the time to catch up.

Dr. Isaac is fellowship-trained in diabetic limb preservation and amputation prevention.  He is the Co-Director of Research with Foot & Ankle Specialists of the Mid-Atlantic.

References

1. Liu R, Petersen BJ, Rothenberg GM, et al. Lower extremity reamputation in people with diabetes: a systematic review and meta-analysis. BMJ Open Diab Res Care. 2021;9:e002325.

2. Isaac AL, Swartz TD, Miller ML, et al. Lower resource utilization for patients with healed diabetic foot ulcers during participation in a prevention program with foot temperature monitoring. BMJ Open Diab Res Care 2020;8:e001440.