Treatment Trends Pushing Diabetic Amputations Down List of Options

by David Gorn, California Healthline Sacramento Bureau

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Diabetes is on the rise in California and the nation, but one of the most feared outcomes of the disease -- amputation -- may be waning.

Advanced complications of diabetes, such as nerve damage, gangrene and infection, can lead to the need to amputate legs and feet. But the decision to amputate may be moving down and sometimes off the list of treatment options. At podiatry clinics and wound care centers in California, patients with advanced diabetes who might be candidates for amputation are being treated with alternatives aimed at making amputation a last -- rather than primary -- option.

According to the American Diabetes Association, diabetes is the leading cause of non-traumatic lower limb amputation in the country. More than 60% of those amputations are diabetes-related, said Patrick Dunlap, executive director of the ADA's Sacramento chapter.

"Early diagnosis and early prevention makes a huge difference," Dunlap said. "It's an epidemic we're dealing with."

The National Limb Loss Information Center reports that more than 133,000 amputations are performed nationally every year, with the majority of them because of diabetes-related complications like infection and peripheral arterial disease.

Assuming similar rates in California, more than 13,000 Californians undergo limb amputations every year. The actual number could be higher, according to Gabriel Halperin, a podiatrist in East Los Angeles.  

California has a large Latino population facing a higher rate of diabetes, which translates into more amputations, Halperin said.

"I see more devastation from amputation among my Latino patients and the African American patients than I do in the Caucasian patients," Halperin said. "I see whole families ravaged from diabetes [among those minority groups], and I don't see that as much in Caucasian patients."

Many candidates for amputation might be able to recover using other methods, Halperin said. If amputation isn't absolutely necessary, it shouldn't be performed, Halperin said.

Tales of Amputation Avoided

Halperin runs a clinic called the East LA Wound Care Center, a little office tucked among the panaderias and mom-and-pop storefronts about five miles east and a world away from downtown Los Angeles. One of the facility's primary goals is to provide foot wound cures without amputation.

Maria Quiñones, one of the clinic's patients, was there recently with her granddaughter, Nadine Quiñones of Los Angeles, who acted as translator for her grandmother.

"It first started off with wounds in her foot," Nadine said, "then it progressed to gangrene, so her whole toe went black. We had taken her to another doctor, and he wanted to amputate her leg, just below the knee."

Maria Quiñones doesn't speak English, but she understood the word "amputation," and she sharply wagged her white-haired head back and forth, chopping one hand firmly into her palm. "No," the elder Quiñones said in a strong voice. "No. Claro, no."

After that appointment, Maria Quiñones and other family members thought they had nothing to lose by trying the East LA Wound Care Center, Nadine Quiñones explained. The elder Quiñones went on a regimen of antibiotics and weekly debridement -- the removal of necrotic tissue from her leg to stem its spread -- and the procedures seem to have worked. Now there is no more talk of amputation, Nadine Quiñones said.

"She's doing great. If they would've amputated her leg, it would have been much more complicated for me to take care of her. And not only that, but for her to enjoy life," she said. "Why would you want to live without your leg?"

Steven Quintanar sat one cubicle over, waiting to see a provider in the busy treatment area. He's a former security guard now a drummer in a rock-salsa and soul band and is much younger than Maria Quiñones. He told a similar story.

"I first came here five years ago. When I went to another doctor, he wanted to amputate my toe," Quintanar said. "When I got here, they said four to five weeks, it'll be cured."

It would've been hard to play the drums without a foot, Quintanar said with a smile. But he dropped the bravado, and his voice, when he talked about the care he received.    

"These doctors are angels in disguise. I really appreciate these people here, what they've done," he said. "Look at me, I'm walking. I feel good."

A Change in Standard of Care?

Near the other end of the state, Karen Harris, clinical manager for NorthBay Center for Wound Care in Vacaville, has similar ideas about how to treat diabetes-related vascular problems. She uses antibiotics, debridement, hyperbaric oxygen therapy and vascular surgery before any amputation is contemplated.

Wound care has become a bit of a specialty around the state and Harris said wound care centers may take a slightly different approach than conventional medical facilities toward the alternative of amputation.

"That may be standard of practice in some places, but it certainly shouldn't be the first step or first [line of] defense," Harris said. "Unfortunately, wound care centers are few and far between."

Her facility is the only wound care facility in Solano County. She said the idea is to treat the infections and vascular issues with a variety of approaches. "We do limb salvaging," Harris said.

That shift in medical approach has taken place throughout California, said Richard Thorp, president-elect of the California Medical Association.

"In the last 5 or 10 years, there has been a change in the technology related to vascular disease," Thorp said. "In the past, the only way to deal with [diabetes-related vascular disease] was to amputate the toe or the foot."

Now, he said, the movement in medicine is toward preventing those amputations -- in a number of ways.

"Today we're a little more aggressive about it. We're checking people's feet more regularly, we're making them more aware of the complications. We've been using testing more extensively in the last 10 years, and along with the increase in testing was a shift in technology."

In years past, vascular surgeons would have to do bypass surgery, and that was a tricky and complex procedure with mixed outcomes. "Today we're using more interventional techniques, we do a procedure that cleans the plaque out and suctions it out."

Wound care centers utilize an array of procedures to push amputation down the list of choices, Thorp said. "Many practices have sprung up to do just that," he said.

"Clearly there's a move to be more aggressive about prevention, and about treating people to prevent amputation," Thorp said. "The standard of care has shifted to a more aggressive approach. Amputation is definitely not the first option."

Obstacles to Better Wound Care

According to Halperin, there are many providers in California who still practice what he calls "old school" medicine, where amputation is the default choice of diabetes-related vascular infections.

"A good 10% of our patients at one time or another were told they needed an amputation," Halperin said.

Halperin said he wishes his clinic wasn't so busy, but he waves a hand at the full treatment rooms, the packed waiting room, the line of people out the front door.

"We see 120 to 140 patients a day, five days a week," he said. "And I would say that less than 1% of them actually end up with the amputation. It's rare. It's rare enough that they stick out in our minds."

Halperin speculated that, because diabetes is a lifestyle malady, some providers may have concerns that all the effort and work put in by a medical team might simply be undone by a patient's inability to monitor personal diet choices.  

Morbidity and mortality rates escalate dramatically in the two years after an amputation, Halperin said, and that makes it a threat to life as well as limb.

"When people have a heart attack, every effort is made to keep that person alive, no matter the cost or number of surgical procedures," Halperin said.

"But this is different. It's ugly, it's smelly, the patient is very sick. So they don't receive the wound care they should really get," he said. "It takes so much time and attention to heal these wounds. It's not easy."

Halperin said the cost of an amputation is roughly $45,000. "But there's also the cost of the prosthesis, there's a cost of in-home support, and there's a cost to society because those people don't usually work again," he said.

"It's devastating. I've seen it. It's devastating to the person, it's devastating to the family," Halperin said. "And it's devastating to us for letting that happen."

Susan Pfettscher
Another radical approach being performed by vascular surgeons is early vascular intervention. They believe that the symptoms associated with peripheral neuropathy (loss of sensation, burning in feet, etc.) are associated with significant vascular lesions. Before an amputation is required, they are doing angioplasties and saving the limb. According to them, all patients with burning feet, sensation loss should have testing for vascular flow lesions....their patients seem to be very happy that their legs are saved!

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