Who is at risk of limb loss and what to do about it?

Lower limb amputations were performed on over 105,000 individuals in United States short-stay hospitals between 1989 and 1992. Additional amputations were performed in VA, military, Indian Health, and charitable orthopaedic hospitals. Half of all lower extremity amputations occurred in individuals with diabetes. When the causal chain leading to diabetic amputations was examined in 80 consecutive patients at the VA Medical Center, Seattle, WA, 23 unique pathways were identified. Multiple pathway components were identified for 96% of patients, while in 4% a single ischemic pathway was sufficient in itself to require amputation. The majority of the scenarios leading to amputation began when patients with absent peripheral sensation sustained a pivotal event that initiated the causal chain to amputation. In nearly half the patients, this event was foot-wear-related. The pivotal event was followed by ulceration and faulty wound healing in 73% of patients. Each year thousands of individuals with diabetes undergo amputation in VA facilities, resulting in substantial cost to the Department of Veterans Affairs and to themselves. If the VA is to address the prevention or delay of limb loss, the causal pathway information indicates that attention to the footwear of diabetic patients is necessary.