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Lower-limb Amputations: Risk Factor Identification and Prevention

It is common knowledge among wound care experts that the number of non-traumatic lower-limb amputations is at a worrisome level. According to the Amputee Coalition, about 185,000 amputations are done in the United States every year. Racial inequities in the healthcare sector put minority populations, such as African Americans, at significantly higher risk of having a limb amputation. According to research, Black people are four times more likely to have an amputation than their non-Hispanic white counterparts. This article will discuss the main risk factors for lower-limb amputations and preventative measures wound care professionals should embrace to salvage limbs. 

Risk Factors for Lower-Limb Amputations

Limb loss can occur for several reasons, including trauma, a congenital anomaly, or disease. However, diabetes and peripheral vascular disease are the most common causes of lower-limb amputations overall. 

Diabetes Mellitus (Type-2 Diabetes)

Diabetes is a persistent problem in America which dramatically increases the likelihood of foot ulcerations culminating in limb loss. According to the CDC, 34 million Americans, or 1 in every 10 individuals are diabetic. Slow-to-heal wounds (diabetic foot ulcers) affect approximately 15% of persons living with diabetes. According to research, patients with Type-2 diabetes are 10 times more likely to undergo an amputation. 

Diabetic ulcers appear as open sores or calloused blisters. Due to tissue neuropathy, patients are unable to feel pain in the feet which can prevent them from receiving timely treatment. A leading cause of diabetes is high blood sugar (hyperglycemia) from over-consumption of processed foods high in sugar, salt, and trans fats. Delayed wound healing in diabetic patients significantly increases the risk of infection. Without timely and adequate treatment, local wound infection progresses into Osteomyelitis (bone infection), increasing a patient's risk of lower-limb amputation. Due to diminished sensation in the feet, the first symptom of ulcers for many patients is a foul-smelling (purulent) drainage from the affected feet that leaches into the socks. The affected limb also appears red (erythema) and swollen (edema). 

Peripheral Vascular Disease (PVD)

Another risk factor for amputation is Peripheral Vascular Disease (PVD). PVD occurs due to a buildup of fat in the blood vessels outside the heart. The narrowing of the blood vessels (vasoconstriction) causes poor circulation to the lower extremities which limits the body's ability to heal wounds. One of the most common indications of PVD in patients is claudication (pain in the thighs, calves, or buttocks during some physical activity, such as walking that decreases while at rest). Peripheral Arterial Disease (PAD) affects the arteries outside the heart and brain is a leading cause of lower-limb amputations in the U.S. It is an age-related ailment affecting mostly the elderly, although smoking and diabetes can increase the risk in adults under 60 years of age. 

PVD Prevention and Treatment

As in the case of diabetes, timely diagnosis, and regular wound care for patients with PVD is critical to lower the risk of amputation. Management of PVD borders on making lifestyle adjustments (on the part of patients) and treatment to improve circulation in the legs. The National Institute for Health and Care Excellence (NICE) recommends daily walking sessions of up to 2 hours for 3 months to improve the symptoms. Patients should also consider quitting smoking and eating a balanced diet containing fruits and vegetables. 

Timely and repeated vascular assessment of chronic wounds can mitigate complications that may put patients at risk of amputation. Non-invasive methods employed by podiatrists today for diagnosing arterial disease include the ankle-brachial index (ABI), Magnetic resonance angiography (MRA), skin perfusion pressure (SPP), pulse volume recordings (PVR), and transcutaneous oximetry (TCOM). The above methods provide a reliable means for quantifying or visualizing chronic lesions and circulation in the affected limb(s). 

There are various treatments for vascular disease. Angioplasty or stenting is a procedure involving the use of tiny medical balloons or stents (metal scaffolds) to keep the arteries open, improving circulation to the affected limbs. In most cases, a vascular surgeon will insert the medical balloons or stent into the artery of the groin under X-ray guidance and using local anesthesia. Medical prescription for improving perfusion in patients living with peripheral artery disease (PAD) includes Statin, which helps to lower the production of bad cholesterol that can clog the arteries, vasodilators that help to open up constricted arteries, and anticoagulants, which help to prevent undesirable reactions from taking drugs that prevent the blood from clotting. 

Diabetes Prevention and Wound Management

Preventative measures for patients include eating a diet rich in fruits and vegetables, regular exercise, and avoiding ultra-processed foods. Patients living with diabetes can manage the condition by eating healthy, regularly monitoring cholesterol and blood pressure levels, and staying active. For patients with foot ulcers, timely diagnosis, and regular wound care is vital. Patients should see a podiatrist (foot and ankle surgeon) immediately after any signs of ulcers are found to reduce healthcare costs and lower the risk of infection and amputation. Management of diabetic ulcers involves regular offloading of the wound, disinfection, application, and changing of wound dressings, and surgical intervention in the case of osteomyelitis. 

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