In the United States, approximately 150000 patients undergo a lower extremity amputation each year. The increasing number of lower extremity amputations is due to a rise in peripheral artery disease and diabetes. While amputation is an undesirable treatment choice for a patient, it might be a life-saving procedure in certain situations. But, given the significant psychological and physical impact of amputation, modern wound care should focus on preventive strategies.

What Is Lower Extremity Amputation?

Lower extremity amputation is the surgical removal of the lower limb to remove ischemic, dead necrotic tissue. It's used in situations where the damaged limb cannot be salvaged. While amputation should be avoided as much as possible, there are times when it is necessary, as the infection can pose a threat to the nearby healthy tissue. 

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Lower limb amputation is known to be a worst-case outcome, resulting from uncontrolled diabetes. Patients with peripheral artery disease are also at an increased risk of developing critical limb ischemia, which results in a compromised blood supply to the patient's lower extremities. This causes patients to develop persistent leg pain, non-healing ulcers, and wound infections. Some other indications for lower limb amputation include trauma, severe soft tissue infections, gangrene, and locally invasive malignant tumors.

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The psychological impact of amputation should not be underestimated because it results in immediate disability. Depression frequently follows an amputation procedure and patients face other psychological issues as they struggle to adjust to their new reality. It is vital for clinicians and wound care specialists to focus on preventive strategies that can reverse the increasing trend of amputation rates. 

Prevention of Lower Extremity Amputation

The American Heart Association (AHA) in its policy statement expressed concern over the increasing rates of non-traumatic lower limb amputations. The following are evidence-based preventative strategies recommended by the American Heart Association (AHA) that can help ease the burden of lower-limb amputations.

Early Diagnosis of Peripheral Artery Disease (PAD)

The guidelines published by the American Heart Association recommends screening for peripheral artery disease in high-risk individuals. Some identified risk factors include; smoking, older age, family history, African American ethnicity, diabetes, high cholesterol, and hypertension. 

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A non-invasive test that can help clinicians detect peripheral artery disease early is the ankle-brachial pressure index. The early detection screening has been linked to a reduction of mortality rates. It can also be used for the early detection of critical limb ischemia.

Cessation of Smoking

Smoking is strongly connected to the increased risk of developing peripheral artery disease. It's estimated that about 20% to 30% of all patients diagnosed with this disease in the US are smokers. Given the significant link between smoking and peripheral artery disease and its progression, quitting smoking is highly advised to all patients diagnosed with this illness. 

Diabetes Treatment

Diabetes is one of the major risk factors for developing peripheral artery disease. The risk of amputation is higher in patients with poorly-managed diabetes. In contrast, patients with better-managed diabetes have a lower risk of undergoing lower extremity amputation. So, clinicians should actively monitor the glycemic index of diabetic patients.

Foot Care

Diabetic foot ulcer is a leading cause of lower limb amputation. Diabetic neuropathy impairs the ability of the patient to sense trauma, and results in patients developing non-healing ulcers. The early detection and management of diabetic foot ulcers are essential to prevent amputations. Patients with diabetes should be offered regular diabetic foot exams and assessment. They should also be educated about regular self-inspection and foot care. Educating patients about the importance of appropriate footwear can also help reduce the risk of lower extremity amputation.

Lipid-Lowering Medication

Patients with peripheral artery disease should be urged to use statins as these have been linked to lower the risk of amputation. Statins are lipid-lowering medications that have been documented to play a role in lowering the risk of cardiovascular disease.

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Appropriate Wound Care

Chronic wounds in lower limb extremities should be regularly assessed and treated by wound care specialists and podiatrists. A comprehensive wound care plan should be offered to patients which involves regular inspection, and vascular assessment. 

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The wounds should be inspected for signs and symptoms of infection and treated accordingly. Treatment by multidisciplinary wound care teams composed of vascular surgeons, podiatrists, prosthetists, nutritionists, and wound care specialist nurses can significantly lower the rates of amputations. 

Revascularization

Revascularization procedures aim to restore the blood supply and the blood flow to the lower limbs affected by peripheral artery disease. Early referral to vascular specialists on suspicion of critical limb ischemia should be done for the procedures to be effective. Some examples of revascularization procedures include endovascular interventions and surgical bypass grafts.

Role of Skin Substitutes In Prevention of Lower Extremity Amputation

The advancement in wound care technology has led to the introduction of “skin substitutes” for the management of cutaneous chronic wounds. Many bioengineered skin substitutes are associated with minimal risk of rejection and infection. It shows promise in improving the healing rates for non-healing chronic ulcers such as diabetic foot ulcers. A study based on Medicare databases reported a 50% reduction in the amputation rates of patients treated with skin substitutes compared to patients who did not receive it. So, skin substitutes have a promising potential to lower the national and global rates of lower limb amputations. Wound care specialists should employ advanced wound care techniques to lower the burden of amputations.

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