Comment on Hoffstad et al. Diabetes, Lower-Extremity Amputation, and Death. Diabetes Care 2015;38:1852–1857

We have read with interest the article by Hoffstad et al. (1), as lower-extremity amputation (LEA) is a topic in which we have had a long-standing interest (2,3). Thus, we would like to share some of our thoughts about its findings.

This article focuses its attention on the large increase in the incidence of death among patients with diabetes who underwent a LEA, as has been previously reported by several authors, including ourselves (1,3). This article further highlights the incomplete relationship between mortality and known diabetic complications, such as cardiovascular disease or renal insufficiency, and suggests that the presence of other unspecified factor(s) may be responsible for this increased mortality.

The data from our group support this hypothesis, as we noted that our patients with diabetes and critical limb ischemia who had unsuccessful salvage procedures and therefore major amputations had a mortality rate of 43.6% after 16.7 ± 19.6 months, while patients who healed after successful salvage procedures had a 30% mortality rate after 51.2 ± 28.2 months. As we reported, the two groups were similar not only for age and duration of diabetes but also in the incidence of ischemic heart disease, carotid artery disease, stroke, requirement for renal dialysis, and high blood pressure (3).

This observation suggests the need for a new approach of research to understand which factor(s) may be responsible for this excess of mortality. The patient’s amputation level (above or below knee), type of rehabilitation provided, recovery of mobility, presence of depression, or loss of self-interest might be potential factors. However, only studies specifically designed to explore these and other factors will clarify this issue.

We would like to address another important issue raised in the article by Hoffstad et al. (1). They conclude by saying that “it is also important that GPs [General Practice physicians] communicate to their patients about the risk of death to assure that patients have proper expectations about the severity of their disease” (1). It is our opinion that this information should be given to the patients before they undergo LEA. Providers and patients often consider amputation a fast and effective solution, but a large percentage of LEAs are performed without any attempt at a revascularization procedure (4), which could probably make many of the LEAs avoidable.

Unfortunately, health care providers, especially those not directly involved in diabetic foot care, are sometimes moved to perform an avoidable amputation because of reimbursement policies, a perception of reduced time of recovery, or shorter in-hospital stay (4). The patient may be easily influenced to accept a LEA by the wish for a rapid recovery of mobility, the possibility to avoid a long-term antibiotic treatment, or perhaps a hope to speed pain control. Studies have shown a progressive decline of patient quality of life the longer the ulcer duration is (5).

We think it is crucial that the now clearly demonstrated increased mortality observed in amputee patients with diabetes should be considered whenever there is a discussion about performing an amputation in a patient with diabetes and foot ulceration. Having this information will probably change the view of both the health providers and the patient and reduce avoidable LEAs.