Basics of Lower-Extremity Amputation Prevention

Dr. Bill Releford
March 28, 2022

Lower extremity amputation is performed to remove ischemic, infected, necrotic tissue and is at times a crucial and potentially life-saving treatment option for most patients. However, this procedure is often preventable even among patients with diabetes and advanced peripheral artery disease (PAD). Thus, there needs to be a concerted effort and policies to mitigate its incidence and improve limb outcomes for at-risk patients.

The Five-Step LEAP Program

Early access to care for at-risk patients is of significant importance. A study conducted in 1994 demonstrated that treatment of diabetic foot ulcers and other preventive measures cost significantly less than amputation. Hence reduced amputation rates are a benefit to both patients and the healthcare system at large. The LEAP program was developed in 1992 by the HRSA’s National Hansen’s Disease Program (HNDP) to bring down the numbers of lower extremity amputations.

Step 1: Annual Foot Screening

Annual foot screening forms the foundation of amputation prevention. Screening is used to identify patients who have non-healing wounds from an injury and have ultimately lost the protective foot sensation. Without the sensation, one can even incur injuries from normal walking.

Peripheral arterial disease (PAD), alone or in combination with diabetes is responsible for more than one-half of all amputations that happen in the United States. PAD makes the feet vulnerable to wounds or ulcers that quickly worsen if not treated properly. More than 80% of these amputations begin as foot ulcers. Diagnosing PAD in a patient with a non-healing wound is crucial. If left untreated, these sores could develop an infection leading to long term health complications and ultimately, limb loss

The foot screening uses a 5.07 monofilament, which exerts 10 grams of force, to identify at-risk patients. Initial foot screening should be done on all patients during diagnosis and at least once a year thereafter. PAD, diabetic, and other at-risk patients should have their feet examined at least four times a year to help prevent the occurrence of foot problems.

Step 2: Patient Education

Patient education involves engagement between the patients and healthcare providers. Patients are advised on proper nutrition, exercise, and cessation of habits such as smoking, as ways to prevent lower limb loss.

Diabetes awareness creates the basis for the diagnosis and management of diabetes and related conditions such as PAD. Hence, there need to be conversations between at-risk patients and clinicians on the signs, symptoms, treatment, and complications of the disease. If people can understand the risk of lower extremity amputation, then they can go for early screening.

Step 3: Daily Self-inspection

Daily self-inspection is one of the most effective ways to prevent lower-extremity amputation. People who have lost foot sensation spend most of their time away from the healthcare center and thus, daily inspection should form a vital part of the self-management program.

Lack of sensation means a person won’t know when an injury occurs, and this necessitates daily self-examination. One should look out for foot injury symptoms such as redness, blisters, swelling, calluses, bunions, and non-healing wounds. A serious problem should be reported immediately to a health care provider.

Step 4: Footwear Selection

The right kind of shoe always makes a difference and goes a long way in preventing lower limb loss. A person with normal sensation on his or her limbs can wear almost any shoe style with little risk of injury. However, if a patient has lost the protective sensation, then poorly designed or ill-fitting shoes can cause serious foot complications. Such a patient should always avoid walking barefooted, wearing narrow-toed shoes, boots, or heeled shoes that are either too loose or too tight.

The footwear of choice should always fit the shape of the feet having at least a ½ inch spacing between the longest toe and the end of the shoe. A properly fitting shoe can have a small amount of leather pinched up. The use of therapeutic braces and orthotics is also important for patients with severe foot deformity.

Step 5: Management of Simple Foot Problems

Most patients with peripheral artery disease can prevent lower limb amputation by getting proper wound treatment in the early stages. The LEAP program encourages patients at-risk of lower extremity amputation to report all injuries to the health care provider who then suggests the best wound care method. Wound care usually consists of cleaning, debridement, and the use of a variety of local wound care products.

Diabetic neuropathy is a disease that affects the autonomic nerves in the foot causing motor nerve dysfunction. This disease often causes dry cracked skin, greatly increasing the probability of non-healing wounds. Diabetic neuropathy cannot be reversed but instead managed by medication such as pregabalin, gabapentin, duloxetine, and amitriptyline.

Bottom Line

Lower extremity amputation prevention strategies abide by the principle, “the earlier the better” – early screening and routine follow-ups can help salvage limbs. Patients can manage some of the foot problems if they are taught simple, basic self-management techniques. However, severe complications should always be reported to a healthcare provider.