By Roger Greenhalgh
It is with some distress that many of my colleagues and I have worked a lifetime to reduce major amputation and we like to think we save legs. The plain fact is that too many legs are lost today that should not be. This is not confined to one country or even one continent! Surely we need to do better, to look and see what can be done.
I will start with the UK, which is one of the worst we know about. From NHS Hospital Episode Statistics data there were 10,763 amputations in England in 2007/8 – an increase of 600 over the previous year! Major amputation rates have increased significantly in the past year from 2,248 to 2,394 (6%) for above knee amputations and from 2,294 to 2,435 (again, 6%) for below-knee amputations. Against this and despite the MIMIC trial emerging from the UK, that country has the lowest angioplasty/revascularisation rates in Europe!
In Switzerland, there is no major amputation rise from 2000 to 2007 according to the Swiss Federal Office of Statistics but there is a rising toe amputation rate.
The proportion of patients subjected to vascular evaluation and intervention has increased. It is reasonable to ask whether this policy has brought about the differences in outcome.
In Germany two-thirds of all amputations are associated with diabetes, but the total number has decreased. Against this background has been the development of National Guidelines for diagnosis, treatment and prevention. There has been the Certification of diabetes centres by the German Society for Diabetology and Certification of Vascular Centres by the German Society for Vascular Surgery (DGG). This information is courtesy of Professor Hans-Henning Eckstein who is President of the DGG this year. But major amputation is a big problem still in Germany and colleagues are not complacent. There were 63,005 in 2005 and 62,880 in 2006 – getting better but too many!
In Denmark, Holstein et al, Diabetologia, 2000, reported that in two decades rates of arterial reconstructions rose and major amputations decreased.
In Finland, Eskelinen et al in 2006 reported that from 1990 to 2002 major amputations fell by 23% in diabetics and 40% in non-diabetics.
In the US, the rate of lower extremity amputations has decreased against an increase in endovascular interventions, which is also associated with a reduction in surgical reconstruction just as demonstrated by the EVEM monitor.
Where does this leave us? Practice is better in some parts than others. Complacency is not warranted. Prevention is always desirable but not of proven value. What is required is rapid referral from the community to specialist care. This will trigger urgent wound care, foot care and though toe amputation may occur for diabetics, major amputation should be reduced. No single specialty should seal exclusive rights. Interdisciplinary collaboration should improve patient outcomes.