Perspectives in Circulation Today

The above slide is taken from the slide presentation on the Circulator Boot website (www.circulatorboot.com/slideshow/SlideSho3.ppt) The various references can be found in the website library. The Carrington abstract is given below. The "take home" points to note: (1) Not much progress has been made in the last 50 years in preserving the second leg. (2) Data showing benefit for special footwear in patients without deformities is lacking. (3) While the threat of a second amputation is commonly appreciated at the time of the first leg amputation, the fate of the second leg remains grim even if the patient attends a special follow-up clinic. It is the belief of the Circulator Boot Corporation that early treatment of ischemia with boot therapy will spare most patients a second leg amputation.

Carrington AL, Abbott CA, Griffiths J, et al.: A foot care program for diabetic unilateral lower-limb amputees. Diabetes Care 24:216-21, 2001. OBJECTIVE: To assess the efficacy of a specialist foot care program designed to prevent a second amputation and to assess peripheral vascular disease (PVD) and peripheral neuropathy in diabetic unilateral lower-limb amputees. RESEARCH DESIGN AND METHODS: Investigations were carried out in 143 diabetic lower-limb unilateral amputees referred to a subregional rehabilitation center for prosthetic care from a catchment area of approximately 3 million people. Peripheral vascular and nerve assessment, education, and podiatry were provided for each patient. RESULTS: For the patients referred to the foot care program, there were no baseline differences between the patients who proceeded to a bilateral amputation (n = 22) and those who remained as unilateral amputees (n = 121) in their level of foot care knowledge and mean neuropathy scores. Mean ankle-brachial pressure index was significantly lower for the bilateral amputees (0.75 +/- 0.04) compared with the unilateral amputees (0.90 +/- 0.03, mean +/- SEM, P < 0.05), but there was no difference in the level of oxygen in the skin. However, the level of carbon dioxide was significantly lower in patients with bilateral amputation (24.21 +/- 2.16 vs. 31.20 +/- 0.85 mmHg, P < 0.03). Overall, the establishment of a specialist foot care program made no impact on contralateral limb amputation (22 of 143, 15.4%) compared with matched patients without the program (21 of 148, 14%) over a 2-year outcome period for each patient. CONCLUSIONS: PVD is more closely associated with diabetic bilateral amputation than neuropathy or level of foot care knowledge. Preventative foot care programs for diabetic unilateral amputees should therefore place greater emphasis on peripheral vascular assessment to identify patients at risk and on the development of timely intervention strategies.

Other references likewise pointing to the difficulty improving outcomes with the use of prescribed foot wear are likewise abstracted on the website.

Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ, Harkless LB: Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care 24:1019-22, 2001.

Litzelman DK, Marriott DJ and Vinicor F: The role of footwear in the prevention of foot lesions in patients with NIDDM, Conventional wisdom or evidence-based practice? Diabetes Care 20:156-162, 1997.

Maciejewski ML, Reiber GE, Smith DG, Wallace C, Hayes S, Boyko EJ: Effectiveness of diabetic therapeutic footwear in preventing reulceration. Diabetes Care 27:1774-82, 2004.

Reiber GE, Smith DG, Wallace C, Sullivan K, Hayes S, Vath C, Maciejewski ML, Yu O, Heagerty PJ, LeMaster J.: Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. JAMA 287(19):2552-8, 2002.

Snyder DC, Salameh JR, Clericuzio CP. Retrospective review of forefoot amputations at a Veterans Affairs hospital and evaluation of post-amputation follow-up. Am J Surg. 192:e51-4, 2006. While Carrington et al, addressed the fate of patients with major amputations, these authors addressed the fate of those with forefoot amputations. Both groups found that specialized follow-up offered no significant benefit.

Thomson FJ and Masson EA: Can elderly diabetic patients cooperate with routine foot care? Age and Aging 21:333-337, 1992.

Perspectives in Circulation Today

Volume 1, Number 3