What role does function play in deciding on limb salvage versus amputation in patients with diabetes?

Background: Patients with diabetic foot disease are at an increased risk for lower extremity amputation (LEA), premature mortality, and reduced healthrelated quality of life. In the setting of chronic infection, signifcant tissue loss, and/or an unstable deformity, limb salvage may not be possible, and major amputation is necessary. Methods: The primary goal of this study was to review the literature with an emphasis on the functional aspects associated with successful limb salvage versus major LEA. A secondary goal was to review the epidemiology, quality of life, mortality, and energy expenditure associated with diabetic foot disease. Results: After major LEA, patients with diabetes are 3 times more likely to die within 1 year of surgery compared with patients who have not undergone LEA. Only two thirds of diabetic patients who undergo major LEA will ambulate with a prosthesis. This increased risk of death is not fully explained by complications of diabetes mellitus such as heart attack, stroke, or kidney failure. Preservation of lower extremity function is the primary goal of treatment, and reconstructive surgery should strive to achieve a plantigrade foot that is ulcer free and stable. Patients who have undergone successful limb salvage fear major amputation more than death. The energy costs of ambulation after LEA increase as the site of LEA becomes more proximal. Conclusions: Major LEA is a devastating complication in patients with diabetes. Once amputation becomes medically necessary, preoperative evaluation with a clinic specializing in amputations is very benefcial for these patients.