SPECIAL ARTICLE

Lower-Extremity Amputation
in People With Diabetes
Epidemiology and Prevention

The age-adjusted rate of lower-extremity amputation

(LEA) in the diabetic population is 15 times that of
the nondiabetic population. Over 50,000 LEAs were
performed on individuals with diabetes in the United
States in 1985. Among individuals with diabetes,
peripheral neuropathy and peripheral vascular disease
(PVD) are major predisposing factors for LEA. Lack of
adequate foot care and infection are additional risk
factors. Several large clinical centers have experienced
a 44-85% reduction in the rate of amputations among
individuals with diabetes after the implementation of
improved foot-care programs. Programs to reduce
amputations among people with diabetes in primarycare settings should identify those at high risk; clinically
evaluate individuals to determine specific risk status;
ensure appropriate preventive therapy, treatment
for foot problems, and follow-up; provide patient
education; and, when necessary, refer patients to
specialists, including health-care professionals for
diagnostic and therapeutic interventions and shoe
fitters for proper footwear. Programs should monitor
and evaluate their activities and outcomes. Many issues
related to the etiology and prevention of LEAs require
further research. Diabetes Care 12:24-31, 1989

ndividuals with diabetes experienced an age-adjusted rate of lower-extremity amputation (LEA) ~15
times that of people without diabetes (1). In the
United States, this rate has been estimated to be
59.7/10,000 people with diabetes per year (1). In 1985,
104,488 nontraumatic LEAs were performed in private
hospitals (National Center for Health Statistics, National
Hospital Discharge Survey, unpublished observations),
and 8000 LEAs were performed in the Veterans

24

Diane E. Bild, MD, MPH

Joseph V. Selby, MD, MPH
Pomeroy Sinnock, PhD
Warren S. Browner, MD, MPH
Paula Braveman, MD, MPH
Jonathon A. Showstack, MPH

Administration hospitals (L. Turner, personal communication). Approximately half of these amputations occurred in individuals with diabetes (1). The direct cost
of an amputation including hospitalization, surgery, and
anesthesia, is $8000-12,000 per case (American Diabetes Association, Government Affairs, personal communication). Thus, the direct medical-care costs for all
amputations in the diabetic population within the United
States is $500 million/yr, not including rehabilitation.
The 3-yr survival rate for people with diabetes who have
undergone an LEA is only 50% (2). It is estimated that
>50% of the amputations within the diabetic population
could be prevented by reducing risk factors for amputation and improving foot-care (3).
Individuals with diabetes are predisposed to LEA primarily because of the presence of peripheral neuropathy
and peripheral vascular disease (PVD), but other factors
contribute. Figure 1 illustrates the major causal pathways leading to LEA in individuals with diabetes. Although the individual links in this causal chain have
been established by clinical or epidemiologic studies,
direct association between some early risk factors, e.g.,
smoking and hypertension and amputation, have not
been demonstrated. Diabetes, hypertension, smoking,
and hyperlipidemia are independent risk factors for PVD
(4). Diabetes is associated with obesity (5) and hypertension (6). Obesity is implicated in the development of
From the Division of Diabetes Control, and the Training and Laboratory Program
Office, Centers for Disease Control, Atlanta Georgia; the Division of Research,
Kaiser Permanente Medical Care Program, Oakland; and the Clinical Epidemiology Program, and the Department of Family and Community Medicine,
Institute for Health Policy Studies, University of California, San Francisco, San
Francisco, California.
Address correspondence and reprint requests to Diane Bild, MD, MPH, Division of Diabetes Control, Centers for Disease Control, 1600 Clifton Road, NE,
Atlanta, CA 30333.

DIABETES CARE, VOL. 12, NO. 1, JANUARY 1989

D.E. BILD AND ASSOCIATES

Diabetes
Inadequate knowledge,
practices and services

Obesity |
HyperglycemJo]

Hypertension

Smoking

NEUROPATHY

Hyperlipidemia
1 '

Minor trauma/lack
of perception

PERIPHERAL VASCULAR DISEASE |

FIG. 1. Casual pathways leading to

lower-extremity amputations in individuals with diabetes.

hyperlipidemia and hypertension (5). Although diabetes

is sometimes associated with lipid abnormalities, the
relationship may vary by age, sex, type of diabetes, and
treatment for diabetes (7). Hyperglycemia is thought to
be the major risk factor for the development of peripheral neuropathy (8,9). Peripheral neuropathy can lead
to the loss of sensory perception of foot trauma. PVD
can cause gangrene and poor healing of foot lesions.
Infection frequently intervenes, exacerbating tissue
damage. Throughout this process, the quality of foot
care may determine whether risk factors, underlying pathology, and manifest foot lesions ultimately lead to amputation.
Herein, we review the epidemiologic evidence regarding the causes and prevention of amputation in individuals with diabetes and apply this information to the
development of programs aimed at reducing the incidence of LEA in the diabetic population. The monitoring
and evaluation of programs and research needs are also
discussed.

RISK FACTORS FOR LEA

PVD. There is an increased prevalence of PVD among
individuals with diabetes in both sexes compared with
nondiabetic individuals (10), and the pattern of PVD
tends to involve vessels below the knee more often than

DIABETES CARE, VOL. 12, NO. 1, JANUARY 1989

| POOR FOOT CARE|

INFECTION

GANGRENE
AND
AMPUTATION

in nondiabetic individuals (11,12). In epidemiologic

studies, PVD is commonly measured as intermittent
claudication, the symptom of cramping calf pain induced by walking and relieved by rest (10), or as arteriosclerosis obliterans, the absence or marked impairment of at least one major arterial pulse (13). In the
Framingham study the relative risk of intermittent claudication in individuals with diabetes was 4-5 times that
of those without diabetes, even after adjusting for blood
pressure, cholesterol, and smoking (10). In those with
diabetes, the prevalence of PVD increases with age and
duration of diabetes, and is increased in men (13,14).
A study from Rochester, Minnesota, found an 8% prevalence of arteriosclerosis obliterans at the time of diagnosis of diabetes, a 15% prevalence at 10 yr, and a 45%
prevalence at 20 yr (13). In the general population of
the Framingham study, smoking doubled the risk of intermittent claudication in both sexes, and hypertension
increased the risk 2.5 times for men and 4 times for
women (4). Risk factors for PVD in the general population, including hypertension, elevated cholesterol, and
smoking (15), appear to present a similar magnitude of
risk for diabetic individuals (12,14,16,17). The presence
of PVD increases the risks for ulcer, gangrene, (13,18,19),
and amputation (20) among those with diabetes. Therefore, it is logical to consider smoking, hypertension, and
elevated cholesterol as risk factors for amputation itself
in diabetic individuals.

25

LOWER-EXTREMITY AMPUTATION IN PEOPLE WITH DIABETES

Peripheral neuropathy. Peripheral neuropathy is a

common complication of diabetes, although its exact
prevalence has not been established because of the lack
of standard definitions. In a longitudinal study in Brussels (21), the prevalence of peripheral neuropathy was
found to be 8% at the time of diagnosis of diabetes and
increased to 50% after 25 yr duration. The diagnosis of
peripheral neuropathy was based primarily on loss of
Achilles and patellar reflexes and decreased vibratory
sensation. The importance of hyperglycemia in the development of peripheral neuropathy is well documented
(8,9,22). In a prospective study of Pima Indians with
diabetes (23), absence of peripheral reflexes and impaired vibration perception in the great toe were predictive of amputation, after controlling for age, sex, and
duration of diabetes.
Distal symmetric polyneuropathy, the most common
form of neuropathy in individuals with diabetes (9,24),
may involve sensory, motor, and autonomic nerve fibers. Reduced thermal and pain sensation, numbness,
and painful paresthesias are the most frequent manifestations of sensory impairment in this syndrome (9,24,25).
As a result, those with peripheral neuropathy may fail
to notice minor trauma, pressure from poorly fitting shoes,
or thermal trauma resulting in calluses, ulceration, infection, and gangrene (19,25). Motor nerve impairment
may cause muscle atrophy, which leads to foot deformities and a maldistribution of pressure over the surface
of the foot (25). Autonomic neuropathy has also been
implicated in the development of foot lesions (26). The
absence of sweating may result in dry, cracked skin (25).
Vasomotor instability may produce arteriovenous shunting in the foot (27), possibly due to abnormal sympathetic innervation, resulting in lower tissue oxygen tension (28,29).
Peripheral neuropathy may be the most important
pathologic precursor for the development of foot ulcers
(3/25,30,31), although it is difficult to separate the contributions of various risk factors. In a study of 239 people
(30) with diabetes and foot ulcers, 62% of foot ulcers
were classified as neuropathic and 38% were classified
as ischemic according to clinical examination. In addition, 59 (60%) of the ischemic group had neuropathy.
The chronic granulomatous infection of Hansen's disease (leprosy) can produce peripheral neuropathy, which
leads to ulceration in the absence of vascular disease
(32).
Infection. Infection is present in the majority of foot
ulcers (30,33) and is a frequent precursor to amputation
(34,35). The foot is the most frequent site of infection
among individuals hospitalized for diabetes and infection (36), and foot infections account for more in-hospital days than any other complication of diabetes (37).
Typically, foot infections occur with multiple organisms,
both aerobic and anaerobic (33). Whether there is a
general increase in susceptibility to infection among
people with diabetes is controversial (38).
Hyperglycemia. Hyperglycemia was associated with
increased risk of LEA in the Pima Indian study (23). As

26

described earlier, hyperglycemia appears to be the major risk factor for neuropathy and probably impairs host
defenses against infection as well. There is little evidence that hyperglycemia hastens the development of
large vessel disease (12,14), but it may be associated
with a more peripheral smaller vessel disease common
in diabetes (12).
Foot care. Because diabetes predisposes to foot ulcers
and other lesions, proper foot care plays an important
role in the early detection of disease and prevention of
amputation. Preventable minor trauma, poorly fitting
shoes, and failure to detect (19,25) and treat injuries
early can allow the development of infection and gangrene that may lead to amputation. Although it is recommended that clinicians examine the feet of those with
diabetes who are at high risk for foot problems at each
clinic visit (3,39), one study found that such examinations occur in only 12.3% of visits at a diabetes specialty
clinic (40). Several studies (discussed later) have suggested that programs of proper foot care can significantly
reduce the rate of amputation (30,41-43).
Minor trauma due to friction from poorly fitting shoes
is a common initiator of foot ulcers and calluses, especially in individuals lacking protective sensation
(27,32). Shoe modification or footwear designed to fit
the foot, especially when the foot is deformed, is strongly
recommended (44). However, specially made shoes
can be expensive ($100-400/pair). Replacing usual
footwear with athletic running shoes has been shown to
reduce the size of plantar calluses (45).
Race. The risk of amputation in people with diabetes
has been found to be 2.3 times greater for Blacks than
Whites in South Carolina (1) and 1.4 times greater for
non-Whites than Whites in New Jersey (46). The rate of
amputation among Pima Indians with diabetes has been
found to be 3.7 times greater (23) than the rate of amputation among those with diabetes in six states (1). It
is not clear whether race itself or low socioeconomic
status contributes to this increased risk. One study suggests that the increased prevalence of hypertension and
smoking in Blacks may play a role (47).
Age and duration of diabetes. Among individuals with
diabetes, the risk of amputation increases with age.
Compared with individuals with diabetes aged <45 yr,
the risk of amputation in those aged 45-64 yr is 2-3
times higher, and in those >65 yr old, it is 7 times higher
(1). Approximately 64% of all LEAs occur in those who
are aged ^65 yr, and 96% of all LEAs occur in those
aged ^45 yr (Table 1). The risk of amputation appears
to parallel the prevalence of neuropathy, which increases with duration of diabetes (21), and the prevalence of PVD, which is also associated with duration of
diabetes and, independently, age (12-14). In the Pima
Indian study (23), duration of diabetes was a significant
risk factor for amputation even after controlling for age
and sex. Thus, duration of diabetes should be considered a risk factor for amputation.
Sex. The risk of LEA has been found to be 1.4-2.6 times
greater for men than for women with diabetes (1,23,46).

DIABETES CARE, VOL. 12, NO. 1, JANUARY 1989

D.E. BILD AND ASSOCIATES

TABLE 1
Estimated age-specific proportions of lower extremity
amputations among individuals with diabetes
Age (yr)

Age distribution of general

population (%)*
Age-specific prevalence of
diabetes per 100,000t
Age distribution of individuals
with diabetes (%)*
Annual amputation rate among
individuals with diabetes per
10,000
Proportion of amputations among
people with diabetes (%)||

<45

45-64

69.3

18.6

12.1

570

5790

7970

16.2

44.2

39.6

65 +

tual amputation, although empirical data to support this

are lacking. However, in the best of circumstances, at
a specialized foot-care clinic, healing was achieved in
86% of neuropathic ulcers and in 72% of ischemic ulcers (30). Nonhealers were treated with various surgical
techniques, although most required some form of amputation. Patients with previous ulcers have demonstrated a propensity for foot problems and should also
be considered high risk (3).

INTERVENTIONS TO REDUCE MORBIDITY

Rationale for interventions. Interventions to prevent

14.1

45.0

101.4

3.7

31.9

64.4

*Ref. 53. tRef. 54. Ref. 1.

Based on 1st and 2nd entry. ||Based on 4th and 5th entry.

Men with diabetes are at higher risk for PVD (2), although smoking has been found to be a confounding
factor (14). In the Framingham study (10), the age-adjusted incidence of intermittent claudication was 50%
greater in men than women with diabetes. The prevalence of neuropathy has been found inconclusively to
be slightly greater in men than women (21).
Type of diabetes. The effect of what type of diabetes
has on the risk of amputation is unknown and difficult
to assess because of the strong confounding effects of
age and duration of diabetes. Those with insulin-dependent diabetes mellitus (IDDM) have been found to have
a slightly higher prevalence of PVD than those with noninsulin-dependent diabetes mellitus (NIDDM), after adjusting for age (14). Individuals diagnosed with diabetes
before age 30 yr have a higher age-specific prevalence
of foot ulcers than those diagnosed at or after age 30 yr
(2). These differences may also be related to duration of
diabetes. Because the risk of amputation increases with
age, and the NIDDM population is older and >10 times
greater in size than the IDDM population, the overwhelming majority of amputations occur in individuals
with NIDDM.
Previous amputation and foot lesions. For those with
diabetes who have had an amputation (below the knee
or above the knee), the risk of amputation of the contralateral leg within 3 yr (48) has been found to be 1020 times greater than the risk of amputation in the general diabetic population (1). A recent study found the
incidence of contralateral amputation in those with diabetes to be 53% 4 yr after the first amputation (49).
The risk of amputation is presumably increased after a
minor amputation, e.g., toe amputation, compared with
individuals with diabetes who have never undergone
such a procedure.
Individuals with diabetes who have a foot lesion such
as an ulcer, deformity, or infection are considered to be
at very high risk for progression of the lesion and even-

DIABETES CARE, VOL. 12, NO. 1, JANUARY 1989

LEAs in people with diabetes should be aimed at the

prevention of peripheral neuropathy and PVD and the
prevention, early detection, and treatment of foot lesions that occur in individuals with these conditions.
Although no interventions for prevention of peripheral
neuropathy and PVD have been proven effective, efforts
targeted at reducing smoking and controlling hypertension, hyperlipidemia, and hyperglycemia should reduce
the incidence of these conditions and eventually reduce
the incidence of amputation in the diabetic population.
Because a large proportion of those with diabetes already have manifest peripheral neuropathy and PVD,
interventions should also focus on prevention of ulceration, infections, and gangrene through intensive footcare programs. Patient education and prophylactic treatment are the mainstays of preventive foot care. These
strategies should have a more immediate impact on the
amputation rate in the population than those aimed at
preventing PVD and peripheral neuropathy.
Published studies of effective interventions. Several
studies of clinical interventions have demonstrated that
improved foot care may reduce the frequency of amputations among those with diabetes (30,41-43). Grady
Memorial Hospital in Atlanta instituted a diabetes unit
that integrated inpatient and outpatient services, included comprehensive podiatry services, and added
several nurse clinicians and an extensive education program (41). The hospital serves an indigent, inner-city,
mainly black population. The annual number of LEAs
decreased by almost 50% from 172 in 1973 to an average of 92/yr from 1974 to 1982 among the 8000 clinic
patients (50).
At Kings College Hospital in London, the diabetes foot
clinic added the services of podiatrists and shoe fitters
to those of nurses, physicians, and surgeons (30). The
amputation rate declined 44% in 2 yr with a program
that consisted of intensive chiropody (podiatry), antibiotic therapy, and specially constructed shoes. The effect of shoes on recurrence of ulcers was particularly
dramatic; the recurrence rate was only 26% among
those with specially fitted shoes compared to 83% among
those with regular shoes.
In Memphis, Tennessee, the County Health Department transferred 800 patients with diabetes from the
city hospital outpatient clinic to decentralized, small

27

LOWER-EXTREMITY AMPUTATION IN PEOPLE WITH DIABETES

neighborhood clinics close to the patients' homes (42).

Specially trained nurse practitioners provided care under specified protocols. The frequency of patient-clinician contacts and of home visits increased markedly.
Hypertension and glycemic control improved in the patients receiving care in the decentralized clinics, and a
68% reduction in hospital days for PVD-related illness
and amputation was noted during the 2-yr follow-up
period, compared to a 13% reduction in those who continued to use the city hospital.
At the University Hospital of Geneva, an 85% reduction in below-knee amputations was observed over a 4yr period after patient education and training in foot care
was instituted for those with diabetes (43).
These studies, although uncontrolled, suggest by their
results that comprehensive foot care, including podiatric
care, education, and specially fitted shoes, can significantly reduce LEAs in individuals with diabetes.

PROGRAM IMPLEMENTATION
Identification, evaluation, and treatment of high-risk
individuals. Individuals at high-risk for LEA must be
identified, evaluated, and treated according to their risk
status. Poor access to health care should be considered
a fundamental high-risk characteristic. Demographic
characteristics, especially age, may be used to identify
a high-risk group in a diabetic population. Clinical history, especially history of foot ulcer or LEA, may also
be used to identify high-risk individuals. The clinical
evaluation that determines the presence of significant
peripheral neuropathy, PVD, foot ulcer, callus, or deformity, will most closely define the patient's clinical
risk status. Table 2 shows which individuals with diabetes are at highest risk for amputation in decreasing
order of risk. These categories should be used to define
or describe the population that a program chooses to
target for intervention.
At minimum, individuals with diabetes should have
TABLE 2
Risk status among individuals with diabetes, according to
available information
Demographic
characteristics
and history

Risk group
1 (highest risk)

Previous amputation
Past history of foot ulcer

Clinical evaluation
Current foot ulcer
Foot deformity

2 Neuropathy and/or
peripheral vascular
disease
3 >40 yr old
Diabetes of >10 yr
duration
Individuals will fall into more than one risk group depending on the
types of information available. To identify or describe a high-risk group,
individuals should be placed into the highest-risk group into which
they fall, based on available information.

28

a complete foot evaluation annually, including general

inspection and assessment of peripheral nerve status,
peripheral vasculature, and type of footwear used (3,39).
At each visit, the primary-care professional should examine the feet to check for the presence of ulcers, calluses, and other lesions. Guidelines for clinical risk assessment, treatment, and follow-up of individuals are
available (3,39). [The American Diabetes Association is
developing guidelines for foot-care to be published in
Diabetes Care.]
Interventions to prevent LEAs among individuals with
diabetes should be incorporated into existing comprehensive primary care and include a broad range of strategies. Behaviors required for good health in the general
population, including smoking cessation, exercise, weight
control, and hypertension and cholesterol control, are
particularly important for those with diabetes, and strategies to change unhealthful behaviors should be included in the intervention program. Specific preventive
and therapeutic foot-care strategies must also be provided, tailored to the individual's risk status.
A team approach to comprehensive primary-care for
individuals with diabetes has been recommended
(3,30,41). Although not feasible in all health-care settings, it has been recommended that professional team
members regularly involved in foot care at the primarycare level include the nurse, the primary-care physician,
the diabetes educator, and the podiatrist (25). The services of the infectious-disease specialist, orthopedic surgeon, vascular surgeon, physical therapist, and shoe fitter should be available for consultation and to render
medical assistance as necessary. Of course the patient,
and often a family member, must be involved in daily
management.
Patient education. All individuals with diabetes, especially those at high-risk, should learn the principles
of self-foot examination and care. If the patient is unable to examine his or her own feet, family members or
others should learn to perform this function. Specific
instructions for patients on self-foot examination and
care are available (25). As warranted, instruction should
be provided on smoking cessation, hypertension control, glycemic control, cholesterol reduction, diet, and
exercise.
Professional education. Professional education strategies should be aimed at all members of the comprehensive health-care team, especially primary-care practitioners. These strategies should stress the identification
of high-risk patients, assessment of clinical risk status,
performance of regular foot examinations, and assurance of follow-up according to risk. It should also include treatment methods and when to refer patients to
specialist health-care professionals and shoe fitters.
Professional education programs may also be targeted
to orthopedic and vascular surgeons to emphasize
appropriate corrective and therapeutic surgery and to
improve the coordination of care with primary-care
practitioners. The basic components of a foot-care program for individuals with diabetes are summarized in
Table 3.
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D.E. BILD AND ASSOCIATES

TABLE 3
Components of foot-care program for
individuals with diabetes
Identification of individuals at high risk from history and clinical
evaluation of the feet and footwear and determination of clinical
risk status
Follow-up and treatment of the patient according to risk status,
including examination of the foot at each clinic visit
Education of the patient on principles of self-care, including daily
inspection
Consultation with specialty services for care, including orthopedic
and vascular surgeons and podiatrists, as needed
Use of modified footwear and specially fitted shoes as needed

PROGRAM EVALUATION
To evaluate the impact of programs that seek to prevent
LEAs in diabetic populations, information must be collected on outcomes of interest (51). Computerized hospital discharge data are available in many states and are
a useful source of population-based information for the
numbers and rates of LEA (52). A comparison of amputation rates among target areas or an analysis of trends
over time may serve as measures of program impact.
Hospital discharge abstracts containing both a diagnosis
of diabetes (ICD-9-CM codes 250.0-250.9) and a lowerextremity surgical procedure (codes 84.10-84.19) identify LEA in individuals with diabetes. Traumatic amputations can be eliminated from the data by excluding
diagnosis codes 895, 896, and 897.
Intermediate outcome data, such as prevalence of foot
ulcers or significant peripheral neuropathy in the target
population, may also provide useful evidence of program impact. These measures are not readily ascertained on a population basis and must be gathered from
clinical settings. The ability to evaluate intervention
strategies using this approach is limited, however, unless the intervention has been randomized and a comparison group has been identified and followed.
In addition to measuring outcomes, measures of program activity (such as the proportion of patients whose
feet are examined at each visit or fitted with special
shoes), should be monitored to help establish a relationship between intervention and outcome.

RESEARCH ISSUES
Many issues related to the etiology and prevention of
LEA are unresolved. Basic and operational research should
be undertaken to answer questions about the translation
of effective management into community practice. These
issues include 7) the precise prevalence and relative impact of various risk factors for LEA; 2) the development
of feasible, meaningful measures for clinical risk assessment; 3) the determination of optimal preventive and
treatment strategies for PVD, peripheral neuropathy, and
DIABETES CARE, VOL. 12, NO. 1, JANUARY 1989

foot lesions; 4) the coordination of primary care and

specialty services; 5) the financing of foot-care services;
and 6) the development of methods to measure program
impact.

CONCLUSION
LEA is a major health problem in the diabetic population
and is associated with significant morbidity, mortality
and disability, and high costs. Although there are gaps
in the understanding of the epidemiology and pathogenesis of LEA, many effective preventive interventions
are available and, if implemented fully, could greatly
reduce the rate of LEAs. Programs to prevent LEA in the
diabetic population require systematic identification,
evaluation, and follow-up of those at risk and the application of a broad range of preventive strategies.

ACKNOWLEDGMENTS
The preparation of this manuscript was supported by a
contract with the Division of Diabetes Control, Centers
for Disease Control, Department of Health and Human
Services.

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