Lower Extremity Amputations: A Scorecard Two Decades After the St Vincent Declaration #ActAgainstAmputation #DiabeticFoot @ALPSlimb @USC @USC_vascular @ResearchatUSC @KeckSchool_USC

For those of you who remember the 1989 St. Vincent’s Declaration, this will be a blast from the past!

November 14 is World Diabetes Day, chosen because it is the birthday of Dr Fredrick Banting, one of the codiscoverers of insulin. The 2022 theme is “education to protect tomorrow,” with a focus on providing “access to quality diabetes education for healthcare professionals and people living with diabetes.”1 The International Diabetes Federation has launched an accompanying global survey to explore access to diabetes education for providers and individuals with diabetes (available at https://worlddiabetesday.org/wddsurvey).

In 1989, the St Vincent Declaration set a target of decreasing the number of lower extremity amputations (LEAs) by 50% over the 11 years leading up to 2000.2 This target is still unmet. In one sample of 20,060 patients older than 40 years who had LEAs in Ontario, Canada, between 2005 and 2016, 63.7% had above-the-ankle amputations, 81.8% were persons with diabetes, 93.8% had peripheral arterial disease, and 75.6% had both peripheral arterial disease and diabetes. Although the amputation rate declined from 9.88% in 2005 to 8.62% in 2010, it increased to 10% in 2016.3 Prof Fran Game2 speculated on the need for these LEAs, arguing that LEAs are a treatment, not a disease. Although some patients may benefit from amputations and prostheses, the functional status of most patients does not improve, and the trauma has severe consequences.

Reverse innovation is a process to bring low-cost innovations from the developing world to the developed world. In one example from Guyana, a Canadian and Guyanese team established a Diabetic Foot Center at Georgetown Public Hospital Corporation.4 The faculty trained 15 interprofessional members of the clinical team with a yearlong key opinion leader certificate course at the University of Toronto, as well as preceptorships and screening for high-risk diabetic foot in the waiting room of the hospital diabetes clinic. This process reduced amputations by 68%.4

In Northern Ontario, indigenous, remote, and isolated communities have high LEA rates. There is often a delay in receiving healthcare services from outside specialists or expensive air ambulance evacuations. One solution is to train healthcare professionals from these communities and provide them toolkits for care to build local capacity, as was done in Guyana. A group of foot specialists and an interprofessional team have devised kits that would serve these communities. The first step is to determine the hemoglobin A1C for diabetic control. The remaining components are VIPs (vascular, infection, pressure, and sharp surgical debridement):

  •  Vascular: Audible handheld Doppler can detect multiphasic wave sounds and adequate blood supply to heal and is not influenced by calcification.
  •  Infection: Can be diagnosed at the bedside with any three or more NERDS criteria (local infection) or any three or more STONEES criteria (deep and surrounding infection). Higher doses of some oral antibiotics may serve as an alternative to IV formulations with similar results.
  •  Pressure: The contact cast and the removable cast walker (made irremovable) are the criterion standard of care. However, these devices and the expertise needed to use them are often not present in nursing stations or other remote and isolated Indigenous communities. Further, the Northern climate can make these devices dangerous. Accordingly, specialists recommend low-cost, all-purpose boots with a deep, enclosed toe box. Inserts can easily be traced with two thicknesses of Plastazote-PORON medical sheets (Grogan Group) that can be cut and fitted for pressure redistribution.
  •  Sharp Surgical Debridement: It may be important to remove callus and debris, creating an acute wound within a chronic wound.

Education also needs to accompany the toolkits; this will be delivered via an ECHO (Extension for Community Healthcare Outcomes) Ontario Skin and Wound with a hub-and-spoke model of care. The qualifying communities will participate in twice-monthly sessions where the spoke communities present deidentified cases for help from the other spokes and expert interprofessional cohubs. This virtual model and live introductory session will provide wound care education to help improve local capacity. Only time will tell if this can reduce the LEA rate and improve the everyday activities of persons with diabetes.

For more content on underserved communities, watch for our special issue on diversity, equity, and inclusion in February 2023.

R. Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM

Elizabeth A. Ayello, PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN

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