If there is one thing that we had in abundance at the University of Texas Health Science Center at San Antonio, it was underinsured patients with severe diabetic foot infections and vascular disease. The busiest on-call week I ever experienced was 19 surgeries for DFI’s. (and then John Steinberg beat me during the next few weeks! I thought I would hold that record for a while.)

Dr. Yuki Morita-Izumi, a former UT resident who now works at a WHO hospital in Japan, spearheaded a research team that included me, Dr. Lawrence Harkless, Dr. Larry Lavery and Dr. Shuko Lee to take that goldmine of data. We examined two questions to put some old wives’ tales to rest:

1. Which limb is at greater risk for further amputation in the six months following the initial amputation. We baby the surgical limb, while the patient, often obese and with an unstable gait, puts a great deal of pressure on the contralateral limb. We were unsure of which limb would be at the greatest risk for further amputation. Of course, the amputated limb always ran the risk of further surgery if there was return to the OR. We prided ourselves on being definitive the first time if at all possible though.

After calculation of our ten years’ worth of data, we discovered that the risk factors governing the surgical limb outweighed those of the contralateral limb.

“Although risk to the contralateral limb rises steadily, it never meets the level of that of the ipsilateral limb,” we reported in Diabetes Care in 2006. 

So those of us who were "guessing" that the increased demand on the contralateral limb would do it in, were ABSOLUTELY incorrect. I lost a dinner to a resident over that one.

A few months ago, in the January 2009 Diabetes Research and Clinical Practice, we settled another argument about the importance of comorbidities in amputations. In first-time major amputees, the comorbid conditions are less important players in minor amputees. Remember that in our population, that first amputation was often the patient's FIRST entree into the healthcare system! But in the major amputees, the comorbid conditions are huge because the frequent cause of death in major amputees in this early period is sepsis. Again, though, that could have been the patient's first entree into the healthcare system. Sobering thought, huh? Doesn't make a government run healthcare system, like Medicare, look too bad after all.

As experienced diabetic foot physicians and surgeons sometimes we think we know all of the answers but when we pull out the charts and do the hard work of evidence-based medicine, it is only then that we get the real answers – as surprising as they sometimes can be!

Izumi Y, Satterfield K, Lee S, Harkless LB

Izumi Y, Satterfield K, Lee S, Harkless LB, Lavery LA