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HbA1C level good predictor of amputation outcome

Control at 7% or under was predictive of successful healing for diabetic patients after transmetatarsal amputation.

Issue: September 2004

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SEATTLE — Control of blood glucose levels at 7% Hb1AC or under was found to be a positive predictor for a transmetatarsal amputation healing successfully in patients with diabetes mellitus, according to results of a study conducted by Canadian investigators.

Debridement after a transmetatarsal amputation (TMA) was significantly associated with “a greater chance to go on to below knee amputation (BKA). That’s not surprising,” said Alastair S. Younger, MB, ChB, FRCSC. “Patients need to have their diabetes controlled for the foot to be salvaged — the sooner the better.”

And although it has been used widely, the presence or absence of pulse is no longer a true predictor of outcome in these cases, according to Younger, of Vancouver, British Columbia, who presented these results at the American Orthopaedic Foot and Ankle 20th Annual Summer Meeting.

“We find that 75% of our TMAs are successful. … We believe all patients should have a TMA if the skin will support it,” he said. “The Hb1AC is the best predictor of outcome.” Younger added that although other methods are predictive of TMA, they are not available outside of teaching hospitals.

TMA vs. BKA

A cohort study Younger and his co-investigators conducted examined differences that existed between 21 diabetic patients with TMAs and 21 patients who had failed TMAs and went on to have a BKA within a year. All procedures were done for similar indications.

Younger said the TMA technique used, which always includes a heel cord lengthening, was described in an article that was scheduled to be published this year. It involves complete debridement of the posterior and peroneal compartments and insertion of medical grade calcium sulfate pellets (Osteoset-T, Wright Medical Technology) that contain tobramycin into the wound.

Investigators found no major differences between the groups in age, sex, type of diabetes, presence of Charcot fractures and previous contralateral surgery or debridement.

“There was a trend if you looked at smoking in pack years with a slightly greater use of smoking in the BKA group,” he said.

Associated trend

“There was an associated trend of about eight months’ duration of ulcers in those that failed and about four months in those that didn’t. If we had more numbers we’d probably find this to be significant.”

The difference between the two groups was highly significant for blood glucose levels (P=.001). Patients who failed a TMA had levels at 10% or higher. “It is almost always successful for those with glucose levels at 7% Hb1AC,” Younger said.

“If you can optimize the diabetic control, hopefully it will improve the outcome of the amputation. It may even prevent the amputation.”

For more information:

• Younger AS, Meakin CD, Kalla TP, et al. Risk factors for failure of transmetatarsal amputation in diabetic patients: A cohort study. Presented at the American Orthopaedic Foot and Ankle Society 20th Annual Summer Meeting. July 29-31, 2004. Seattle.