A1c Predicts Success of Amputation in Diabetics
Issue 219 Item 2

An A1c of greater than 10% suggests that an amputation will fail and further surgery will be required. In diabetic patients being evaluated for lower extremity amputation, a hemoglobin A1c (HbA1c) value greater than 10% strongly suggests that a transmetatarsal amputation (TMA) will fail and that a below-knee amputation (BKA) will be required, new research shows. Conversely, values below 7% usually predict success.

When a diabetic patient shows signs of having a foot ulcer – which is an open wound on the bottom of the foot – doctors first try to heal it using a variety of methods. If those methods fail, the ulcers become severe and often infected, causing many doctors to quickly perform a below knee amputation. This results in a patients’ loss of mobility and independence.

An alternative to a BKA is a transmetatarsal amputation (TMA) in which the front portion of the foot containing the ulcer is removed. TMAs have a 75% success rate, but for the 25% of patients whose TMA’s fail, the process of getting another corrective surgery is monetarily, physically, and mentally taxing. This failure rate has caused many surgeons to skip an attempt at a TMA and simply perform a BKA.

Senior author Dr. Alastair Younger, from St. Paul’s Hospital in Vancouver, British Columbia stated that, a high HbA1c value should not make surgeons jump straight to a BKA, rather they should consider referring the patient to an endocrinologist or take other measures to improve glucose control before surgery.

To determine risk factors for TMA failure in diabetics, the researchers compared data from 21 patients with a failed TMA and 21 matched subjects with a successful TMA. A variety of factors were evaluated, including age, sex, smoking, pulse status before surgery, presence of heel ulcer, and Hb1Ac.

Dr. Younger presented his teams’ findings last Thursday at the annual meeting of the American Orthopedic Foot and Ankle Society in Seattle.

The only preoperative factor significantly associated with TMA outcome was the HbA1c value. Postoperatively, only the need for debridement predicted TMA failure.

“The results were very surprising to us,” Dr. Younger said. “It didn’t matter what the pulse was like or anything else — the only absolutely key factor in predicting TMA failure was the quality of diabetic control as measured by the HbA1c. Regardless of any other factor, a HbA1c over 10% meant that the TMA wasn’t going to heal.”

When a diabetic patient starts getting a foot ulcer, “the first thing that you have to do is get their glucose consistently under control,” Dr. Younger noted. This could help them avoid amputation in the first place or at least improve their chances of successful TMA, thereby avoiding a BKA, he added.

Annual meeting of the American Orthopedic Foot and Ankle Society, July 22, 2004
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