If you were born with all your limbs intact, you’d ideally want to keep them functioning well until the end.
Unfortunately, diseases such as diabetes rob some of us of a limb or two.
Amputation is the loss or removal of a body part such as a finger, toe, hand, foot, arm or leg, whether accidentally or purposefully.
It impacts all aspects of a person’s life, including the ability to move, work, interact with others and maintain independence.
Globally, it is estimated that every 30 seconds, one leg is amputated due to diabetes.
As the frequency of diabetes increases in Malaysia, the incidence of lower limb amputations (the thigh, lower leg and foot) is also expected to rise.
The longer you have diabetes, the higher the risk of developing foot problems, mainly due to neuropathy (damage to the nerves) and/or peripheral arterial disease (where arteries become narrow, thus reducing blood flow to the limbs, especially the legs).
ALSO READ: Peripheral artery disease: Blood block in the legs
In diabetes, excess blood glucose can damage small blood vessels, which nourish the nerves.
Damaged nerves can result in tingling, pain, numbness or weakness, as well as muscle weakness and loss of sensation.
Half the patients with diabetic neuropathy do not have any symptoms until they suffer a non-healing wound, likely caused by excessive pressure or trauma to the foot.
Due to the loss of sensation, these individuals may not notice minor scrapes and injuries, which can quickly turn into serious wounds if not treated promptly.
ALSO READ: Foot ulcers cost the most among all diabetic complications
An increasing trend
Worldwide, roughly one million amputations are performed annually on diabetic patients.
Hospital Kuala Lumpur (HKL) Orthopaedics & Traumatology Department head Dr Siti Hawa Tahir explains: “Amputation is a major surgery which is usually performed by orthopaedic surgeons, but can also be done by vascular surgeons, who take care of anything to do with blood vessels.
“When it comes to lower limb amputations, about 70% of them from our hospital are due to complications from uncontrolled diabetes.
“The remaining ones are from traffic accidents (traumatic amputations) and a small percentage are from an infection as a result of peripheral arterial disease.”
According to HKL’s statistics, there were 337 lower limb amputations carried out in 2023, which increased to 427 in 2024.
Of last year’s cases, 251 amputations were of the toes and foot; 91 below the knee; 53 above the knee; and 32 disarticulation (where the limb is severed through a joint, rather than through a bone).
She says: “That’s only from our department – it is a lot!
“There is definitely an increasing trend.
“Vascular surgeons can perform the same kind of amputations – we don’t know what their numbers are.”
Malaysia’s Clinical Practice Guidelines on Management of Diabetic Foot states that 80% of non-traumatic lower limb amputations in patients with diabetes are preceded by a foot ulcer.
Around half of patients with diabetes die within five years of developing a foot ulcer, and up to 70% die within five years after an amputation.
Lower limb amputations occur much more frequently than upper limb amputations, with toe amputations being the most common procedure.
Not only is it a risk for disability and death, but amputations also pose a major burden to the patient, caregivers and the healthcare system.
In denial
From Dr Siti Hawa’s personal observation, patients are mainly in their early 30s to 60s.
“Looking at the way they eat, their lifestyle and mentality, especially the young ones, I’m not surprised they have diabetes.
“Most of them belong to the lower socioeconomic group and it’s not easy to convince them about diet control, what is important and the measures they need to take,” points out the consultant orthopaedic surgeon.
She adds: “Quite a number will take all sorts of supplements to heal their wounds, and by the time they come to us, it’s too late already.
“A small group is compliant to the follow-ups and the way they perceive total well-being is to leave their healthcare purely in the hands of the attending doctor.”
Patients usually come to the hospital through the emergency department, via clinic follow-ups or referrals from other doctors who are unable to administer further treatment.
“When we admit them, we can identify that their wound is not clean so we have to treat it aggressively or they will end up with amputation.
“There are certain criteria to guide us to know if a patient’s leg can or cannot be salvaged.
“Most of the time, their blood glucose is also haywire.
“It’s like a chicken-and-egg scenario: the fluctuating blood glucose can be due to an infection, or their uncontrolled diabetes led to a bacterial infection,” she says.
Sometimes, patients are in denial that their wound is serious, despite it having a foul smell, as happens in 99% of those coming through the emergency department.
“With diabetic patients, we cannot wait as the blood glucose spike itself can accelerate infection spread, so we need to stop that by removing the source of infection soonest.
“We debride by removing certain tissues that are not good and leave structures that are viable if their blood vessels are good.
“Then we give antibiotics and change the wound dressing daily to see if it helps.
“We also have to stabilise their blood glucose,” explains Dr Siti Hawa.
For some patients, this line of treatment might be enough to save their limb.
If not, the doctors look at blood circulation because long-term diabetes can cause blood vessels to become weak.
Normally, only blood vessels on one leg are affected.
The small capillaries get blocked first as these are the furthest from the heart (distal).
Without oxygenation, the tissues they supply die spontaneously.
She says: “For diabetic patients, it happens very gradually and goes unnoticed.
“The nerve gets affected, impacts healing, and if there is a wound, it can turn into an ulcer.
“It’s like a time bomb – one day, the blood glucose goes up, bacteria gets into the wound and can travel to the heart within 24 hours, so the patient deteriorates quickly.
Hence, many patients end up with amputation because there is simply no time to waste; doctors have to literally hurry to cut in order keep them alive.
Lifting their spirits
It’s easier to remove the wounded area than treat the wound.
ALSO READ: Caring for chronic wounds can be complicated
However, in non-diabetic individuals, their oxygenation is still good and strong medications can kill the bacteria.
“In an emergency situation and if the patient is alert, we get his consent, along with his closest family members, before proceeding with the amputation.
“But in a non-emergency setting, we refer to the rehabilitation physician first.
“This is because patients can be emotionally and psychologically affected, and our rehab team will counsel them on how their life will change and that it’s not the end of the world.
“If they’re feeling down, we need to bring their spirits up as it can affect recovery.
“If they’re positive, it’s much easier on our team and recovery is faster,” says Dr Siti Hawa.
Should the specialists anticipate a problem or if the selected patient cannot accept or refuses amputation, a psychologist will be called in.
She says: “We’ve got to tell them that their life will be in jeopardy if they don’t amputate and 3-5% will still refuse.
“So, we have to respect their decision and continue treating with medications and debridement.”
Indeed, there have been occasions where amputations have been done multiple times, beginning with the toes.
“When conditions permit, we can try to do the distal area first and monitor the progress.
“Sometimes, we also kesian (pity them)– in certain cases, we can tell from the X-ray that the bone is only mildly infected, so we give a chance to save the limb.
“If their blood vessel is good, we debride and treat with strong antibiotics to kill the organism, as well as use a special dressing or skin graft later,” she says.
A single toe can be amputated in less than 30 minutes, while a bigger limb can take up to three hours, depending on the patient’s size and muscle bulk.
Post-surgery pathway
Once the patient is out of surgery, he is sent for rehabilitation while being monitored by the orthopaedic surgeon.
This is where consultant rehabilitation physicians like Dr Julaina Terimo come in.
“They are actually referred to us before admission, but since the majority of them come in via emergency, we see them after the amputation.
“For cancer cases, there is more time to prepare them for life after surgery.
“Whether or not they get prosthetics does not matter,” says the HKL Rehabilitation Medicine Department head.
When her team sees the patient in the ward, they immediately try to establish rapport by letting them know that rehabilitation involves a multidisciplinary team who are there to empower them.
Team members include physicians, doctors, nurses, occupational therapists, physiotherapists, wheelchair service professionals, prosthetists and orthotists, among others.
Dr Julaina says: “Before amputation, we get their informed consent, but after amputation, there is a pathway to follow from post-amputation to pre-prosthetic, receiving prosthetic and long-term care.
“We follow them up for life to check their progress.”
Not all patients are suited for wearing a prosthetic as they need to be medically assessed first.
“We want to know his personality, whether he is motivated or not, has good cognition, is physically able and how he is managing pain.
“We might start off with pharmacological treatment, massage or use a transcutaneous electrical nerve stimulator (TENS), which sends electrical pulses through the skin to start your body’s own painkillers.
“From here, we can gauge if he can be prescribed prosthetics.”
Prior to that, the amputee also needs to learn how to sit, stand and have a cardiac (heart) evaluation.
“In traumatic cases or if the patient is young, we prescribe prosthetics as soon as his wound is healed and is conical in shape,” says Dr Julaina.
For patients with diabetes, they must use a special technique (stump bandaging) to mould the amputated leg.
Wrapping the stump keeps the limb from swelling and shapes it so that it fits more comfortably in a prosthetic.
She says: “They have to be proactive in providing us with information – some tell us at night the stump gets very hot or they experience phantom pain, which is pain in a body part that’s not there any more.
“We have a peer group for amputees that meets several times a year, so they share information and learn from each other.”
Prosthetics are not cheap, but to ensure underprivileged patients are not deprived, financial sources and funds are available at HKL.
Dr Siti Hawa concludes: “Diabetes is the main culprit for amputations.
“Everybody, including schoolchildren, knows about the disease, and yet, public awareness is still poor.
“I’m not sure whether it is a socioeconomic issue or due to their lifestyle from young.”
“We really have to change our mindsets to aggressively maintain our blood glucose in the acceptable range.”
This is one of the best ways to ensure our limbs remain with us throughout our lives.
Read StarHealth on Feb 23 (2025) to get the vascular surgeon’s perspective on amputation.
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