Significant reduction in major lower limb amputations

The significant decrease of 33% is evident when one looks at a peak of 133 in 2003 to 89 in 2010. 

Minister Joe Cassar said that the final result is a better quality of life for patients who also maintain their independence.

"A significant investment was made in the Orthotics and Prosthetics Unit so that patients still needing major amputation surgery are given an improved service and a good quality artificial limb in the shortest time possible," Cassar said.

The decrease in amputations has been possible due to a series of investments, amongst which were the employment of two Consultant Interventional Radiologists and a Consultant Vascular Surgeon.

Cassar said that the government further invested in equipment such as a Vascular Ultrasound Scanner (used in the diagnosis of blocked arteries to the legs), a CT scanner (with facilities to provide good quality images in the diagnosis of blocked arteries to the legs), a Vascular C-arm (for intra-operative use to assist performance of bypass operations) and Vascular Assist Doppler, which is an important tool when identifying patients with problems with blood supply to the feet.

Consultant Vascular Surgeon Professor Kevin Cassar, while addressing the press from an operating theatre at Mater Dei Hospital, explained that the reduction is mainly due to the significant increase in lower limb bypass surgery which has increased more than four-fold in the last three years.

"As the number of bypass procedures increases, the number of major amputation is decreasing. He said that major lower limb amputation carries a very high mortality rate and that reducing number of major limb amputations obviously also reduces mortality," Cassar said.

Professor Cassar explained that, while the most important factor is indeed the quality of life of the patient, a large proportion of patients undergoing major lower limb amputations require a long hospital stay (around 30 days). 

The 33% reduction is also due to the fact that more cases are picked up earlier when only the toes or foot is affected, and by improving the blood supply only the toe or part of the foot is lost but the leg is preserved. This is shown by the very significant increase in the number of amputations of the toes or foot (minor amputations).  By detecting the problem earlier and amputating the toes, major amputation of the leg (below or above the knee) is avoided.

Where a major amputation is required, it is preferable to amputate below the knee rather than above the knee as those undergoing below knee amputation are more likely to walk with a prosthesis and return to full independence.  As the total number of major amputations has decreased, another major difference is that the proportion of below knee to above knee amputations has increased significantly.

Professor Cassar also attributed the success achieved to a more efficient service which was enhanced with the setting up of a multidisciplinary diabetic foot clinic, composed by Diabetologists, Vascular Surgeon and Podiatrists, working together to identify and treat patients at risk of limb loss.  He also referred to the setting up of a nurse led Tissue Viability Unit that identifies patients with vascular problems and refers them directly to the vascular service. 

Mr Joseph Vassallo, a former patient of Professor Cassar, explained how he had to undergo three bypass operations due to his condition and praised Mater Dei staff for their strong commitment which led to him still being in good shape, and most of all, avoiding a major amputation.