In Reply

Lower Limb Amputation in Germany An Analysis of Data From the German Federal Statistical Office Between 2005 and 2014 by Prof. Dr. med. Knut Kröger, Dr. med. Christian Berg, Dr. med. Frans Santosa, Dr. med. Nasser Malyar, and Prof. Dr. med. Holger Reinecke in issue 8/2017

Tanudjaja mentions a US publication that describes the importance of podiatry for amputation rates (1). Even though the study‘s subject matter fits well with our results (2), the term podology as foot care administered by medical professionals needs to be carefully distinguished from podiatry, a science that focuses in the study of the foot, its anatomy, physiology and pathophysiology, and the correct treatment. Podologists are not allowed to make incisions and are not allowed to treat wounds, whereas podiatrists, as physicians, are obviously allowed to do so. Podiatry is a medical subdiscipline especially in the Anglo-American area, which has not become established in Germany so far. The option to prescribe podological treatment to patients with diabetic foot syndrome, with the expense covered by the health insurers, is a particularity of the German healthcare system that hardly exists anywhere else in the world.

The problem of all comparison studies on the subject of amputation is the fact that the decision to amputate and its timing are often made on a highly individual basis, and that hardly any generally applicable criteria exist that would make the indication for amputation objectively verifiable. The statement is therefore entirely correct, that many minor amputations have been undertaken only on the basis of detected osteomyelitis, although no pressing need existed to do so.

We thank Chantelau for the additional literature citations. Especially the publication by May et al. on data of patients in the German statutory sickness fund scheme (3) deserves highlighting, as it is based on individualized patients and their progress—unlike our own publication. The study by May et al. focuses on the prevention of amputations by means of interdisciplinary collaborations. It is nigh-on impossible to put in numbers the effect of networks and their added value for the diabetic foot syndrome, as networks are based on the will to collaborate and the ability to communicate with one another. Neither of these factors is reflected in the system of diagnosis-related groups and in outpatient billing systems, but they are crucial for the success of a network.

Schirmer and Fansa are, of course, right to point out the option of microsurgical flap reconstruction to cover large defects in the lower limb in patients with diabetes and peripheral arterial occlusive disease. Interdisciplinary collaboration in particular makes it possible to form an anastomosis between free flaps and autologous venous bypass grafts, which simultaneously improve perfusion. In our experience, however, a minority of plastic surgeons is enthused by working on the diabetic foot syndrome, and the result of their work also depends on whether the patient from the network is presented at the right time and, having had microsurgery, s/he receives an adequate long-term follow-up.

DOI: 10.3238/arztebl.2017.0400

Prof. Dr. med. Knut Kröger

Klinik für Gefäßmedizin

HELIOS Klinikum Krefeld GmbH, Krefeld

Dr. med. Christian Berg, Dr. med. Frans Santosa,
Dr. med. Nasser Malyar, Prof. Dr. Holger Reinecke

Conflict of interest statement

Prof. Kröger has received reimbursement of conference attendance fees and travel costs as well as payments for lectures from UCB Pharma, Sanofi, and Bayer.

Prof. Reinecke has received payments for consultancy from Bristol-Myers, Pfizer, and Pluristem. Study support (third-party funding) was provided to him by Pluristem, Bard, Bayer, and Biotronik.

The remaining authors declare that no conflict of interest exists.

References

1. Schmidt BM, Wrobel JS, Munson M, Rothenberg G, Holmes CM: Podiatry impact on high-low amputation ratio characteristics: a 16-year retrospective study. Diabetes Res Clin Pract 2017; 126: 272–7

2. Kröger K, Berg C, Santosa F, Malyar N, Reinecke H: Lower limb amputation in Germany—an analysis of data from the German Federal Statistical Office between 2005 and 2014. Dtsch Arztebl Int 2017; 114: 130–6

3. May M, Hahn S, Tonn C, Engels G, Hochlenert D: Decrease in (major) amputations in diabetics: a secondary data analysis by AOK Rheinland/Hamburg. J Diabetes Res 2016, Article ID 6247045