Volume 87 • Number 6 • June 1997 255 Diabetes mellitus is the most common underlying cause of lower extremity amputation in the US and Europe. Approximately 120,000 nontraumatic ampu- tations are performed each year in the US. Of these amputations, 45% to 83% involve diabetes. 1-3 Patients with diabetes are at 15 to 46 times greater risk for receiving a lower extremity amputation than people without diabetes. 3, 4 Approximately one half of dia- betic amputations are performed at the level of the foot. 5 Diabetes-related amputations are an important public health issue because many amputations can be prevented when high-risk patients receive preven- tive medical care. 6-8 The authors have observed that while numerous studies have focused on lower extremity amputa- tions in general, amputations at the level of the foot are often treated as a single level or not stratified by specific site within the foot. In the majority of cases, this is because of the fact that data are gathered from secondary databases that do not provide specific documentation about amputation location. Perhaps for this reason, the authors have not encountered any works in the medical literature that have reported on Amputation and Reamputation of The Diabetic Foot DAVID G. ARMSTRONG, DPM* LAWRENCE A. LAVERY, DPM, MPH* LAWRENCE B. HARKLESS, DPM† WILLIAM H. VAN HOUTUM, MD‡ The authors compare the level of foot amputation by age, prevalence of arterial disease as a precipitating factor, gender, and ethnicity in per- sons with diabetes mellitus. Medical records were abstracted for each hospitalization for a lower extremity amputation from January 1 to December 31, 1993, in six metropolitan statistical areas in south Texas. Amputation level was defined by ICD-9-CM codes and were catego- rized as foot, leg, and thigh amputations. Foot-level amputations were further subcategorized as hallux or first ray, middle, fifth, multiple digit or ray, and midfoot amputations. Only the highest amputation level for each individual was used in the analysis. Of 1,043 subjects undergoing a lower extremity amputation in south Texas in the year 1993, 477 re- ceived their amputation at the level of the foot. African-Americans re- quiring a foot-level amputation were at significantly higher risk to un- dergo a midfoot-level amputation than was the rest of the population. Nearly 40% of all subjects undergoing a foot-level amputation had a previous history of amputation. However, nearly 40% of subjects un- dergoing foot amputations had not been diagnosed either before or dur- ing admission with peripheral arterial occlusive disease, suggesting a causal pathway dependent primarily on neuropathy. This implies that better screening of diabetic patients with appropriate risk-directed treat- ment at the primary care level may significantly impact the large num- ber of preventable diabetes-related lower extremity amputations. *Assistant Professor, Department of Orthopaedics, Uni- versity of Texas Health Science Center, San Antonio, TX; Diabetes Research Group, San Antonio, TX. †Professor and Director of Podiatric Surgical Residency, Department of Orthopaedics, University of Texas Health Science Center, San Antonio, TX; Diabetes Research Group, San Antonio, TX. ‡Research Scientist, Department of Orthopaedics, Univer- sity of Texas Health Science Center, San Antonio, TX; Dia- betes Research Group, San Antonio, TX. Mailing address: 7703 Floyd Curl Dr, San Antonio, TX 78284-7776.