Beyond those factors, some general physicians aren't trained to look for certain kinds of disease. And, because some of the alternative procedures are relatively new, even when a problem is correctly diagnosed, doctors aren't always aware of available preventive measures.

Medical experts increasingly concur that many of the lower-limb amputations are unnecessary. "The majority of amputations are preventable," says William Pearce, chief of vascular surgery for Northwestern Memorial Hospital in Chicago.

In a paper published in late 2003, the American Diabetes Association declared that most limbs can be salvaged these days with the latest medical advances. It estimates the risk for a leg amputation is 15 to 40 times greater for those with diabetes.

Instead of losing a leg or foot, patients can undergo intravenous antibiotic therapy, dead-tissue excision, or revascularization through operations that remove or bypass a blood-vessel blockage. Several newer endovascular techniques to unclog the insides of arteries can be performed on an outpatient basis.

In one 1997 Mayo Clinic study of Olmsted County, Minn., doctors reduced the rate of major amputations by 50% through greater use of revascularization techniques including bypass operations and angioplasty.

In some cases, multiple circulatory complications or the likelihood of prolonged treatment with minimal healing may make amputation and life with a prosthesis the best decision. But to avoid amputation, it's crucial that patients and doctors look for a problem where one might not be obvious. Simple mishaps like a toenail-clipping accident or abrasions from a wrong shoe size can develop into unrelenting infections -- because the blood can't reach the infected skin tissue. "I just think it doesn't dawn on people that it could be blocked circulation," says Dr. Pearce. "And by the time it is diagnosed, it could be too late."

A 1998 study by doctors at Mercy Catholic Medical Center in Philadelphia found that primary-care physicians who saw patients with symptoms of severe circulation blockage apparently misjudged the severity and delayed referring them to a vascular surgeon by nearly 12 weeks on average -- time for disease to settle in and raise the chances of amputation.

WHAT TO WATCH OUT FOR   Some foot-related early warnings signs of diabetes that if untreated can result in amputation:   • Numbness   • Swelling   • Feet feel cold to the touch from decreased blood circulation   • Noticeable changes to the feet     Source: American Podiatric Medical Asssociation

Last November, the American Podiatric Medical Association launched an educational campaign called "Knock Your Socks Off" to alert people who may be at risk for diabetes to request a foot screening whenever they visit their regular doctor.

Mr. Friedley didn't even feel the cut he'd sustained on the bottom of his right heel; diabetics like him frequently lose some or all the feeling in their feet. Then one day in September 2002, he noticed he'd left a trail of bloody spots across his white kitchen floor. Over the next few months, he tried intravenous antibiotics, physical therapy, whirlpools and wound debridement, or the removal of dead tissue.

Mr. Friedley sought a second opinion at Riverside Methodist Hospital in Columbus, Ohio. The hospital is home to Gary Ansel, a cardiovascular specialist who evangelizes for cutting-edge outpatient procedures that save limbs. He regularly addresses groups of doctors with a PowerPoint presentation built around his mantra: Keeping the Foot in the Shoe.

To keep feet in shoes, vascular surgeons use procedures similar to those used on the heart. Bypass surgery, in which part of a patient's arteries or veins is used to circumvent the blockage, has typically been the first line of offense with limbs that are ischemic, or starved for blood. When a bypass operation fails, doctors often recommend amputation.

But Dr. Ansel and other endovascular doctors say such cases are no longer necessarily lost causes. When retired electrician and diabetic Thomas Caldwell showed up at Dr. Ansel's practice in 2003, he'd already had one leg amputated and his second was in danger of being cut off because of a small wound on his right foot. In a complex procedure, Dr. Ansel and partner Mitchell Silver used an angioplasty to install stents in arteries in Mr. Caldwell's leg. That restored blood-flow and allowed antibiotics to reach the wound.

Less-invasive endovascular procedures -- in which tiny wires and catheters are used to unclog blood vessels -- can be performed on an outpatient basis with local anesthetics. While studies have suggested that bypass surgery is better at keeping blood-vessel blockages from recurring, some doctors believe the endovascular methods often can have quicker recovery times and lower risk of infection and death.

Costs vary. The average charge for a lower-extremity amputation was $38,733 nationwide in 2002, according to the Agency for Healthcare Research and Quality. A so-called peripheral vascular bypass ran $40,000 while the typical angioplasty procedure for a noncoronary artery was $31,388.

In January of last year, Mr. Friedley underwent an atherectomy, in which a blood-vessel blockage was removed from his right leg. Then in June, doctors performed an angioplasty, using a tiny balloon to unclog one of Mr. Friedley's arteries. His leg was saved. Last month, the retired minister stood through a wedding ceremony he performed as a favor to a friend. His wife, Sue, says she left a phone message at the office of the orthopedic surgeon who wanted to cut off her husband's leg. "Put away your saw," she said.

Write to Michael J. McCarthy at mike.mccarthy@wsj.com¹