Evaluating And Refining The Team Approach To Limb Salvage

Recent data suggests that three visits to a podiatrist prior to development of an ulceration correlates with better overall outcomes with fewer hospitalizations and decreased associated healthcare costs for patients with diabetes.1 As the incidence of diabetes continues to rise among the general population, this study reinforces the value of the podiatric physician within the community and the overall realm of public health.

   One can detect subtle changes in skin texture, turgor and overall neurovascular status with repeat routine visits at various intervals, depending on a patient’s individual risk factors. As a result, podiatric physicians can make aggressive referrals and consultations to appropriate team members for early intervention.

   It is well known that diabetes has associated complications that have the potential to be disabling and may lead to increased morbidity and mortality. An aggressive team approach is important in managing all aspects of diabetes, particularly the diabetic foot. As podiatrists, we play a critical role in the prevention and early recognition of complicating factors that may lead to less than desirable outcomes for the diabetic foot if left untreated.

   When it comes to the team approach to limb salvage, which medical specialties and subspecialties should make up the team? Of these, how do we choose these providers? Does the team function cooperatively with a single leader or is this a large, collaborative effort among all involved? Who determines whether a limb is, in fact, salvageable? What can we do to promote preservation as opposed to facing the challenges of full-blown salvage attempts?

   Limb preservation, as opposed to limb salvage, implies a more aggressive, proactive, multidisciplinary team approach while treating the patient with diabetes. Preservation aims to prevent those complications that will ultimately require major therapeutic interventions to maintain all or a portion of an affected extremity, and even save the life of a patient.

Selecting Members Of The Multidisciplinary Team

Unfortunately, not every specialist who treats a patient with diabetes should qualify for your team. You should ask yourself if the particular physician in question truly understands the epidemiology of the diabetic foot. Do these practitioners realize that ulcerations occur in 15 to 25 percent of patients with diabetes and are often a precursor to 85 percent of major amputations?2 Studies have also shown that the first six months following initial lower extremity amputation, patients have the highest risk for re-amputation at a more proximal level.3,4

   Up to 51 percent of lower extremity amputation patients will undergo contralateral limb amputation within two years of the initial amputation.3,5 According to the National Limb Loss Information Center (NLLIC), one of every 200 individuals with diabetes has had an amputation and approximately 1.7 million people with diabetes in the United States are living with the loss of a limb.6

   An immediate, aggressive team approach is required when treating patients with diabetes who are at risk for ulcerations and further complications.

   Does the patient need to see an endocrinologist for glycemic control? Has the patient ever seen a cardiologist, given the occurrence of cardiovascular disease and possible sudden death in patients with diabetes? Has the patient ever been screened for peripheral arterial disease (PAD)? If patients demonstrate altered distal arterial perfusion, when should they receive referrals for additional evaluation and treatment? Does your team’s vascular expert understand and perform the contemporary endovascular approaches? Do any of your team members still believe that their patients with PAD are “too old or too sick and there are no easy treatment options”?

   Taking the “team approach” often involves intricate communication and cooperation with a multitude of medical specialties. There are many possible members of the diabetes team. This team may include cardiologists, endovascular specialists/vascular surgeons, endocrinologists, general surgeons, infectious disease specialists, orthopedists, plastic surgeons, podiatrists, psychiatrists/psychologists and radiologists. Additional members may include allied health practitioners such as dieticians, orthotists and wound care nurses.

   Among the most important but often excluded members in the team should be patients themselves and their families. For desirable long-term outcomes, it is essential to have the intimate involvement of the patient with diabetes in the decision-making process throughout the course of both preventative and salvage attempts. Empower your patients with the necessary information to make informed decisions on treatment goals while working toward risk factor modification. Do your patients understand long-term glucose control and hemoglobin A1c values? Do they have a system for daily at-home evaluation of their feet?

   Finally, do all of your team members understand why it is important to avoid major amputations in their patients with diabetes? Do they realize that three years after a below knee amputation, only 50 percent of these patients are still alive?7

Case Study: How A Timely Second Opinion Endovascular Referral Prevented A Below-The-Knee Amputation

A case that we recently managed concerned a 72-year-old African American female, who was scheduled at another hospital for a below-knee amputation in 48 hours. She had insulin-dependent diabetes mellitus, end-stage renal disease, PAD, neuropathy and glaucoma. She also had a kidney transplant procedure. In the past six months, the patient underwent two endovascular procedures, a hallux amputation, a revisional first ray amputation and, only two weeks prior to our evaluation, underwent a popliteal-distal posterior-tibial reverse saphenous vein bypass graft.

   One of our team internists also saw the patient and contacted us on a Friday evening for a second opinion. We evaluated the patient, counseled her and then transferred her to our team’s endovascular specialist at another hospital. Within six days, the patient had a revisional endovascular procedure using more contemporary technology and received a referral back to our service with improved blood flow in the posterior tibial artery to the plantar arch.

   We then took the patient back to the operating room after six days to allow tissue perfusion and successfully performed a Chopart amputation with tendo-Achilles lengthening and lateral transfer of the anterior tibial tendon to balance the altered motor power, retain stability and prevent future deformity. At one month after her amputation, she was able to walk with a high-top prescription shoe.

In Conclusion

Diabetic foot complications are among the most costly aspects of healthcare today, both economically and interpersonally. Limb salvage is extremely rewarding to both patients and physicians but there can be significant morbidity and mortality despite early, aggressive wound care therapy and offloading. Prior to beginning a plan of limb salvage and risk of future amputation, one must thoroughly evaluate each individual patient’s needs and expectations in regard to appearance, activity level, recovery course and overall quality of life. It is also important to remember that limb salvage is only an option if the patient’s life is not compromised by an immediate underlying infectious process.

   Overall costs of limb preservation and salvage not only include those direct healthcare dollars but also involve the socioeconomic and psychosocial consequences of chronic ulcerations and amputations on patients and their families. For further involvement, there are numerous local and national organizations such as “Save A Leg, Save A Life,” that are dedicated to the team approach to limb salvage. Additionally, annual conferences such as the Diabetic Limb Salvage conference (www.dlsconference.com) are aimed at further development of the team approach to limb preservation and salvage.

   Dr. Pupp is a Fellow of the American College of Foot and Ankle Surgeons. He is the Director of the Foot and Ankle Clinic at Oakland Regional Hospital in Southfield, Mich. He is also a member of the Residency Training Committee at Providence Hospital in Southfield, Mich.

   Dr. Scholl is a PGY-3 surgical resident at Providence Hospital in Southfield, Mich.

   Dr. Steinberg is an Assistant Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C. He is a Fellow of the American College of Foot and Ankle Surgeons.

References:

1. Gibson T, Bagalman E, Wang S, et al. Podiatrist care and likelihood of amputation or hospitalization for patients with diabetes and foot ulcer. Late breaking abstract poster presentation, American Diabetes Association’s Scientific Sessions, June 2010, Orlando, FL. Diabetes 2010; 59(suppl1). 2. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA Jan 12 2005; 293(2):217-228. 3. Izumi Y, et al. Risk of re-amputation in diabetic patients, stratified by limb and level of amputation: a 10-year observation. Diabetes Care 2006; 29(3):566-70. 4. Ziegler-Graham K. Estimating the prevalence of limb loss in the United States–2005-2050. Arch Physical Med Rehab 2008; 89(3):422-439. 5. Adler AI, et al. Lower extremity amputation in diabetics: independent effects of PVD, sensory neuropathy and foot ulcers. Diabetes Care 1999; 22(7):1029-35. 6. National Limb Loss Information Center. Available at https://www.amputee-coalition.org/nllic_about.html 7. Aulivola B, Hile CN, Hamdan AD, et al. Major lower extremity amputation:outcome of a modern series. Arch Surg 2004; 139(4):395-399.