Adapting To New Paradigm Shifts In Treating Patients With Diabetes And Peripheral Vascular Disease

Guy R. Pupp, DPM, FACFAS

The past few years have produced a plethora of studies, publications and lectures on the combination of diabetes and peripheral vascular disease, and their impact upon the lower extremities. One recent study looking at over 600 patients with diabetic foot ulcers and severe peripheral arterial disease (PAD) who did not have revascularization found that one-third of patients died unhealed.1

   I have been fortunate to be involved with a group of leaders in various associated specialties that deal with these devastating pathologies. I have long had an interest in limb preservation and reconstructive foot and ankle surgery. I was the director of an outstanding clinic (Kern Hospital in Warren, Mich.) for many years with the advantage of meeting and interacting with multiple specialists in a symbiotic relationship. This was a teaching clinic and I had the opportunity to train many fine residents who have subsequently become leaders in our profession. Our clinic also had a significant referral base from a large geographical area that allowed us to be exposed to a vast range of pathology.

   There has always been a great working relationship with our vascular surgeons. This enabled us to treat patients who were at risk for major amputation and a debilitating lifestyle. We had considerable success due to the academic and passionate performance of our team. Unfortunately, due to significant comorbidities, many patients, especially those with critical limb ischemia, had compromised health to the extent in which the risks of treatment advances outweighed the benefits. Many of our patients were too old or too sick for major “open” bypass surgeries and they were excluded from treatment. The morbidity and mortality of extensive bypass of the lower extremity was high.

   Often, our clinic was the patient’s “last hope” to save a limb and return to an ambulatory status. However, we were forced to be very cautious with proper patient selection due to many other factors. Many of our patients required non-weightbearing status for extended time periods postoperatively. Our patient profile was challenging as many were obese, experienced motor and sensory neuropathy, and had difficulty managing crutches and walkers in an attempt to allow our surgical procedures to heal. For example, for many patients, we would perform bone grafting with internal fixation in order to help heal multiplanar osteotomy and arthrodesis sites.

   Fortunately, advances in external fixation allowed more reliable fixation attempts with patients enjoying “limited, guarded weightbearing” with a walker or crutches postoperatively during the healing process. The use of external fixation allowed for more aggressive attempts at limb salvage. We also learned that “functional” limb preservation was our ultimate goal and were always cognizant of the “next day” or what the patient’s status would be after treatment and healing. We learned that a transmetatarsal amputation (TMA) was desirable to saving two toes or that selected tendon lengthening and transfer could give “good results,” even in notoriously “bad result” levels of foot amputation such as amputations at the Chopart joint level.2-5

   I would constantly remind the residents that the best teacher in medicine is “Doctor Retrospect.” Evidence-based medicine helped us make better decisions although anecdotal treatment by an experienced, honest academic seemed too many times to be equally appropriate in our high-risk patient group who suffered with diabetes and associated comorbidities such as Charcot neuroarthropathy with soft and hard tissue disintegration and critical limb ischemia.

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