Rethinking Proper Patient Selection For Limb Salvage Interventions

By Ronald A. Sage, DPM

   Reducing the number of lower extremity amputations is a goal for all clinicians caring for patients with diabetes. In spite of this, the numbers of limb-threatening infections and subsequent amputations continue to rise each year. While medical and surgical interventions are frequently successful in facilitating limb salvage in patients facing amputation, failures in limb salvage attempts do occur. These failures result in multiple trips to the operating room, significant potential morbidity and prolonged disability.

   In order to more accurately predict which patients are more likely to benefit from limb salvage attempts, we need to modify our patient selection criteria. Enhanced criteria may also help identify which patients would be better served by a single definitive procedure at a level likely to heal with a subsequent, timely initiation of rehabilitation. The following cases illustrate the point.

What Two Case Studies Reveal

   A 58-year-old patient presents with a 20-year history of type 2 diabetes. His control has been mediocre with hemoglobin A1c levels around 8.5 percent. He has been treated for hypertension and is being monitored by cardiologists. The patient has a history of chest pain but no events of myocardial infarction or cerebrovascular accidents (CVA). He developed a pressure ulceration of his fifth toe that led to osteomyelitis. Preoperative indices for healing were borderline.

   Surgeons amputated the toe but it failed to heal. Peripheral vascular surgeons performed an angioplasty and the patient’s foot perfusion improved. He did require an amputation of the adjacent fourth toe due to progressive necrosis of the wound edges from the previous amputation. This wound also dehisced but improved slowly over time, probably due to the vascular intervention. In the meantime, his chest pain became worse and he required a coronary angioplasty.

   The patient also required prolonged local foot wound care to achieve healing. After two foot procedures, a vascular intervention, cardiac complications, lengthy wound care and a disability that lasted over a year, the foot finally healed and the patient returned to work in his previous occupation. He wears accommodative shoes and sees his podiatrist for regular follow-up visits. This case illustrates a difficult protracted course of limb salvage but nevertheless, the patient successfully returned to productive community activity.

   In contrast, a 62-year-old patient had a similar diabetes history but more vascular problems and evidence of the early stages of renal failure. He had a history of myocardial infarction and coronary artery angioplasty before a minor injury to his second toe resulted in distal cyanosis and ischemic pain. The toe was cool, there was no break in the skin and there were no pulses in the foot.

   Surgeons performed peripheral vascular stenting and the patient’s ankle brachial artery indices improved. However, the aforementioned toe remained cool and painful. Despite a second toe amputation, the wound still failed to heal. The vascular service performed yet another angioplasty as well as extensive debridement of bone and soft tissue, yet little improvement in the wound occurred. Amputation to the Syme’s level was recommended but the patient was adamant about making more efforts to try to save more of the foot. He proceeded to undergo a transmetatarsal amputation. The amputation site presented a non-viable wound that clinicians treated for over a week before the patient demonstrated signs of progressive necrosis and sepsis. Finally, the patient underwent a transtibial amputation.

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