Rethinking Proper Patient Selection For Limb Salvage Interventions

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Leaving an isolated digit predisposes the foot to other ulcerations due to the biomechanically unstable deformity. (Photo courtesy of Kathleen Satterfield, DPM)
Rethinking Proper Patient Selection For Limb Salvage Interventions
Here one can see an X-ray of a transmetatarsal amputation. These procedures can reportedly facilitate long-term success for limb salvage. (Photo courtesy of Christine Salonga, DPM, and Peter Blume, DPM)
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Author(s): 
By Ronald A. Sage, DPM

   In making decisions about proceeding with heroic measures to save a limb, one needs to consider the severity of these conditions. When it comes to patients with the greatest number of metabolic factors working against them, one may need to consider high amputation at a level likely to heal as opposed to exposing them to all the risk and potential comorbidity associated with partial foot procedures, vascular interventions and prolonged antibiotic therapy. Taking these other factors into account may help tilt the decision-making process in one direction or another in borderline cases rather than relying only on the limited criteria now in common use.

   Common criteria for predicting successful limb salvage include the ankle brachial artery index, transcutaneous p02, the evaluation of serum albumin and the total lymphocyte count. Although we may attempt limb salvage with some success in borderline cases, our experience indicates that breaching these criteria frequently leads to failure. One should rigorously apply both the established criteria and new criteria. There is a need now to take a scientific look at the measurements associated with poor control, renal failure and heart disease. Indeed, one should examine the patient’s hemoglobin A1c, pre-albumin, blood urea nitrogen, serum creatinine, creatinine clearance and cardiac ejection fraction. If we can establish correlations of these values with the success or failure of distal wound healing, it will improve our ability to predict the patients who are most likely to benefit from limb salvage interventions.

In Conclusion

   Clinicians need to know the difference between the interventions they can attempt and those they should attempt in treating limb-threatening infections in seriously ill patients with diabetes. It is no favor to put a patient through multiple, sometimes risky procedures on the road to an inevitable below-knee amputation. Transtibial and higher amputations are frequently viewed as clinical failures. However, one can argue that multi-staged transtibial or higher amputations are even worse failures. A good surgeon knows both how and when to perform the procedures in his or her armamentarium.

   A refined limb salvage criteria that includes parameters beyond what we have used to date should reduce the number of failed procedures leading to transtibial and higher amputations. Patients who might be subjected to multiple procedures with a limited chance of success could proceed directly to a definitive procedure and focus on rehabilitation after suffering a serious lower extremity complication of diabetes. In such cases, a one-stage transtibial amputation may be a greater clinical success than putting a patient through multiple surgeries and spending months or even years trying to save a non-functional extremity.

Dr. Sage is a Professor and Chief of the Section of Podiatry at the Department of Orthopaedic Surgery and Rehabilitation at the Loyola University Stritch School of Medicine. He is also a Staff Podiatrist at Edward Hines Jr. Veterans Affairs Hospital.

Dr. Steinberg (shown) is an Assistant Professor in the Department of 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.

For selected articles, see “A Guide To Transmetatarsal Amputations In Patients With Diabetes” in the July 2006 issue of Podiatry Today. Also check out the archves at www.podiatrytoday.com.




References:

1. Izumi Y, Satterfield K, Lee S, Harkless LB. Risk of reamputation in diabetic patients stratified by limb and level of amputation. Diabetes Care 29 (3) 566-570, March 2006.
2. Duggan MM, Woodson J, Thayer, et al. Functional outcomes in limb salvage vascular surgery. Am J Surg 168(2), 188-191, August 1994.
3. Pinzur MS, Stuck RM, Sage R, Hunt N, Rabinovich Z. Syme ankle disarticulation in patients with diabetes. JBJS 85-A, 1667-1672, September 2003.

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