Rethinking Proper Patient Selection For Limb Salvage Interventions

By Ronald A. Sage, DPM

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.    Six weeks later, surgeons fitted the patient with a prosthesis and he began rehabilitation. Although he took early retirement, the patient has returned to independent community ambulation. Had the surgeons performed the transtibial amputation after the failed toe amputation, three operations would have been eliminated from this patient’s five-stage below-knee amputation. His case illustrates the fact that in spite of our best efforts, all limbs with diabetic complications are not salvageable.    Both patients had low normal levels of serum albumin at approximately 3.0 gm/dl. Their total lymphocyte counts were both above 1,700. Their ankle brachial indices were about 0.3 before their vascular procedures and 0.45 afterward. They both had heart disease but who had more severe heart disease? The 58-year-old patient had worse control but the 62-year-old patient had early renal disease. If one measured the degree of control, nutritional status, renal function and cardiac function, would a significant difference between the two in any of these parameters be predictive of their eventual outcome? Right now, we do not know but the fact that many limb salvage attempts fail suggests we should find out.

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