Evaluating And Refining The Team Approach To Limb Salvage

Guy R. Pupp, DPM, and Desiree Scholl, DPM

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”?

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