Evaluating And Refining The Team Approach To Limb Salvage

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

   Taking the “team approach” often involves intricate communication and cooperation with a multitude of medical specialties. There are many possible members of the diabetes team. This team may include cardiologists, endovascular specialists/vascular surgeons, endocrinologists, general surgeons, infectious disease specialists, orthopedists, plastic surgeons, podiatrists, psychiatrists/psychologists and radiologists. Additional members may include allied health practitioners such as dieticians, orthotists and wound care nurses.

   Among the most important but often excluded members in the team should be patients themselves and their families. For desirable long-term outcomes, it is essential to have the intimate involvement of the patient with diabetes in the decision-making process throughout the course of both preventative and salvage attempts. Empower your patients with the necessary information to make informed decisions on treatment goals while working toward risk factor modification. Do your patients understand long-term glucose control and hemoglobin A1c values? Do they have a system for daily at-home evaluation of their feet?

   Finally, do all of your team members understand why it is important to avoid major amputations in their patients with diabetes? Do they realize that three years after a below knee amputation, only 50 percent of these patients are still alive?7

Case Study: How A Timely Second Opinion Endovascular Referral Prevented A Below-The-Knee Amputation

A case that we recently managed concerned a 72-year-old African American female, who was scheduled at another hospital for a below-knee amputation in 48 hours. She had insulin-dependent diabetes mellitus, end-stage renal disease, PAD, neuropathy and glaucoma. She also had a kidney transplant procedure. In the past six months, the patient underwent two endovascular procedures, a hallux amputation, a revisional first ray amputation and, only two weeks prior to our evaluation, underwent a popliteal-distal posterior-tibial reverse saphenous vein bypass graft.

   One of our team internists also saw the patient and contacted us on a Friday evening for a second opinion. We evaluated the patient, counseled her and then transferred her to our team’s endovascular specialist at another hospital. Within six days, the patient had a revisional endovascular procedure using more contemporary technology and received a referral back to our service with improved blood flow in the posterior tibial artery to the plantar arch.

   We then took the patient back to the operating room after six days to allow tissue perfusion and successfully performed a Chopart amputation with tendo-Achilles lengthening and lateral transfer of the anterior tibial tendon to balance the altered motor power, retain stability and prevent future deformity. At one month after her amputation, she was able to walk with a high-top prescription shoe.

In Conclusion

Diabetic foot complications are among the most costly aspects of healthcare today, both economically and interpersonally. Limb salvage is extremely rewarding to both patients and physicians but there can be significant morbidity and mortality despite early, aggressive wound care therapy and offloading. Prior to beginning a plan of limb salvage and risk of future amputation, one must thoroughly evaluate each individual patient’s needs and expectations in regard to appearance, activity level, recovery course and overall quality of life. It is also important to remember that limb salvage is only an option if the patient’s life is not compromised by an immediate underlying infectious process.

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