Cath Lab Digest

While there may be a perception of amputation as a failure in treatment, these authors maintain that amputation salvage procedures do play a role in limb preservation and can enhance the quality of life for patients with diabetes. They address the timing and decision-making with these procedures and review emerging advances in prosthetics.

   Diabetic foot infections can range from a superficial infection on the toe to a raging infection of the entire foot. Given the degree of complexity that can occur with diabetic foot infections, we must work together as a multidisciplinary team to assess the comorbidities that led to the patient’s current condition and try to control or eliminate them.

   When a diabetic foot infection complicates wound healing, we need to consider a variety of questions. Is it because the patient is non-adherent with medications or because the patient has no control over the disease? Does the patient have poor vascular supply to the foot? Does the patient have adequate offloading? Does the patient have the proper footgear for his or her foot type?

   We obviously need to consider all of these things when treating a patient with diabetes. All of our efforts are geared toward expediting wound healing and ensuring limb preservation. The key question: When is amputation the salvage procedure?

   Amputation is a salvage procedure when there are no other means or solutions to resolve an infection. When making the decision to amputate, the patient and the doctor should collaborate together to achieve the best outcome.

   Often, the decision to amputate is straightforward. For example, a patient comes into your office with an infected ulcer on the hallux that probes to bone and is draining purulent material. Following blood work, the erythrocyte sedimentation rate (ESR) comes back at 110. The X-ray shows acute periosteal erosion suggestive of osteomyelitis. One would probably not hesitate to take that patient to surgery to remove all infected bone and soft tissue before progression of the osteomyelitis.

   However, what about the patient who has a persistent but stable non-healing ulcer on the hallux? Should you amputate the hallux because of a non-healing ulcer? What if you have tried a multitude of therapies such as topical therapy, serial debridements and hyperbaric oxygen therapy, and nothing has helped?

   Can the surgeon consider amputation as a treatment option? Of course it is an option, especially if the patient prefers to get back to his or her quality of life. Often, patients are bogged down with extensive treatments and dressing changes. Conservative therapy can be extremely overwhelming and sometimes the patient may not be willing to try.

   Duzgun and colleagues report that four to five months of conservative therapy is a reasonable amount of time to allow a wound to heal.¹ However, if you have exhausted all options at this point and the patient still has a chronic wound, one may consider amputation as a treatment option. There is a controversial thought that amputation leads to morbidity and sometimes mortality, but one should also consider that amputation could increase a patient’s quality of life. There is a general misperception among surgeons that an amputation means they failed in their job. However, amputation can certainly equate to saving a patient’s life.