Should podiatrists refer all post-amputation patients to a pedorthist or orthotist for conservative care in the form of offloading devices?
That was the shared opinion of an expert panel in a recent article which appeared in Podiatry Today.1 In the article titled “Current Perspectives On Post-Amputation Management,” all of the panelists (Kazu Suzuki, DPM, CWS, Ashley Miller, DPM, DABPM and Jeffrey Ross, DPM, MD, FACFAS) agreed that “a referral to an orthotics and prosthetics professional is a crucial post-amputation intervention.”1 This article asked the panelists for their perspectives regarding interventions for amputation “at any level.” As Dr. Suzuki stated in the article, “anything more significant or proximal than a single toe amputation may benefit from an orthotist consultation visit.”1 The interventions cited which might be provided by the orthotist would include custom diabetic shoes and custom inserts, toe fillers, braces, ankle-foot orthoses (AFOs), Charcot restraint orthotic walker (CROW) boots and prosthetic limbs.1
While this panel discussion-article provides very good insight and suggestions for management of the post-amputation patient, it is notable that all three experts shared the opinion that orthotic therapy should take place with someone other than the surgeon who performed the amputation procedure.1 A below-knee amputation certainly requires an expert certified orthotist or prosthetist for fitting of a prosthetic limb. However, the other orthotic interventions discussed by the expert panel are common modalities dispensed by podiatric physicians. Has the scope of practice for podiatric medicine changed?
The pathways outlined by a panel of experts from the podiatric profession regarding the management of the post-amputation patient raises multiple questions:
• Are podiatric physicians no longer adequately trained to evaluate and dispense diabetic shoes and inserts, custom foot orthoses with toe fillers, AFO braces and CROW boots?
• Is this training not being provided in current podiatric residency programs? If so, why are we considering reducing biomechanics training in podiatric residency programs?2
In contrast to the aforementioned panel discussion, a refreshing primer on the postoperative management of the partial foot amputation patient appears in the same issue of Podiatry Today.3 In their article titled “Conservative Care Considerations For Partial Foot Amputation In Patients With Diabetes,” Jakob C. Thorud, DPM, MS, FACFAS and Patrick Flanagan, CO, MBA, FAAOP review options to treat and protect the foot of a patient who has undergone a partial foot amputation.3 The lead author of this article is a podiatric physician, the second author is an orthotist and there is no mention of referral of the post-amputation patient by the surgeon to another specialist for the conservative care and management of their condition. Instead, Thorud and Flanagan outline the important factors to consider when providing modalities for patients with a transmetatarsal amputation (TMA), including patient adherence, lifestyle and biomechanical factors.3
In this regard, Thorud and Flanagan astutely note that the surgeon must evaluate the biomechanics of the foot PRIOR to performing the TMA procedure and that this information will dictate the offloading strategy implemented postoperatively.3 The authors state: “Consider for example a patient who has a preexisting metatarsus adductus with a partial fifth ray amputation. A subsequent TMA for this patient will likely increase pressure to the lateral foot and result in a different presentation than a patient who had a TMA after a failed first ray or central ray amputation, or a patient who had a primary TMA to address an infection that compromised certain tendons.” The authors also note that an underlying biomechanical abnormality such as hallux limitus can increase the risk of re-amputation rate after partial hallux amputation.4
Other authors also stress the importance of recognizing the biomechanical implications of partial foot amputation, which one must consider during postoperative management.5 An acquired varus deformity is an inevitable consequence of a transmetatarsal amputation worthy of consideration in both pre-surgical planning as well as the postoperative phase.6 Patients with a transmetatarsal amputation must undergo continuous monitoring and will require modification of their orthoses as muscular imbalances will inevitably create further deformity and change the plantar pressure distribution in the residual foot.7
The structural changes in the human foot after a transmetatarsal amputation and loss of muscle balancing create significant biomechanical stress on the residual foot. This no doubt contributes to the fact that the risk of re-amputation is as high as 46 percent within five years of a transmetatarsal amputation procedure.8,9 In my experience, the patient with a TMA is best followed and treated conservatively by a podiatric physician who understands the biomechanics of the procedure and also has the capability of implementing, monitoring and modifying the offloading devices designed to protect the residual foot. In my opinion, the best description of the biomechanics and orthotic management of the TMA patient was published over 20 years ago by Drs. Catanzariti, Mendicino, Haverstock and Grossman; all prominent podiatric surgeons in their own right.10
What Are The Potential Consequences Of An Outside Referral For These Services?
In contrast, consider the implications when the surgeon who performs the TMA procedure turns over the post-operative conservative care to another health-care provider. It is well recognized that adherence by the patient to the daily utilization of footwear and orthoses is critical the prevention of re-ulceration and potential re-amputation.11-13 Would patient adherence improve if the same health-care provider who amputated the body part actually implemented the therapy required for prevention of future complications? If that same health-care provider monitored the patient regularly and also had the ability to modify the orthotic device immediately when noting early complications, would that not improve the prognosis? What happens when there is a delay in modification of offloading devices when the patient must be referred out for that complication?
There are also economic implications for the surgeon when they refer to another practitioner for conservative care of the TMA patient. Current CMS fee schedules show that a single foot orthosis with toe-filler, a pair of diabetic shoes with inserts and a carbon AFO brace could reimburse at near $2000.14 In contrast, the current CMS fee schedule surgeon’s fee for a TMA is $600.15 Clearly, Medicare reimburses the conservative postoperative management of a patient with a TMA far more handsomely than it does for the performance of the surgical procedure alone.
In my opinion, the surgeon who amputates any part of the lower extremity of a patient must be capable and willing to implement all aspects of the postoperative management of that same patient. Certainly, in the case of providing a limb prosthesis, a specialty referral to an orthotist is required. However, for most other orthotic interventions, the podiatric physician should have adequate training to perform these interventions, and should be the best person to assume the ongoing conservative care of the post amputation patient.
Dr. Richie is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. Dr. Richie is a Fellow of the American College of Foot and Ankle Surgeons, and the American Academy of Podiatric Sports Medicine. Dr. Richie is the author of a new book titled "Pathomechanics of Common Foot Disorders," which is available from Springer at https://www.springer.com/us/book/9783030542009 .
1. Suzuki K, Miller A, Ross J. Current perspectives on post-amputation management. Podiatry Today. 2021;34(3):22-23.
2. Richie D. Proposed CPME 320 changes may dramatically reduce required biomechanics cases in residency training. Podiatry Today. Available at: https://www.podiatrytoday.com/blogged/proposed-cpme-320-changes-may-dramatically-reduce-required-biomechanics-cases-residency . Published December 2, 2020. Accessed March 23, 2021.
3. Thorud J, Flanagan P. Conservative care considerations for partial foot amputations in patients with diabetes. Podiatry Today. 2021;34(3):30-35.
4. Oliver NG, Attinger CE, Steinberg JS, Evans KK, Vieweger D, Kim PJ. Influence of hallux rigidus on reamputation in patients with diabetes mellitus after partial hallux amputation. J Foot Ankle Surg. 2015;54(6):1076-1080.
5. Iosue H, Rosenblum B. Transmetatarsal amputation: predictors of success and failure. Podiatry Today. 2017;30(8):42-47.
6. Roukis TS. Flexor hallucis longus and extensor digitorum longus tendon transfers for balancing the foot following transmetatarsal amputation. J Foot Ankle Surg. 2009;48(3):398-401.
7. La Fontaine J, Brown D, Adams M, Van Pelt M. New and recurrent ulcerations after percutaneous Achilles tendon lengthening in transmetatarsal amputation. J Foot Ankle Surg. 2008;47(3):225-229.
8. Thorud JC, Jupiter DC, Lorenzana J, Nguyen TT, Shibuya N. Reoperation and reamputation after transmetatarsal amputation: a systematic review and meta-analysis. J Foot Ankle Surg. 2016;55(5):1007-1012.
9. Rathnayake A, Saboo A, Malabu UH, Falhammar H. Lower extremity amputations and long-term outcomes in diabetic foot ulcers: A systematic review. World J Diabetes. 2020;11(9):391-399.
10. Catanzariti, AR, Mendicino, RW, Haverstock, BD, Grossman, JP. Considerations for protection of the residual foot following transmetatarsal amputation. Wounds. 1999;11(1):12-20.
11. Waaijman R, Keukenkamp R, de Haart M, Polomski WP, Nollet F, Bus SA. Adherence to wearing prescription custom-made footwear in patients with diabetes at high risk for plantar foot ulceration. Diabetes Care. 2013;36(6):1613-2628.
12. Binning J, Woodburn J, Bus SA, Barn R. Motivational interviewing to improve adherence behaviours for the prevention of diabetic foot ulceration. Diabetes Metab Res Rev. 2019;35(2):e3105.
13. Keukenkamp R, Merkx MJ, Busch-Westbroek TE, Bus SA. An explorative study on the efficacy and feasibility of the use of motivational interviewing to improve footwear adherence in persons with diabetes at high risk for foot ulceration. J Am Podiatr Med Assoc. 2018;108(2):90-99.
14. Centers for Medicare and Medicaid Services. DMEPOS Fee Schedule. April 2021 DMEPOS Fee Schedule Information. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule . Accessed March 23, 2021.
15. Centers for Medicare and Medicaid Services. Physician Fee Schedule – January 2021 Release. Available at: https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-relative-value-files/rvu21a . Accessed March 23, 2021.