How Far Should You Go?

One of the most difficult aspects about practicing medicine is determining not only the best treatment for a particular patient, but also when to change, or even cease, that treatment. As caregivers, we are trained to provide medical care whenever possible. However, sometimes there is a point to call it quits.

It's funny how disparate parts of our lives can often be linked. An interesting confluence of events took place for me just yesterday, as I was writing this editorial. Early in the day, I was talking to one of my colleagues at Western University. He asked me an interesting hypothetical question: What do you do when you run out of treatment options?

He brought up the example of patients with certain life-threatening disorders. Let's take cancer as an example. Say you're an oncologist treating a patient with malignant melanoma that has metastasized to the brain. After several rounds of chemotherapy and radiation, nothing has changed, and you've run out of options. Now what? In so many cases, Western medicine keeps trying to help, prescribing treatment after treatment until, eventually, the patient dies. Is there a point when the patient should be made comfortable and allowed to die in peace, with dignity?

We have a version of this in podiatry: Charcot neuroarthropathy. For many years, our profession has pioneered increasingly aggressive surgical procedures to salvage the limb. The most significant question (even assuming the procedures themselves are successful) is this: Does the surgery provide a positive outcome that significantly outweighs the alternative (major limb amputation)? Let's look at this for a moment.

I have a patient with midfoot Charcot arthropathy, plantar ulceration, and osteomyelitis. After one bone debridement and antibiotics, he continues to have a plantar ulcer and a highly unstable foot on which he is unable to ambulate safely. But he still wants to do whatever he can to salvage his limb. Should I recommend salvage, necessitating more than one surgery, or should I suggest below knee amputation?

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There are three basic ways to look at this question. First, just do whatever the patient wants, because it's his body and he should decide. There are, of course, problems with this, such as the increased cost to society. Second, use my own anecdotal experience to judge (i.e. how successful is Charcot reconstruction "in my hands."). Third, how successful is this using the medical literature? Since we practice in an evidence-based world, let's consider what some of the medical evidence says (not forgetting my own experience and my patients needs and desires).

In 2009 Son, et al performed a retrospective cohort analysis of the 5-year survival of 1,050 patients with Charcot arthropathy versus patients with diabetic foot ulcers (2,100) and those with diabetes alone (the control group of 2,100 patients).¹ The authors found that patients with diabetes with Charcot had a 23% higher 5-year mortality risk. Interestingly, the patients with a diabetic foot ulcer history without Charcot had a 35% higher mortality risk than those with Charcot! This study tells us that approximately 1 in 4 of your Charcot patients will be deceased in 5-years just by nature of their diagnosis, regardless of what I do.

How does this compare with the alternative treatment of transtibial amputation? There are a good number of studies looking at this topic, so for the sake of brevity let's look at one. In 2004 Sandnes, et al. looked at 13,807 patients who underwent nontraumatic major limb amputations (AKA and BKA).² Among other findings, these authors found the 1 year and 5 year post-BKA survival rates to be 80.4% and 60% respectively. We have to be cautious with these results, since this study isn't directly comparable with the Charcot study.

The next logical question is, what is the survival rate of patients who undergo Charcot surgery? Unfortunately, I have been unable to find any study that answers this question. If we had the answer to this question, we would be able to compare my patient's life expectancy with that after surgery, to determine if this would be a legitimate treatment option. Essentially, would the patient survive long enough to make a successful surgical result worth the risks and effort?

Unfortunately, at the end of all this discussion, there's not enough known about Charcot arthropathy and its surgical treatment to answer these questions. For my patient it boils down to my instinct and his desires. I have previously recommended transtibial amputation – which the patient declined – and we are now embarking on surgical debridement, parenteral antibiotics, wound care, and a possible second salvage surgery as a last resort.

It doesn't leave me feeling especially comfortable, but that's part of being a doctor. Many of our treatment options are more art than science. How far should I go with my patient? In this case, as far as he is willing to go. Fingers crossed for a positive result.

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

References:

1. Son M, et al. Diabetes Care. May 2009;32(5):816-821.
2. Sandnes D, et al. J Am Coll Surg. Sept 2004;199(3):394-402.

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