David Davidson, DPM reviews the options available for prevention of limb amputations and outlines precautions to take in order to offer a successful outcome when amputation is the only choice. Dr Davidson focuses on the diabetic patient and addresses specific concerns and misconceptions in relation to care of the diabetic foot.
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Release Date: 03/16/2018 Expiration Date: 12/31/2018
David Davidson, DPM
Center for Wound Care & Hyperbaric Medicine
Erie County Medical Center
Buffalo, New York
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Moderator: Our first presenter is Dr. David Davidson who is here on a return engagement for us from sunny balmy city of Buffalo, New York. He is going to be talking to us on Surgical Options for Limb Salvage. Dr. Davidson?
Dr. David Davidson: Good afternoon. I applaud you for your stamina, it�s almost over but I appreciate the opportunity to be here again. This conference snowed me last year and snows me even more this year and I applaud the people at Present and the VA for putting this program on. This is me. As Bob said, I�m from sunny Buffalo and it is not snowing yet. I am on the staff of a very large wound center, level 1 trauma center in Buffalo which has been open for about 2 years and we are really doing quite well and are quite busy seeing very unusual traumatic wounds. I am on the speakers� bureau for these companies although Vilex did support me on this conference, I will tell you that I�m not talking about any of the products for any of these companies. As I putting this together, I gave my presentation to Alan Sherman 3 or 4 weeks ago, I updated it 2 weeks ago, I updated it again yesterday, I updated again this afternoon because I looked at this and you will see the CDC paper that just came out yesterday, I put an arrow on yesterday�s date that tells us that those of us that are treating high-risk people are going to be very busy and continue to the busy because statistic continue to be alarming.
Let me dispel some misconceptions about the diabetic foot. In the many of the lecturers during the week have talked about many of these things that diabetes is a small vessel disease and predisposes the foot of the diabetic to a poor surgical outcome, I don�t think that�s true at all. Diabetes are more prone to infection, I also don�t think that�s correct. They are prone to complications, I don�t think that�s correct either and they don�t heal and I don�t think that�s correct either. We could probably argue about each of these points but the truth is if you are careful and pick the right patient for the right procedure I don�t think you are going to have any issues with the diabetic foot and we shouldn�t be afraid to operate on that diabetic foot.
Bob Frykberg sitting here and actually he didn�t do this one but the first Dr. [Indiscernible][0:03:01] and others categorized the elective foot surgical procedures in three different categories, prophylactic, reconstructive and traumatic. Bob and others in I think 1994 re-categorized elective non-emergent foot surgery but my favorite classification is this one that all of our good friends collaborated on actually put forth these four categories of non-emergent foot surgery for the diabetic patient. The goals, when we look at the diabetic patient, the goals of elective foot surgery basically are to prevent problems from developing, to prevent foot ulceration, to prevent infection and to prevent amputation by creating stability of the foot, realignment of the structures, creating a foot that more amenable to orthotics, shoe inserts or shoes and obviously reduction of pressure points. What we are trying to avoid is this, what we are trying to avoid is, on your left, a BKA amputation and we know that statistic show that approximately 50% of those people will die in 5 years so we certainly want to prevent the gentleman or gentlelady on the right. In order to do that we need to be a little bit more careful about evaluation. Obviously, we want this patient to have optimal glycemic control. In the perfect world, it would be less than 7.
We have heard talks about vascular perfusion, adequate perfusion, both ABIs and TBIs are very important. We need a multidisciplinary team that�s been talked about over and over again here and in other programs. We will optimize the cardiovascular system and the renal function and it is up to us to make sure that we have adequate skin hydration if we want these things to heal.
This is what separates podiatric surgeons from all other specialties I think is that we understand, hopefully, the biomechanics so we can functionally plan what surgical procedure will work for what patient. We can evaluate the plan of particular surgical procedure and not only that we can evaluate the patients postoperatively to determine how we are going to deal with that patient following surgery. We now have not only our hands and eyes and measuring devices but we have things like the F-scan available to us and I saw that they were out there and there are others out there but we now have the ability with computerized technology really plot out and look at pressure distribution. In a perfect world, I wish every single wound center would have the ability to do this at their center, I think it would be awesome. Of course, we have got new technology and things are changing with instrumentation all the time and this is a new staple that just came out. They are different than they were 5 or 10 years ago, they are better designed, they are stronger and certainly much easier to use
The newer technology is seen with everything, it is seen with the screws, seen with the plates, with the implants, in mini rails etc and endoscopic instruments too. What this means is this new technology gives us shorter disability. We can get these people to heal faster and get them up on their feet faster so that�s what we need to do especially with the diabetic patient. We can treat hallux valgus deformities multiple ways. Again, with this new instrumentation, new technology we can press the osteotomy site so we can get these osteotomy sites to heal much faster. We can get these patients ambulatory much quicker than we were able to do several years ago.
I spoke about this particular procedure last year at length for an adducted short first metatarsal, the opening osteotomy plate is really a great addition to our surgical armamentarium and that allows weightbearing from day 1 in a cam walker. Again, we want our diabetic patient, we want to correct their deformities but we want them up, we want them ambulatory and we want to heal them as fast as we can. We can take a first ray deformity, whether it�s an elevated first metatarsal, plantarflex first metatarsal, we can internal fixation and appropriate techniques we can correct that, we can shorten the long metatarsal with a Weil osteotomy which has been around for a very long time. The methods of fixating a Weil osteotomy has changed dramatically so those people are healing faster and we can lengthen a short metatarsal. These are things that we couldn�t do several years ago. The digital deformities we can correct quite easily with some of the new technology.
I put this slide up because this is the subtalar arthroereisis procedure which takes 7 minutes and it�s a no brainer and we can take a foot that has a severe pronator deformity that will certainly in a high risk patient create multiple ulcerations medially etc because of the pressure points and we can with an orthotic and with the subtalar arthroereisis procedure correct a lot of that deformity. However, the big black that we have here is insurance companies still consider this experimental. Really? I mean we have been doing this for years and hopefully we are going to be able to, I�m fighting that fight up in Buffalo, New York and hopefully everybody is fighting that fight to make it a non-experimental procedure so it can be reimbursed.
I don�t want anybody to not think about learning these new endoscopic techniques. Again, especially with the diabetic patient we need to minimize trauma, we need to get patients walking so we can do in this tarsal tunnel, endoscopic tarsal tunnel is very new, and there is a learning curve to all these endoscopic techniques but I encourage all of you to take courses and learn how to use these techniques because these are significantly better in most cases if you chose the right patient in most cases, again, solve the problem and keep people ambulatory. Simple is better in a diabetic patient.
When we talk about ablative surgery amputation, that�s a whole another topic that we have to be really concerned about there because not all our wound treatments work. Again, understanding the biomechanics allows one to really functionally plan the amputation site. We can evaluate the triplane deformity, we can evaluate their functional biomechanics to plan what�s a practical procedure for this particular patient unlike our colleagues in General Surgery or Vascular Surgery. We have that ability to understand the biomechanics and plan accordingly which will prevent complications from arising in the future. We need to set ourselves up for success.
This picture I put up on this presentation this morning because this is what I left my young associate when I came here from Phoenix, I got a call for an emergency room. This is a post transmetatarsal TMA that was non-compliant and misses first three postoperative appointments, kept going back and forth to the emergency room, and we were never notified. Then the emergency room calls me about an hour and half before I�m getting on the plane to come here. My partner sent me this picture yesterday at 8 o�clock at night before we went into surgery. He did send me a text message at 10:30 at night saying he is just getting out of surgery. I guess he just wanted to make me feel bad but whatever. We need to consider the vascular status of the patient. This is really true here. Amputation unless it�s urgent should not be done until you can assure there is good perfusion.
Number 1, a vascular surgeon or vascular interventionalist should be our best friends. Don�t amputate unless you got blood flow and unless it is urgent. Obviously, consider infection or the extent of the infection before you do any surgery. Consider, the level or degree of the surrounding viable tissue, what�s viable what�s not, understand the ambulatory status of the patient. If the patient is wheelchair bound or bed bound, it may be a different type of amputation you would consider. Did this gangrenous process occur fast or slow, you want to talk about a short term solution or do we want to talk about long term function. Evaluate the whole foot, not just the part you are going to remove and preserve as much as possible. Sometimes preserving the leg means removing toes that maybe healthy. Again, when you are considering amputation let�s talk about the whole foot versus the one toe at a time, that�s something that you need to avoid.
Knowing what you have to work with, will improve your outcomes especially for flaps if you need them and communication among specialties is really important. None of us should be working in a silo. Time lost during healing is a critical factor that has to be considered. What�s going to heal fastest? How quickly the patient can be ambulatory is really important, I try really hard to get people to go home rather than to a facility because they seem to heal faster when are in home, if they have appropriate care. It�s a team approach when you plan on amputation or any kind of surgery for the diabetic. A very important member of the team is the patient. If the patient is going to be non-compliant, you are going to have a problem to begin with and if the patient needs family support, nursing support etc.
Rear foot and forefoot have that form fits function aspects to their anatomy. You have to take that in to consideration when you planning the amputation. When a single toe is amputated some sort of an imbalance is going to occur. We need to understand that and prevent the complications from occurring before they do. Lesser toes aren�t such a big deal, the minute the great toe is gone, the extensor and flexor tendons are gone, you now have an apropulsive gait. What I try and do before I do that, if time permits, is have an orthotist in my office or my clinic to fabricate the device that the patient is going to wear soon after surgery. I will do an amputation of the great to and put them in to an offloading shoe but they go from the offloading shoe to an already prepared offloading device as quickly as possibly because what happens when you lose the great toe, you get adduction of the toes towards that empty space and you are going to submit to problem. We need to get an orthotic with a shoe filler to fill in that space and some sort of metatarsal support to off load the lesser MP joints. This is also something you need to think about before surgery.
Removal again, this one toe at the time thing has to stop. What happens is your remnants of toes don�t give any more stability and what they do do is create a probable problem later on as you can see in this picture. This person already has a preulceration on the great toe, would it be more proper to do a TMA in this patient? I would say yes. TMAs do preserve foot function, they maintain that metatarsal parabola expect for the picture you saw before but also consider TAL if you are in a state that allows you to do that.
When does three not equal three. Consider a more proximal level amputation if there is viable tissue present and adequate perfusion is observed. Lisfranc or Chopart�s amputation should be considered way before BKA because this particular patient is now ambulatory with an appropriate AFO. He has got two legs and he can resume a normal life. I will tell you and you all know these patients that have a BKA do not lead a normal life following surgery in most cases.
Multiple variables as you see have to be considered when you determine what may or may not be salvageable. We need to consider the whole patient. As I said earlier, the patient has to be part of the team. They need to have the ability, they need to have the desire to get better. So weigh out your options before you � this is all part of the planning process of amputation. Recognize the need, evaluate for neuropathy, evaluate for vascular perfusion, evaluate all types of imaging, evaluate their biomechanics and if you don�t have the ability to do that, again there should be some member of that team that you can use to do that for you and choose the appropriate procedure.
You have seen this slide before, the multidisciplinary team of all our patients, all our diabetic patients, the podiatrist and vascular surgeon or vascular interventionalist are truly the key players here but we need everybody else. I should add patient family, I should add patient to this team because too often we forget about that. My friend, Bob Warriner, who recently passed away Chief Medical Officer of Diversified Clinical Services said this and I put this pretty much in all my slides, �Wound care or surgical care is driven by clinical evidence, evidence-based medicine that should drive us to do the right thing for the right reason at the right time in the right manner for the right patient every time.� That was Bob Warriner, a good friend of all of us and we are certainly going to miss him in the world of wound care. Thank you.