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Release Date: 03/16/2018 Expiration Date: 12/31/2018
Robert Frykberg, , DPM, MPH,
PRESENT Editor - Diabetic Limb Salvage
Carl T Hayden VA Medical Center
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TAPE STARTS – [00:00]
Male Speaker 1: These are case discussions and I want a few experts here up on the panel with me. This is very important that we have some feedback from the audience because it's going to be point-counterpoint. And I'm going to ask for your opinions as well. We have a microphone up here that I'd like you to use. Steve and Richie [phonetics] make sure that this microphone is active please. Okay. We like to do this because it's very instructive and it gives you insights on to how we might think and how we might approach a given problem. So this isn't the formal exercise, but I'm going to ask Dr. Garofalis [phonetics] and Huddy on how they might approach a problem. Okay. And I forget what the outcome is on here, so that’s fine. Okay. We have this patient, a 68-year-old diabetic man on dialysis, currently on dialysis. He already has a right Syme amputation. And he presents to your clinic with a foot looking like this. So I'm going to ask our expert how do we approach that now. Viewing this patient's complicated history, what kind of an immediate workup -- and we don't need to be too exhaustive here. Just basically what you're going to look for, then what do we do now. And this is the question that you should all be asking yourself. Alright. I see this patient walking in. Here is the history. Now what do I do? Go ahead.
Male Speaker 2: What's the blood flow?
Male Speaker 1: Right. What's the blood flow? Number 1, so what would you do?
Male Speaker 2: I would get vascular studies right away.
Male Speaker 1: Sue Huddy [phonetics]
Female Speaker 1: I'd do the same. I'd also want to actually know a little bit of history on the other side of the Syme. How recent was [CROSSTALK]
Male Speaker 1: Okay, good. The Syme was healed. He has PAD. Okay. We recognize that and he is on dialysis. So does this look acutely infected to you?
Female Speaker: No.
Male Speaker 2: No. It looks -- it's not like an emergency situation. There is no pus draining out of it. It is little chronic but it is ischemic and so we want to find out what the blood flow is.
Male Speaker 1: Right. So it’s dry gangrenes. It's not really an emergency, but it's still something that we all recognize as a problem. We're not going to go doing any reconstructive procedures on this. We have gangrene on the forefoot here. We got a history of an amputation on the right side. He is on dialysis, big risk factor for limb loss. So we have to approach this very judiciously. This is a plantar aspect of his foot. Good. He has got a nice plantar -- he has got nice plantar tissues there. I don't recall of giving you the waveforms or not, but let's say he had adequate waveforms, PVR waveforms by the way because his SOPs, ABIs are going to be falsely elevated. So let's say he had adequate PVR waveforms, adequate TCOMs at the ankle but not at the forefoot level or the TMA level. What would you consider doing then and why? Go ahead Sue Huddy, you're Diana.
Female Speaker : I think sometimes history dictates and history repeat itself if his vascularity is only adequate to the ankle level. I mean I think you're going to look --I'm assuming he was not revascularized on the contralateral.
Male Speaker 1: There was no option for revascularization.
Female Speaker : I'm going to play my cards and say that probably that is not an option on this side. And you're probably looking at bilateral amputee and you probably try at the Syme's level given that he has adequate flow and nice flap, really.
Male Speaker 2: He is headed for Syme. I mean, clinically do you have capillary refill anywhere there on the plantar aspect of the foot or is that not happening...
Male Speaker 1: You know, the color looked okay. I mean we're going based on PVR waveforms and I forgot if we had TCOMs on here or not. But obviously, our main decision is going to be predicated on tissue coverage, right? Would anybody want to do an open amputation on this type of patient? Okay, we have one.
Male Speaker 3: I'm sorry. Would you consider something like an orthosis for this person?
Male Speaker 1: That's a good point. No. But it's a good point, so I'm going to consider. And we do use orthosis on occasion when there is no option. Dr. Turano [phonetics]
Male Speaker 4: So when you won't dive them for a little bit. In other words, you have some time here assuming that he is optimized vascularly and he has an adequate ABI at the ankle level, dive him for 20 treatments to get the flap ready for closure.
Male Speaker 1: Okay, a flap. There is no way to save that forefoot I presume.
Male Speaker 4: No.
Male Speaker 2: I think diving is a great option if it's available. Many VAs don't have that available. But outside the VA system, if you had that opportunity, it isn't acute and you can advantage of it, you might buy yourself some time here and you might buy yourself some length in where you're going to do the amputation. So it certainly isn't -- it's not a bad chance to take.
Female Speaker: I tend to think of as PVRs are only good up to the ankle and given history on the contralateral side, how much are you going to achieve in terms of putting him through these 20s, 30 dives to --
Male Speaker 4: At what cost.
Female Speaker: If there is no vascularity going to that level, you're already taking a risk by creating a flap in the heel to flap here Syme. So --
Male Speaker 4: That would be the point of diving him if --
Female Speaker: But he has --if he has nothing going there --
Male Speaker 1: And where is the data to suggest that that's going to help your amputation level heal?
Male Speaker 2: I think the current data suggests that an ABI greater than 0.4 is statistically helped by diving, especially in a diabetic. I mean that’s what you know and --
Male Speaker 1: What paper was that?
Male Speaker 2: It's actually currently in publishing, yeah.
Male Speaker 1: I see you're from Philadelphia. Didn't Margolis [phonetics] say that there was no real good benefit to HBO? I mean, he is from Philadelphia, right?
Male Speaker 2: He is actually on the paper with Thom [phonetic] as well, but yeah.
Female Speaker: Did we get an ABI from you? Do we know that it's 0.4?
Male Speaker 1: It's falsely elevated.
Female Speaker: Okay, falsely elevated.
Male Speaker 1: I'm sorry for being vague. I have [CROSSTALK] a couple of months. So maybe that's helpful because the thought process that we're going through is valid. I'm not saying, no Michael, I just don't know and we don't have HBO available. I wish I did but we don't have one available.
Female Speaker: Is he ambulatory at all? Does he --
Male Speaker 1: He was ambulatory on the other side.
Male Speaker 4: That was actually my next question was we need to find out how ambulatory is this gentleman to begin with.
Male Speaker 1: The man walks raised [phonetic] -- he is a home ambulator. He has a prosthesis on the right side. I would like to avoid double Syme although I have done double Syme. I'd like to avoid it in a 68-year-old man who is already on dialysis but he --
Male Speaker 4: I know that Chopart really isn't indicated for a lot of people, but in some people we do still do Chopart because they can use it to transfer and the heel pad is still intact. They can still use it to transfer a little bit and move around.
Male Speaker 1: Okay. So we're seeing an intact heel pad which is critical for both the Syme and Chopart. And he's got a good plantar skin with no ulcers, not that that’s absolutely critical in some cases. So I don't know would anybody else consider a Chopart? Would anybody consider a TMA if you have relatively wide forefoot?
Male Speaker 4: If he can be revascularized, then maybe if hyperbaric can help him. I think you could make an attempt at a TMA, but you have to have an expectation that it may dehisce and require revisional surgery later on.
Male Speaker 2: You know something that you can try in the VA setting as opposed to outside the VA setting. You could take him to the surgery, have him consented for a Syme or Chopart but make your incision more distal and see if there is any bleeding to support a more distal amputation as you make your incision. And if there is enough bleeding in your eyes, you see that there is enough blood there, to try something more distal, but you have to be prepared to go further back more proximally.
Female Speaker: My concern is that we're saying that the flap is healthy but if you look plantarly and dorsally, proximal to the metatarsophalangeal joint, that skin is dusky, it is blotchy in appearance. So a lot of times when you cut too close to that, you really just stop the cascade rolling for flap failure both dorsally and plantarly. So have I gotten, I'm going to say, lucky and done, maybe amp at the foot level on patients like this and struggle to get it healed for them because it is their only chance for limb and it's -- they don't want the other Syme, yeah. Is it the majority of the time, no. This gentleman has many comorbidities and he's got atrophic skin changes. Skin is dusky all the way proximal to the MPJs both dorsally and plantarly. He has a dorsal wound that’s not healing there either apparently. So I don't know, maybe I'm erring more on the side being more aggressive as opposed to less.
Male Speaker 1: Okay. All good points. Let's see what we did. Here was his x-ray which you want to get. Okay. He had already had a fifth ray amputation before. It might had an acute infection when we did that. I don't recall if that was current or before, but he has had necrosis of this toe. No gas or anything under there. But he was seen by vascular of course. They had no options for him. He was calcified. They didn't want to do anything on him. Here is his angio. So that’s what you got is what you got. Does this change?
Female Speaker: That’s a game changer right there.
Male Speaker 1: Well, it's not very encouraging.
Female Speaker: I don't know, I'd try Chopart.
Male Speaker 1: This is after revascularization. That’s why I'm not very impressed with our ability to endovascular or revascularization. It's not very good. Okay. He got some thready, thready posterior tibial vessels. He got an anterior tibial that stops right at the mid foot. Does the arch barely -- completes the pedal arch barely. So this is what we are faced with. So we have what a Chopart over here. [Off Mic Conversation] [Laughing] Okay. Right. I mean this is not encouraging. What if I told you I could hear DP and metatarsal signal, Doppler signal, monophasic.
Female Speaker: Can I ask why this rules out the Chopart?
Male Speaker 4: Looking at the vascularity, I just don't think a dorsalis pedis is going to be able to support that much foot. I think we're just trying to buy him some time right now, but ultimately this gentleman need either a BK or maybe even above knee.
Male Speaker 1: But let me finish what I said because I agree. I think it takes multiple areas of assessment here. I was able to -- I always carry a handheld Doppler in my pocket. I had what I thought was reasonably good monophasic signal at the intermetatarsal of the perforator artery. Moderately good signal, believe it or not at the posterior tibial based on the Doppler and moderately good signal at the DP. And sometimes that comes into my calculus as to what I'm going to do as well. And modest ankle PVR waveforms which also comes in toward as well. These are all good points. Remember there is nothing wrong with anything anybody is saying. These are the things that we have to consider when we're thinking about this. So let's see what else happens here. We did a Chopart, how about that. We did a Chopart. Does anybody think it's going to heal? And look I have had Chopart that didn't heal and [CROSSTALK]
Female Speaker: I'm optimistic that it's going to heal.
Male Speaker 1: I just had a couple that didn’t heal. This is the calculus that you make. Let me ask you this, if you have a failed Chopart, does that rule out a Syme?
Female Speaker: No.
Male Speaker 4: No.
Male Speaker 1: I don't think so.
Male Speaker 2: I don’t think so.
Male Speaker 1: Unless it's acutely infected and your ankle gets infected. That’s the one thing. Okay.
Male Speaker 3: If you have considered a Syme and you've done a Chopart, what is your defense in not going and doing the Syme from the very beginning?
Male Speaker 1: I consider the Syme, but I also consider the Chopart. I consider both. And we went ahead. Remember what I said, I think it's really important you can't just look at labs. You can't just look at the angio although that’s important. I question the quality of some of the distal runoff on the angios. Anyways, so I listen -- so if I hear a fairly decent signal right to my perforator artery, the deep plantar artery, if I hear a fairly reasonable signal on the PT. If I heard nothing on the PT, I wouldn't have done this.
Female Speaker: If I read into your question, are you asking, was there a more of advantage doing a Syme versus Chopart, is that what you kind of you're leading to?
Male Speaker 3: There are two things that’s going through my mind. One, which I haven't heard anyone mention was to do the TC, the oxygen measurement.
Male Speaker 1: I don't have the tcpO2 values, but I'm going to say that they were very good in the forefoot. And I'm going to go with the PVR. I'm sorry I don't have everything. Maybe I didn't put it all in here so we can think about all the things we do. Yes, TCOMs or skin perfusion pressure. PVR waveforms, how good were they at the ankle? How much was the drop-off to the mid foot? How good was my Doppler signal that I had when I listen to it? What was the color at these areas? Sue Huddy [phonetics] made a very important observation too that wound on the top disturbed me. Okay. And I can be criticized for this because remember I readily admit I've had these failed too. And I'm not saying this isn’t going to fail. We don't know yet. But you make a clinical decision. Okay.
Male Speaker 3: The other part about it that I'm thinking is now the medical legal responsibilities that we have to deal with whether we did -- should have done the Syme versus the Chopart. I understand the calculations that we're making here but if others challenged us, how do we defend this?
Male Speaker 1: You're trying to save the leg. What if I do-, go right to Syme and it gets infected and he loses the leg. Then why didn't I just take -- why didn't we go for a leg at first. I mean these are the considerations you talk to the patient about. I mean obviously you want to do what you think has a reasonable chance of healing. Could you with certainty say that a Syme would heal? Could you with certainty say that a Chopart wouldn't heal? Could you with certainty say that he would not need a below-knee amputation? Everybody who we do these on, I think we all agree. We say, sir, your leg is at risk but I'm going to do everything I can to try to save it. I'm sure we all would. It's the same thing we talk to people about. So your points are well taken, but you also have to base your decisions on the data you have available, how you're looking at this foot; I realize it's only a picture and what you're hearing, okay. Look, listen and feel. So let's see if this guy is going to heal or we're going to have a miserable failure. Okay. Now, you see that one area on here that gave me pause right here. It's like an ischemic insult on the bottom, that’s not infection, like almost an infarct, but it always gives me pause. When you do Syme, you can see a little bruise on the bottom and that can turn into a full thickness necrosis also. So you might be right there. But is it easier for them to be household ambulator on the Chopart? Yes. Is there a 50% probability that maybe this could heal? Is there a 50% probability that Syme -- my Syme data -- we've done about 80 Syme. I can only give 50% probability of healing. And every one of those patients I've already had on the below-knee amputation advice. Okay. I think that was it. Anyway, let me just say this patient went on to heal very effectively.
Female Speaker: I'll make a comment. So this is a trend in my opinion in dialysis patients for the flap to do something like this. They tend -- a lot of times I've seen vascular surgeons reopen a flap because these patients are more prone to hematoma and clotting in the area of amputation site. And then the flap gets compromised whether it’s compression because the hematoma buildup in that area and a lot of times patient will rebound. I don't know if you've seen that.
Male Speaker 1: Yeah, but I was just happy to see a little bleeding. [Laughing]
Female Speaker: I think in dialysis patient I find that more often than not. Many times I have had to open the flap, a couple of stitches with that area and then they do well.
Male Speaker 1: Yes, they're difficult. Well, this man happened to do well and he healed this up and he is still fine. Okay. Granted that there was -- it was a risk, but I view Syme as a risk too as a first operation although sometimes I wish I would have done Syme first. Okay. Same situation. Go ahead Matt.
Male Speaker 2: I think this part of your explanation -- I mean you have some vascular findings that encouraged going a little bit more distal and I think if you explain this to the patient that we can do -- in layman's term, you can go a little more distal. The chances may not be as good, but we have-, still have an opportunity to give you a little bit more length. We have, maybe, a greater chance of closure if we do Syme, but then you have Syme on both sides and that has some certain compromise issues with it. So if you explain the situation to the patient and yes maybe the chances of the Chopart working out less than if you weren't right to Syme, you're still giving the patient options that explaining what your findings are and what you think. And I think in this case, going a bit more distal is worth it for this patient because now he can still get around at home a little bit easier.
Male Speaker 1: And I think you also, by what you're saying, agree we have not really burned a bridge because many times I do have to convert this -- not many times, but occasionally, I have to convert this over because you still got a good heel pad there. What happens if a Syme failed because of infection or what? Then your leg is dead and that’s why I'm starting to go more towards Chopart in this case. Yeah, that was my point. If he necrosed the flap, would you go to Syme or, and then if he necrosed that, then you go to transtibial. So that's three procedures on a very sick person, very costly too. There is no right or wrong. I just want your thought process on this. Is it either Chopart and/or Syme versus transtibial in your mind or you would go and do the extra procedure most often are all good points, all good points. My clinical assessment and I don't want to discount the importance of that. I don't want to discount the importance of your clinical observation and examination of the patient. I think more than anything and I'm sorry to run the PVRs but I was driven by what I thought were favorable PVRs at the ankle and by hearing reasonable Doppler signals right to the mid foot, but I didn't want to go any shorter than the Chopart. And to your point, these are done under MAC with local. So we're not putting these people to sleep multiple times. The survival for a bilateral amputee, let's say dialysis and below-knee amputation not very good. He is probably going to survive more with the foot level amputation, but these are all the things that we have to consider. And if I can do something local, I'm less worried about multiple operations, but you try to do what you think you can get done with the first time. Okay. I don't think any of us would do something we thought was going to fail initially.
Female Speaker: I also think in regards to watching the flap and watching it if it's going to fail or not and trying to make a determination whether or not your next step would be a Syme versus below-knee amputation or possibly an AK depending on where they go from there. Really at this point it depends, for me to allow -- to give the flap time to demarcate itself and to watch it really done. If it demarcates and goes real proximal, then you're probably looking at the BK. If it demarcates and you've got maybe a centimeter loss of flap, then you probably could be creative with flap reconstruction and do Syme for the patient. Okay. And I still want to say that to me that arteriogram was very compelling for me to do a Chopart. I don't know. Everyone seems like that was the game changer to push him towards something more proximal. That was the thing that kept me more distal. Because I've seen runoff end at the peroneal artery just proximal to the ankle and people heal at distal amp. And to me, that looked a little bit more healthy than I would have expected from the history I got. I mean I don't want to even use healthy because that is the diseased vessel, but there was a lot of collateralization. There was a lot of extra supply going to that region that I wanted heal and I saw an arch forming. So for me that was my game changer [CROSSTALK]
Male Speaker 1: So you put everything together and you could hear signal. So that was it. All good points. I think we have time for one question over there.
Male Speaker 4: The reason I revoked my decision for the Chopart based on that angiogram was because I did have a patient that was almost identical to that. I didn’t have to Dop, the handheld Doppler signals or anything like that, but I went ahead and did the Chopart and he did not heal. And he went on to a BK. And that dehisced. He went on to above knee and then he had a stroke. And so it wasn't a good outcome. I felt like I should have recommended with what I saw an above-knee to begin with. He wasn't that ambulatory either though. There was a difference.
Male Speaker 1: These are all the decisions you have to make based on what you are finding. I mean I have had these failed. I have had Syme failed. I have had Syme healed that I never thought would heal. You have to base it on your clinical document.
Female Speaker: I think at the end of the day, the education you give to the patient, they understand what you're doing is a wound salvage attempt and that there is a potential that it is going to go more proximal.
Male Speaker 1: And is it worth -- maybe we probably going to have to -- no, we will forget about this one. I would rather just keep this discussion going.
Male Speaker 2: That’s good.
Male Speaker 1: Okay. What was the next question?
Male Speaker 5: So at my residency program, typically we after transmetatarsal amputation, we routinely refer to our general surgery or vascular surgery friends for the below-the-knee amputation and just skip altogether Choparts and Syme amputation. So I have --
Male Speaker 1: And then do what.
Female Speaker: BK.
Male Speaker 1: So you go right from the failed TMA right to BK?
Male Speaker 5: That’s correct. And so I have two questions. Forgive me for not knowing, but I was under the impression that Syme level of amputation was beyond our scope of practice in many locations; and two, what's your success with the Chopart and Lisfranc for that matter because we don't do Lisfranc either. What's your success seen with Lisfranc, Chopart, and Syme amputation?
Male Speaker 1: I don't think we're collecting our data on Chopart. First of all, I think that's a common error. I mean to go right from the failed TMA right to BK, what's the mortality data on a diabetic patient with major amputation? It’s 50% five-year mortality. If that’s renal failure, it drops way-way down five year or the survival drops way-way down. So in a patient like this, the more proximal you get, the faster they're going to die generally speaking. If you can get the Chopart to heal, I mean, it's going to be okay. I would like to get these guys ambulating and get them out of the wheelchairs and move along. 50% of our Syme -- or the last review we did was 60% of our Syme healed. 60% healed. Everyone of them had already had a recommendation for below-knee amputation by vascular surgery, by infectious disease or what have you. And if I think that the patient has a reasonable chance of healing, I'll have the discussion with him. I say, if it fails, we know we have tried. And most often, I can do these under a local with MAC because most of the guys are really sick.
Male Speaker 2: You also mentioned the scope issue and the scope issue is very State-dependent. In some States, yeah, we as podiatrists can't do that. In other States, that’s no problem, piece of cake. In Illinois, we can do that. In other States, right, you're not going to do Syme because that's not allowed. So it is very State-dependent.
Male Speaker 1: In some states, you can't do a toe amputation.
Male Speaker 2: Right.
[OFF MIC CONVERSATION]
Male Speaker 2: The APMA has website that list -- on APMA website under state components, it has all the scope of practices about the States where they stand today and it’s updated every year.
Male Speaker 1: And one of my prior resident, not the most exemplary resident, he is not here. [Laughing]
Male Speaker 2: Who you want to point out? [Laughing]
Male Speaker 1: He is now working for the Indian Health Service, very-very, busy-busy practice. He is doing below-knee amputation. Okay. So it totally depends on your licensuring, your State and VA system. You can be in Massachusetts where you're not supposed to be able to take off the toe, but if you have a license in another State that allows you to do all these operations, you can do them because you're in the federal system. Okay. The real point is these are the decisions that you have to make based on your available data, based on what you're seeing, based on your discussion with the patient, based on their history. I mean this patient that we're talking about had a high risk for losing his leg. And he knew that and he says please try to help me and we did and we got lucky.
Female Speaker: I really think in arena of limb salvage though that no one should exclude the option of Lisfranc amputation especially if you're going from a TMA to BK because of infection or tissue loss that could have been salvaged at Lisfranc level. Lot of people worry losing mechanical advantage, losing tendon attachment or losing the length of the lever arm for propulsion, but where we are today with prosthetics and shoeing these patients and getting them to be community ambulators at that level, I'm actually shocked to hear that you guys exclude Lisfranc amputation and goes straight to below-knee amputation because one, you're increasing the mortality rate of this population by doing that. You're throwing these patients into more depressive state. It's enough to have to have an amputation but to lose your leg. These patients may be bread winners at home and maybe they lose their job because of this level of amputation where they can be functional at that capacity anymore where as with the mid foot amputation whether it be TMA, Lisfranc, they may have sustained a little bit more some of their integrity.
Male Speaker 1: I don't know about the wisdom of going right to the BK from failed TMA unless you lost a lot of tissue plantarly. One important thing with the Chopart though that I have learned through my failures, you need a good flap, a good long plantar flap to get that close. You never want to do these in this type of patient, leave it open because then you're doomed to failure on these ischemic patients. So whatever you do, you want to do it so that you can get the thing close and then hope and pray that everything works. Okay. I think we have to move on. Thank you. Hopefully, that was a good discussion. We only got through one case, but it was great. Thank you for the interaction with the audience too.
TAPE ENDS - [31:04]