Optimizing Outcomes in Diabetic Limb Preservation

Announcer:
This is Clinician’s Roundtable on ReachMD. On this episode, we’ll hear from Dr. Paul Kim, who’s a Professor in the Departments of Plastic Surgery and Orthopaedic Surgery at UT Southwestern Medical Center in Dallas, Texas. He’s also the Medical Director of the UTSW Wound Program. He’ll be discussing considerations for limb preservation. Here’s Dr. Kim now.

Dr. Kim:
So as far as your diabetic limb salvage cases, I think the most important thing is to understand the patient’s function and their functional capacity. So it’s not good enough to just save length. It’s more important to save their functional ability. If you believe that you can save enough function of the foot, for example, to attempt a really aggressive limb salvage, then you should, but if the patient’s, for example, bedbound—or even in a wheelchair—perhaps doing a below-knee amputation or major amputation is a better solution for those patients. It’s very individualized based on what the patients’ expectations are. Their age, for example, will also dictate what kind of strategy you take, and also depending on if they’re on dialysis. And the other major piece of all of this in the diabetic limb is perfusion, which is blood flow. If their blood flow is compromised, if they cannot be revascularized—although there are newer techniques, for example, what’s called a DVA, or deep venous arterialization, where veins are converted into arteries, which is kind of an end-stage last-ditch effort to save a limb. But again, it depends on what the patients’ expectations are. If they’re truly that vasculopathic, then perhaps the pain is the biggest issue, and sometimes pain is better alleviated by doing a major amputation. So again, this is a case-by-case. You know, I can argue for preservation of a limb. I can argue for early amputation. It really depends on the situation that the patient is facing.

The core strategies to reduce the risk of amputation and try to preserve function are actually fairly fundamental. In my diabetic patients, it’s largely due to uncontrolled blood sugars for a long time leading to peripheral neuropathy and vascular issues. These patients, we have to remember, don’t just have vascular issues in the periphery, but they have vascular issues in their heart and their kidneys and other areas, so this is more of a global problem than a localized problem. So if you can control the diabetes early on, that’s really the key.

Other easy things like daily foot inspections, making sure they wear the proper diabetic shoes and insoles, if they have a history of amputation or they have peripheral neuropathy is also very important, regular foot care by a local podiatrist in the area, and if, at some point, the wound or the amputation site become significantly compromised, I think there are specialized centers that are capable of using the team approach in taking care of these patients. This includes involving people like the vascular surgeon the podiatric surgeon, infectious disease, the endocrinologist, the hospitalist. Everybody gets involved. And then regular and routine follow-up, following that wound very carefully, using evidence-based medicine, using these approaches that we know have been shown to be more effective than others, and close stewardship of that patient.

Announcer:
That was Dr. Paul Kim talking about how we can prevent amputation in patients with limb-threatening wounds. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!