True multidisciplinary approach essential for limb preservation

CHICAGO — To prevent amputation, physicians must assemble a comprehensive multidisciplinary team to care for patients at risk for losing their limbs, Ramon Varcoe, MBBS, MS, FRACS, PhD, said at AMP: The Amputation Prevention Symposium.

A multidisciplinary approach to limb preservation begins with recognizing the major drivers of amputation. The global public health threat posed by the “tsunami of diabetes,” for instance, is a significant problem, he said.

If a patient develops diabetes, his or her risk for amputation is 15 times as high as someone who does not, according to Varcoe.

“The impact is more than amputation itself, though; it’s a reduction in life expectancy as well,” he said, noting that studies have linked amputation to an increased risk for death and 5-year rates of death exceeding that of some cancers.

About 15% of people with diabetes will have a foot infection in their lifetime, he noted, and nearly one-fifth of total health expenditures in the United States and Europe is due to diabetic foot ulcers.

“Every 30 seconds around the world, there is a major amputation due to diabetic foot ulcer and that is truly unacceptable,” Varcoe said.

Team roles

When looking at the etiology, peripheral artery disease, which is common in patients with diabetes, is a significant issue, according to Varcoe.

“Without proper blood supply, the body has no hope of healing an infection,” he said. “Also, if we look at the impact that diabetes has on the body’s ability to fight an infection, it starts a cascade of effects, including ulcer, gangrene and subsequent amputation.”

Clinical guidelines around the world include the use of a multidisciplinary team, according to Varcoe.

The team should be led by a vascular specialist who needs to do the preliminary assessment as well as evaluate the wound features to determine what must be dealt with immediately, he said. Teams must also involve endocrinologists, infectious disease specialists and podiatrists. They will also need cardiologists as well as input from orthopedic specialists, depending on the symptoms and the way the foot architecture has developed.

His practice, Varcoe said, is to simultaneously address issues of wound care and revascularization. The abscess is drained, and he favors endovascular revascularization first but will also use open surgery when required. Once patients heal, they also institute a maintenance program.

“That is the crux of the best possible care that we can offer patients with diabetic foot ulcers,” he said. “We can’t do it alone. Treatment requires a multidisciplinary group of specialists across the board.”

Aspects of care

The first step to treatment is debridement, which is done by a surgeon, to remove all the necrotic tissue and affected material to decrease bacterial load and stimulate growth factors. Evidence also indicates that debridement should be performed repeatedly, according to Varcoe.

Treatment must involve an infectious disease physician to ensure appropriate antibiotic therapy, he said. This includes initial empirical treatment to address all types of microbes present in the ulcer followed by more tailored treatment. It is important to note, Varcoe added, that the presence of MRSA skin colonization does not necessarily mean MRSA is in the wound. Furthermore, oral therapy is also as effective as IV therapy, he said.

The team should also include an endocrinologist who will help in achieving glucose control, which improves the body’s ability to fight infection.

For wound care, specialists in wound dressing, negative pressure wound therapy, such as vacuum-assisted wound closure, and hyperbaric oxygen therapy, which data show has a higher rate of diabetic foot ulcer healing, are necessary, according to Varcoe.

Wound closure is also important, he noted.

“It’s essential that surgeons attack this very aggressively with things like skin grafting,” Varcoe said.

An orthotist is also needed on the team, as he or she is crucial to the process of pressure offloading, according to Varcoe. Total contact casting is the gold standard because it redistributes the pressure and ensures patient compliance. However, it requires a degree of expertise and is resource intensive. A removable cast walker is an attractive alternative because it can be applied with less expertise and patients are able to walk with it, but it is not as effective and healing takes slightly longer, he noted.

Orthotists are also important in future prevention as well, as the patient should ultimately have a custom-made shoe as an ongoing preventive mechanism to offload the foot, according to Varcoe.

By taking these steps to success and creating a truly multidisciplinary team, physicians can prevent limb loss, Varcoe noted.

“It’s time to say no to below knee amputation. Please think twice before attempting it,” he said. “Diabetic foot ulcer is a truly multifactorial process. Unfortunately, it frequently leads to major amputation unless we take a multidisciplinary approach. We always think about ischemia, but we need to think about debridement, antibiotics, surgery, glycemic control, advanced dressings, hyperbaric oxygen therapy and offloading as well.” – by Melissa Foster

Reference:

Varcoe R. CLI in 2018. Presented at: AMP: The Amputation Prevention Symposium; Aug. 8-11, 2018; Chicago.

Disclosure: Varcoe reports he is a consultant for Abbott Vascular, Boston Scientific and Medtronic.