The patient, a 78-year-old woman with diabetes, hypertension, and a history of foot ulcers, was well known to the team of podiatrists, who over the years had performed several debridement procedures on her feet. Unfortunately, it appeared that she had come to the end of the line, with all signs now pointing to the need for a below the knee amputation.
“She lived independently, and she wouldn’t be able to continue living alone with an amputation,” says Dr. Parind Oza, director, Vascular Surgery at SBH, “So, we were not willing to give up. We did an angiogram and ‘roto rooted’ out the plaque in her artery to allow circulation to get to the foot and grafted skin from her thigh. Now, she is 99.9 percent healed. I told her she would be walking on her foot by Christmas.”
Many patients are not so lucky. According to the CDC, there are 73,000 non traumatic amputations performed annually in the U.S., many due to diabetes. Recent data further shows that the rate of lower limb amputations among adults with diabetes is far greater in the Bronx – more than 38 percent in 2016 – than any other borough in New York City and far higher than the average in New York State. The Bronx number jumped 11 percent from 2009 to 2016.
In an attempt to change this, SBH will open the Amputation Reduction Center (ARC) in early 2020. The center will feature a collaboration of specialists from the departments of vascular surgery, podiatry, endocrinology, infectious diseases, nutrition, anesthesiology and wound healing and hyperbaric oxygen therapy.
“Diabetes is by far the major reason outside of trauma for amputation and a wound on an individual with diabetes needs to be viewed as an emergency,” says Dr. Ridwan Shabsigh, chair, Department of Surgery at SBH. “If you have a patient with a threatened limb, a foot with an ulcer that is infected and ischemic, there will now be a hotline number to call. This will activate an organized team response, like a trauma code, where multiple specialties will take a quick assessment, and, if necessary, fast track the patient to the OR for vascular surgery; and begin aggressive wound care including debridement, hyperbaric oxygen therapy, skin substitutes, prosthetics, and antibiotic treatment as needed.”
Studies show that amputation can have a deleterious effect on a patient, both in terms of their quality of life and their mortality. “Once you lose a limb, your life is shortened,” says Dr. Ronald Verrier, director, Division of General Surgery at SBH and associate medical director of its Center for Wound Healing and Hyperbaric Medicine. “You can lose five years.”
Adds Dr. Emilio Goez, director of Podiatry, “Even a dime-sized lesion on the foot of someone with diabetes can have a higher mortality rate than a patient with breast or colon cancer. An infection can start on the toe or bottom of the foot, and quickly advance up the ankle and the leg.”
Podiatrists and vascular surgeons will be on the front lines at the new center as the need for good communication and expeditious treatment is a priority with the knowledge that a small infected wound can turn into a leg amputation, and even life threatening situation within hours. Once a patient with diabetes is diagnosed with an infected wound in the foot, a podiatrist may apply an offloading cast to help reduce pressure on the foot to improve healing and a vascular surgery PA may be summoned to conduct a vascular study. Should there be a problem with the blood supply, an OR room can be made available and surgery performed immediately.
“There may be the need to clean out the ‘hard as rock’ plaque in the artery, making it more flexible,” says Dr. Oza. “A wound can’t heal without establishing a blood supply to the foot.”
Once this is done, the patient may be treated in one of the hospital’s hyperbaric oxygen chambers to help the wound heal more quickly. This may include one-hour daily “dives” for up to 90 days. “This is where high concentrations of compressed oxygen are delivered as medicine to help fight infections and stimulate the growth of new vessels which in turn will lead to faster healing,” says Dr. Goez. “The clinical data is very supportive of this and I’ve seen it with my own patients.”
PREVENTIVE CARE
According to Dr. Verrier, “If patients have better control of their diabetes, they might never get the wound.” This is why diabetes education and nutrition will play a major role at the center in terms of wound prevention. “Once you have diabetes for a while, you can get neuropathy, where you don’t feel pain in your foot,” says Dr. Verrier. “Patients need to recognize this, and also know that you can’t wear bad shoes, walk barefoot or cut your toenails by yourself.”
Proper nutrition, says Cecilia Moy, clinical nutrition director at SBH, will have an impact on the overall health of diabetes patients. “Hyperglycemia/ uncontrolled diabetes can cause nerve damage with nerves in the feet and legs most often affected,” she says. “Nerve damage can lead to losing feeling in the limbs and lowering the ability to feel pain, heat and cold.”
Most important in prevention, she says, is to keep blood glucose controlled through nutrition therapy and insulin/oral medication regimens to prevent or minimize nerve damage. Blood glucose can be affected by such factors as what one eats – particularly carbohydrates – the frequency of meals and snacks, stress, and infections.
The center, adds Dr. Shabsigh, will follow a “flow to toe” approach in reducing amputations. “Flow” relates to the importance of providing a good blood flow in order to heal a wound, with “toe” relating to the importance of healing small infections before they can grow and advance
