According to the Amputation Prevention Alliance, 154,000 people with diabetes undergo amputation each year. As high as 80% of non-traumatic lower limb amputations are due to complications of diabetes. The care to avoid amputation is fragmented. As a medical community, we need to provide comprehensive coordinated care to preserve limbs. The incidence of lower extremity amputation in patients with diabetes is significantly higher in patients with lack of access to specialists, lower socioeconomic backgrounds, and people of color. The medical community needs to be aware of the disparities and provide patients with the care needed save limbs. Understanding the “Four Pillars of Limb Preservation” is key to providing this care.
Limb preservation goes beyond just treating individual symptoms; it involves a holistic approach that considers the entire patient, their medical history, and the interplay of various factors affecting limb health.
There are four pillars to build a comprehensive program to preserve limbs. These pillars include medical management, revascularization, wound care and management of diabetic neuropathy.
Pillar 1: Medical Management
It is mandatory that the patients with underlying medical conditions resulting in amputations receive comprehensive medical management. Diabetes, hypertension, hyperlipidemia, obesity and nicotine addiction need to be treated with diligent follow-up. Patients with claudication should participate in exercise programs. Working with primary care physicians is vital to coordinate care across disciplines.
Pillar 2: Revascularization
Timely revascularization in patients with arterial insufficiency can prevent amputation. Vascular surgeons, interventional cardiologists and interventional radiologists offer various revascularization procedures. There is debate related to open procedures versus endovascular procedures. In a great number of geographic locations there are no vascular surgeons. In these places, patients will invariably undergo endovascular procedures. Interventional care is also gradually moving out of the inpatient hospital system to an outpatient setting, like office-based labs and ambulatory surgery centers. These facilities tend to be more patient-friendly and efficient. Procedures in the outpatient setting can be done in a timely manner and can be very safe and effective.
Pillar 3: Wound care
Diabetic foot ulcers are the number one cause of major amputations. It is important that the patients with leg/foot ulcers have access to a comprehensive wound care center and receive hyperbaric oxygen treatment when indicated. If a patient with a diabetic foot ulcer can receive comprehensive treatment in a timely manner, it is likely that a major amputation can be avoided. Appropriate wound care may be able to avoid an amputation and also improve quality of life.
Pillar 4: Diabetic Neuropathy
The goal of limb preservation is not limited to avoiding a major amputation. It should include improving the quality of life. Many patients with diabetic neuropathy live a poor quality of life, with constant pain and inability to sleep. Medical therapy has limited efficacy. Newer, high frequency spinal implants have shown very promising results in decreasing the pain in these patients. In addition, early data suggests the device may help the patient regain sensation in the foot. If the sensation in the foot is restored it will help avoid injuries to the foot, resulting in ulcers and early detection in case there is an ulcer.
Limb Preservation Center
A true Limb Preservation Center (LPC) of excellence must provide all patients with holistic and coordinated care. The care team consists of a committed panel of physicians and surgeons including the core team of vascular surgeons and/or endovascular specialists, surgical podiatrists, and hyperbaric-trained physicians. The core team ensures expedient referrals to the appropriate subspecialist, with timely interventions. The protocols are based on the most updated research. All of these components greatly increase the chances for healing the ulcer and avoiding a major lower limb amputation.
In conclusion, advocating for limb preservation through comprehensive and coordinated care is not only in the best interest of our patients but also aligns with our commitment to providing holistic healthcare. By working together across specialties, we can make a significant impact on the lives of those we serve and contribute to the overall well-being of our community. This is a call to action to primary care physicians and advanced non-physician practitioners to provide access for holistic care to your patients with diabetes, to examine the feet, to ask about neuropathy and to refer to the appropriate providers who can help avoid an ulcer or avoid a major amputation if an ulcer is already present.
About Krishna Jain, MD
Dr. Jain is a board-certified vascular surgeon who has dedicated his career to helping patients with diabetes and peripheral arterial disease avoid major lower limb amputations. Dr. Jain has been intimately involved in the growth of office-based endovascular labs (OBLs) throughout the U.S. since 2007. He is a founding member of the Outpatient Endovascular and Interventional Society (OEIS) and a distinguished fellow of Society for Vascular Surgery (SVS). Dr. Jain has authored many widely quoted papers and has written the textbook that serves as an expert guide in developing and operating an OBL, entitled “Office-Based Endovascular Centers” (Jain, K. M., 2019. Office-Based Endovascular Centers. Elsevier Health Sciences).
Dr. Jain is the founder of Limb Preservation Centers of America® and Chief Medical Officer of Amputation Prevention Experts Health Network, LLC, a company that develops and manages outpatient limb preservation/wound care and hyperbaric oxygen centers in hospitals or freestanding physician practices.