Limb Preservation:When Enough is Enough
(The Decision to Amputate)
Charles A. Andersen, MD, FACS, FAPWCA
Chief, Vascular/Endovascular Surgery Service
Madigan Army Medical Center
Thomas S. Roukis, DPM, PhD, FACFAS, FAPWCA
Chief, Limb Preservation Service
Madigan Army Medical Center
SALSAL 10 Oct 09

Amputations
• Amputation is fundamentally the wrong thing to do
• All of us involved in this conference would like to prevent
major amputations when ever possible
• Prior to considering a major amputation, there
are critical factors that need to be considered.
• Like the Super bowel - Take a time out
– Team play – team decision
– Is there anything more that can or should be done
– Can a limb preserving amputation be performed
– How can maximum function be preserved

Bias / Setting the Stage
• I am not an amputation surgeon but a Vascular Surgeon
with 13 years of experience in a “Limb Preservation
Initiative”
• Limb Preservation is a team sport – IMPORTANT
MARRIAGE BETWEEN VASCULAR
INTERVENTION, WOUND CARE AND PODIATRY
• Limb Preservation Initiatives can decrease the rate of
major amputations in the diabetic patients
• (Changing Focus) It is important to define “Limb
Preservation” and the goals of a “Limb Preservation”
Program

Major Amputations
1999-2003
5500 12.0
AMC
10.0
EAp 1000
5000
atients at M
8.0
er
4500 DM patients
6.0
Rate of L
4000
Diabetic P
4.0 Incidence rate
per 1,000
3500 2.0 patients
3000 0.0
1999 2000 2001 2002 2003
Ye ar
Incidence rate was decreased 82%.
Driver VR, Madsen J, Goodman RA. Reducing amputation rates in patients with diabetes at a
military medical center: the limb preservation service model. Diabetes Care 2005 February
1;28(2):248-53.

Amputations ??? Important to define what
we are really talking about
• Although our incidence of major amputations has
remained low, there has been a significant change
in the type and timing of “Limb Preserving
Amputations” that are performed.
• Major shift from attempts to same “all tissue” to
functional preservation
• Tissue preservation is not the same as functional
preservation and/or restoration
• (Emphasis on rapid return to functional life) with
low recurrence of ulceration

Presentation Goals
• Discuss the difference between Tissue
Salvage and Functional Preservation
• Systematic Literature Review
• Discuss factors that are important to
evaluate when considering an amputation

Limb Salvage Initiatives
Historical Perspective
• Initial focus in many centers was to avoid any type of
amputation
• Any amputation even a toe was looked on as a failure
(BLACK MARK IN HEAVEN)
• This led unbalanced feet with isolated toes and a high
rate of recurrent ulcers
• Chronic wounds were a source of morbidity, a source
for infection and set the stage for a more emergent
higher level of amputation
REALIZATION: TISSUE PRESERVATION (TOE
PRESERVATION) IS NOT THE SAME AS
FUNCTION PRESERVATION

Tissue Preservation vs.
Functional Preservation
• Maximal tissue preservation does not
automatically equate to maximal function.
• At times preservation of 1 or 2 toes becomes a
limitation to function when compared to a well
balanced TMA
• Focus shifted from preserving tissue to restoring
function (RAPID RESTORATION OF
FUNCTION TO THE HIGHEST LEVEL)

AMPUTATION ???
Define Terms
ALL AMPUTATIONS ARE
NOT CREATED
EQUAL

Tissue Salvage vs.
Functional Preservation
Salvage of Toes may not give you the
best functional result

TOE or PARTIAL
FOOT
vs.
LOWER LEG
AMPUTATIONS

Toes vs. Leg
Very significant difference between
a limb preserving limited foot amputation
and an AK or BK Amputation
A balanced TMA has very little impact on
function
A BK or AK Amputation has a very significant
impact on function

SYSTEMATIC
LITERATURE
REVIEW

Structured Literature Search
 Engines Searched:
•
National Library of Medicine
•
Pubmed/Infotrieve
•
Cochrane Collaboration
 Diabetes AND Amputation OR Limb Salvage
 Date limited to after 2000; English only
 Results: 2,968 manuscripts
 Reviewed all titles [Mostly vascular literature]
 Reviewed all pertinent abstracts: 436
 Reviewed 47 manuscripts in entirety

OUTCOMES OF STRUCTURED
LITERATURE REVIEW
Three Basic Literature Types Identified:
1.Focus on pre-operative tests to predict
healing rates – retrospective analysis
2.General algorithms by expert peers
3.Health related quality of life studies
No real good prospective studies

Health Related Quality of Life
PATIENTS
 Healed vs. Unhealed Ulceration [FAI 27(4):274, 2006]
• Level of Evidence: II; Prospective, Cross-sectional,
Consecutive Patients
• Patients with diabetic foot ulcerations experience
profound compromise of physical quality of life
which is worse in those with unhealed ulcerations
• Patients with unhealed ulcerations were frustrated
with healing and had anxiety about the wounds
resulting in marked negative impact on well-being

Health Related Quality of Life
CAREGIVERS
 [Diabetologia 48:1906, 2005]
• Evidence: I; Part of Prospective, Randomized,
Double-blind, Placebo-controlled Trial.
• Treatment of diabetic foot ulcers poses a great
burden for both the patient and caregiver.
• Healing of a chronic diabetic foot ulcer was
associated with a large improvement in emotional
well-being of both patients and caregivers.

Health Related Quality of Life
Chronic Foot Ulceration vs. Lower-limb Amputation
 [FAI 29(11):1074, 2008]
• Level of Evidence: III; Retrospective Case Control
Study
• Physical limitations were identical between the
chronic ulceration and lower-limb amputation
groups
• Physical limitations were worse for patients with
chronic ulceration vs. a healed partial foot
amputation
• Even though lower-limb amputation is a major
traumatic event, its influence on quality of life is not
worse than suffering from a chronic foot ulceration

Health Related Quality of Life
(Redefining outcomes)
Traditional outcomes – Provider focused
• Focused on healthcare provider (WE ARE GOOD)
• Morbidity and Mortality
• Wound Closure
• Amputation Rate
New Outcome measures – patient focused
• Focus on the Patient and Caregiver
• Quality of life
• Functional level !!

Questions for Consideration
What is the value of individual
toes
 a partial foot worth saving
Is
What factors are important in
the decision to amputate
“The surgical amputation level must balance
biology and function”
Douglas G. Smith, MD: Foot Ankle Clinics 6(2):271, 2001

What factors determine
the need for amputation
What factors determine
the need for an amputation
and
and the level of the amputation
the level of the amputation

FACTORS INVOLVED IN DECISION TO AMPUTATE
AND LEVEL OF AMPUTATION
Vascular Inflow
•With associated vascular insufficiency, if inflow can not
be improved, toe or partial foot amputation may not be
feasible (inline flow)
•Goal should then be to choose the most appropriate
level of amputation based on perfusion
•Very important to understand the tools utilized to
measure perfusion
•Amputation should not be performed without an
arteriogram to evaluate the revascularization options
•The concept on micro vascular disease has led to a
large number of unnecessaryPerfusion vs.
Ankle amputations.
Regional foot
perfusion

FACTORS INVOLVED IN DECISION TO AMPUTATE
AND LEVEL OF AMPUTATION
Soft-Tissue Envelope
•Is there progressive or necrotizing infection present?
•Will the tissue support healing
•Are the tissues durable enough for the ulceration to
remain healed?

FACTORS INVOLVED IN DECISION TO AMPUTATE
AND LEVEL OF AMPUTATION
Skeletal Deformities
•Rigid structural deformities create osseous
prominences that are difficult to “off-load”
•Can these deformities be surgically corrected to
produce a functional foot capable of withstanding
repeated ambulation?
“The pathway to amputation is littered
with bandages and dressings which
have deceived both doctor and patient
into thinking that by dressing an ulcer,
they were curing it” PAUL BRAND, MD: 1966

FACTORS INVOLVED IN DECISION TO AMPUTATE
AND LEVEL OF AMPUTATION
Sensation
•Is there any sensation to protect the foot after salvage?
•Are shoe modifications or brace therapy available.
•Can the foot be surgically reconstructed to produce a
functional foot capable of withstanding repeated
ambulation?
3 Months 3 Days 3 Months

FACTORS INVOLVED IN DECISION TO AMPUTATE
AND LEVEL OF AMPUTATION
Soft-tissue Contractures
•Digital, Ankle, and Knee contractures are common in
patients with chronic wounds
•How will the contractures affect the function and
durability of the salvaged foot?
•Can the soft-tissue contractures be surgically released
and balanced to produce a functional foot capable of
withstanding repeated ambulation?

FACTORS INVOLVED IN DECISION TO AMPUTATE
AND LEVEL OF AMPUTATION
Rehabilitation Potential
•Does or will the patient ambulate?
•If non-ambulatory, then clearly define goals
Minimizing complications especially reoperations
Improve transfers
Minimizing sustained nursing care requirements
•In non-ambulatory patients, it is not usually the ability to
wear a prosthesis, but the ability to safely transfer
independently that makes the difference between being
able to return home and requiring constant nursing
supervision

FACTORS INVOLVED IN DECISION TO AMPUTATE
AND LEVEL OF AMPUTATION
Functional Level
•Goal is to achieve maximum function level
•Maximal Functional level is determined by considering:
Patient’s previous level of ambulation
Intelligence + Cognitive Skills
Motivation
Compliance
Cardiopulmonary capacity LIGER!
Spasticity + Contractures
Individual rehabilitation goals
Family + Social support network
All Variables are considered

FACTORS INVOLVED IN DECISION TO AMPUTATE
AND LEVEL OF AMPUTATION
Patient’s Choice
•Clear and direct discussion regarding multiple surgical
procedures and need for life-long shoe +/- brace therapy
vs. primary amputation at appropriate level to heal and
what this will mean is mandatory
•Must understand and digest severity of their problem

FACTORS INVOLVED IN DECISION TO AMPUTATE
AND LEVELOFAMPUTATION
Surgeon’s Experience and Institutional Support
•Must be well trained to perform conservative and
surgical options including plastic coverage, tendon
balancing, skeletal reconstruction, amputations and
understand shoe +/- brace requirements for each
•Best performed in medical center/university with
smooth multi-disciplinary team environment
VS

SUMMARY - FACTORS INVOLVED IN
DECISION FOR AMPUTATION AND
THE LEVEL OF AMPUTATION
Very Complex Decision (team decision)
 Vascular Inflow
 Soft-Tissue Envelope – necrotizing infections
 Skeletal Deformities
 Sensation
 Soft Tissue Contractures
 Rehabilitation Potential
 Functional Level
 Patient’s Choice
 Surgeons Experience

Major Amputations - Indications
After carefully weighing the factors, a
major amputation or certainly a limb
preserving foot amputation may lead to
maximal functional preservation and/or
functional restoration in select individuals.
The main goal is functional preservation
and not necessarily tissue preservation.

YOU CHOOSE THE
TIMING and
POTENTIALLY THE
OUTCOME
(AVOIDING THE CHOP - CHOP)

Avoiding Ascending Sequential Failure
(Chop –Chop)
WEEK 76
THIS FOOT WAS INITIALLY SALVAGED
HOWEVER, WAS NEVER FUNCTIONAL!
(PLAGUED WITH RECURRENT
Could multiple operations
ULCERATION AND INFECTION)
have been prevented – 76 weeks
Would a well-planned and executed balanced
TMAmorbidity
of have been successful; thus, limiting
the patient to a single operation, avoiding
recurrent ulcerations and infections and
even preventingWEEK 60 Amputation
WEEK 0 WEEK 22
WEEK 48
a BK 72
WEEK
WEEK 76
WEEK 3

FINAL THOUGHTS
Decision to amputate is VERY COMPLEX
Conservative therapy is not appropriate for
every patient OR every wound; Beware of the
chronic wound in the patient with diabetes
Whittling the patient away is demoralizing,
costly, and makes subsequent partial foot
amputation more difficult [“Glass Foot”]
Functional limb preservation requires a multi-
disciplinary team with appropriate training.
May require referral to a Limb Preservation
Center

FINAL THOUGHTS
Diabetic Foot Ulcers
Chronic Wound in the diabetic foot
– If failing to heal, the problem is probably not the
dressing, but failure to stop repetitive trauma (altered
biomechanics with inadequate off loading) or lack of
adequate perfusion
– The longer an ulcer is present the more likely it is that
acute infection and/or osteomylitis and/or major
amputation will occur.
– Consideration should be given for an elective limb
sparing amputation to remove the ulceration restore
balance and prevent recurrent ulceration.

FINAL THOUGHTS
In proper situations FUNCTIONAL
LIMB PRESERVATION with a well-
balanced partial foot amputation
through virgin tissues as the index
procedure is frequently the most
humane treatment option and will
provide a durable native foot with better
quality of life compared to a chronic
wound or a prosthetic limb.

THANK YOU !
Mt. Rainier at Sunset