What exactly does limb salvage mean?

[iceman69]

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I'm trying to figure out what limb salvage means in the context of podiatry. I have found that there is a trauma route, and a diabetic route. For those of you in the know, can you please tell me what you know about this aspect of podiatry. Thanks a lot.

 

[Dr_Feelgood]

I'm trying to figure out what limb salvage means in the context of podiatry. I have found that there is a trauma route, and a diabetic route. For those of you in the know, can you please tell me what you know about this aspect of podiatry. Thanks a lot.

Limb salavage is just what it sounds like, saving a patient's leg. I'm working with a group of top pods that do a lot of limb salvage.

Diabetes is the easy and more common form. We had a lady from Idaho fly to Des Moines b/c they told her that they need to amputate both feet due to chronic ulcers and Charcot arthropathy. The doctors reconstructed both feet and the last we heard she is doing great. She will be able to stand and walk very soon.

A traumatic case involves a patient that had massive necrosis due to a rare pathology called purpura fulminans. She had an exposed calcaneus and wanted to keep her legs. She consulted the doctors to see what they could do, but I am unsure if she has decided on how she would like to proceed.

 

[iceman69]

How can one get involved in these types of cases in private practice? That stuff sounds like it would be interesting and challenging to work on.

 

[Feli]

How can one get involved in these types of cases in private practice? That stuff sounds like it would be interesting and challenging to work on.

Most of your limb salvage patients are inpatients. A lot of them have an infected ulcer, are at high risk for ulcer, are on IV meds, or are in fairly urgent need of surgery (usually I&D, revascularization, reconstruction, or amp). You don't have to be full-time or have a clinic at the hospital to do limb salvage, but you would probably have to visit your patients in hospitals a fair amount (and be on call for new patients) if you want to focus on this arena. You could certainly do some of the follow-up on an outpatient basis... prosthesis and shoe fittings, post-ulcer site inspections, wound care after the limb-threatening insult or infection is tamed, etc.

A limb salvage team is more common in a big academic hospital and might consist of internist, vascular, podiatrist, infectious disease, endocrinologist, pedorthist, interventional radiologist, etc. You will see a fair amount of wound care and limb salvage in VA and community hospital settings also, but you might not have as many different specialists available.

A pretty good intro book is "Clinical Care of the Diabetic Foot" by Armstrong and Lavery. It's written in fairly simple terms that any pod student - and probably anyone who has had cell bio and a fundamental understanding of diabetes - can understand, but there is a still lot of good info.

 

[Dr_Feelgood]

Most of your limb salvage patients are inpatients. A lot of them have an infected ulcer, are at high risk for ulcer, are on IV meds, or are in fairly urgent need of surgery (usually I&D, revascularization, reconstruction, or amp). You don't have to be full-time or have a clinic at the hospital to do limb salvage, but you would probably have to visit your patients in hospitals a fair amount (and be on call for new patients) if you want to focus on this arena. You could certainly do some of the follow-up on an outpatient basis... prosthesis and shoe fittings, post-ulcer site inspections, wound care after the limb-threatening insult or infection is tamed, etc.

A limb salvage team is more common in a big academic hospital and might consist of internist, vascular, podiatrist, infectious disease, endocrinologist, pedorthist, interventional radiologist, etc. You will see a fair amount of wound care and limb salvage in VA and community hospital settings also, but you might not have as many different specialists available.

A pretty good intro book is "Clinical Care of the Diabetic Foot" by Armstrong and Lavery. It's written in fairly simple terms that any pod student - and probably anyone who has had cell bio and a fundamental understanding of diabetes - can understand, but there is a still lot of good info.

I'm sorry to say I disagree. Limb salvage is very alive in private practices. Any patient with a history of chronic ulcer would be consider limb salvage, with or without infection. There are definitely acute limb salvage patients but I would say that the majority are dealt with on an out-patient basis. They are told that they need a BKA b/c of X, Y, and Z. They seek out a second opinion on the topic.

Being involved with wound care and diabetes is the easiest way to get involved. For traumatic or acute limb salvage, you need a strong reputation or to be in a hospital setting.

 

[Feli]

I'm sorry to say I disagree. Limb salvage is very alive in private practices. Any patient with a history of chronic ulcer would be consider limb salvage, with or without infection. There are definitely acute limb salvage patients but I would say that the majority are dealt with on an out-patient basis...

No offense taken. I think much of it could depend on where you are practicing. If you're in a setting with compliant and insured patients who have reasonable income and transportation, then you are definitely right that they can be managed outpatient. I guess I was talking more about acute limb salvage, and you are certainly right that many chronic or post-op patients are still technically limb salvage.

I think that acute cases are actually what I've seen more of down here. What comes to my mind is the trainwreck cases that present to the ED (or office patients that are sent for immediate admission). I've seen a fair share of folks with low socioeconomic status who are presenting with an acute purulent wound and N/F/C after missing many appointments... or as a totally new patients without any history whatsoever (and often little ability to speak or understand English). It's probably more common here since many patients are under- or uninsured and living in poverty. It's unfortunate but true that I've actually seen as many or more of those tough inpatient limb salvage cases than the simple, compliant return patient for an office shoe fitting or debridement of a 1cm UT 1A.

Last week, I saw a couple surgeries on a woman flown here from a Carib country for treatment. She had an I&D and transmet amp. She will probably stay in the hospital for the delayed primary closure and then another week before being sent on her way with oral Abx and maybe a cam walker (if she can afford it?). It sounds pessimistic, but good luck on ever seeing her again until next time she presents to the ED with another wound... or maybe even suture abcess in a couple months since she missed her appointment for removal. 🙁

 

[Dr_Feelgood]

No offense taken. I think much of it could depend on where you are practicing. If you're in a setting with compliant and insured patients who have reasonable income and transportation, then you are definitely right that they can be managed outpatient. I guess I was talking more about acute limb salvage, and you are certainly right that many chronic or post-op patients are still technically limb salvage.

I think that acute cases are actually what I've seen more of down here. What comes to my mind is the trainwreck cases that present to the ED (or office patients that are sent for immediate admission). I've seen a fair share of folks with low socioeconomic status who are presenting with an acute purulent wound and N/F/C after missing many appointments... or as a totally new patients without any history whatsoever (and often little ability to speak or understand English). It's probably more common here since many patients are under- or uninsured and living in poverty. It's unfortunate but true that I've actually seen as many or more of those tough inpatient limb salvage cases than the simple, compliant return patient for an office shoe fitting or debridement of a 1cm UT 1A.

Last week, I saw a couple surgeries on a woman flown here from a Carib country for treatment. She had an I&D and transmet amp. She will probably stay in the hospital for the delayed primary closure and then another week before being sent on her way with oral Abx and maybe a cam walker (if she can afford it?). It sounds pessimistic, but good luck on ever seeing her again until next time she presents to the ED with another wound... or maybe even suture abcess in a couple months since she missed her appointment for removal. 🙁

I agree that it is regional. We have limb salvage consults everyday. While we work in a hospital it is still a private practice setting. We have had some crazy ones too, like people from Third World countries that have been attacked or in car wrecks or had previous surgery in their homeland. My favorite is a lady that had to run away on a broken ankle to get away from armed rebels.

 

[itinalaga]

check this link out, it may be somewhat helpful.
http://www.youtube.com/watch?v=60liuVqxzl4

 

[Dr_Feelgood]

Nice clip. I love the shout out to Barry. My only thought is they mention hyperbaric therapy. How many pod students or active pods have first hand experience with hyperbarics? And I don't know of a school that has the money for a hyperbaric chamber.

 

[Stafocker]

Nice clip. I love the shout out to Barry. My only thought is they mention hyperbaric therapy. How many pod students or active pods have first hand experience with hyperbarics? And I don't know of a school that has the money for a hyperbaric chamber.

Two of my attendings works at a huge wound center in pittsburgh, and really only a few places can afford to have them because insurance companies are crap. The studies supporting the use of HBO are usually found in the Vascular Surgery journals (the wound center is run by a VS) so they would know the insurance game better. I've seen a lot of clinical evidence of HBO's abilities to enhance wound healing, but i'm not sure about the cost-to-benefit ratio.

 

[Dr. Agape]

check this link out, it may be somewhat helpful.
http://www.youtube.com/watch?v=60liuVqxzl4

Great clip!