The goal of a limb preservation center (LPC) is to prevent amputations and improve quality of life. LPCs can be free-standing entities, be a part of a hospital, be a part of a practice, or be centered around an office-based lab (OBL) or an ambulatory Surgery Center (ASC). It is logical for the LPC to be centered around an OBL/ASC and wound care center, since most of the procedures required for limb preservation can be performed in the OBL/ASC and wound care center.
The most common causes of limb loss are diabetic complications such as Peripheral Artery Disease (PAD), ischemia with or without infection, followed by osteomyelitis, trauma, venous disease and other minor causes like frostbite, tumor etc. Optimal care can only be realized using a comprehensive, multidisciplinary approach.
Primary Care: It is important to make sure that the patient’s risk factors are managed. Since the most common cause of non-traumatic limb loss is related to PAD and diabetes-related complications, it is crucial that the center works with the primary care physician to achieve optimum management of diabetes and other risk factors like hypercholesterolemia, hypertension, and smoking cessation. Patients with venous disease should have appropriate medical management.
Podiatrists: Podiatrists should be an integral part of the limb preservation team since they may be the first ones to see patients with foot ulcers and also be involved in wound care centers. There are several studies demonstrating the benefits of a podiatrist in this role. Podiatrists play a very important part in preventing ulcers by using offloading techniques and improving overall care of the foot. Podiatrists who specialize in surgical care of the foot can perform foot-sparing amputations, complex debridement, and correct foot deformities.
Interventionalists: Intervention may be carried out by a vascular surgeon, interventional cardiologist, or interventional radiologist. Endovascular intervention consists of balloon angioplasty, stent placement and atherectomy when indicated. For managing venous disease, the interventionalist should be able to carry out vein ablation for venous reflex in superficial veins and angioplasty and stent placement in managing deep venous obstruction.
Vascular surgeons: Endovascular treatment is gradually becoming the first line of therapy for peripherally arterial occlusive disease. However, there will be failure of endovascular therapy necessitating bypass surgery. In certain patients a bypass may be the first option. Vascular surgeons also manage the complications of endovascular procedures.
Infectious disease specialists: Many patients present with complicated wound infections, especially diabetic ulcers. The treatment may need inpatient or outpatient antibiotic therapy. For long term outpatient intravenous therapy, a peripherally inserted central catheter can be placed in the OBL/ASC.
Nephrologists: Patients with end-stage renal disease have a higher incidence of PAD and less favorable outcomes after intervention. Nephrologists play an integral part in managing kidney disease as well as hypertension.
Cardiologists: Cardiologists can help optimize the cardiac function, thereby improving peripheral perfusion. For the patient to be in a supervised exercise program it is important to maximize the cardiac function so that the patient can meet the exercise goals. Management of congestive heart failure is critical to healing a wound since edema causes a decrease in microcirculation and clearance of bacteria from the wound.
Neurologists: Many patients with Diabetes have peripheral neuropathy that can be best managed by neurologists which may help diminish the incidence of neuropathic diabetic ulcers.
Rheumatologists: Many patients with vasculitis and rheumatoid arthritis associated ulcers will benefit from the care provided by a rheumatologist.
Orthopedic surgeons: Orthopedic surgeons and podiatrists should work together to offer all the surgical options that can be used to save a limb.
Plastic surgeons: Plastic surgeons, though needed sparingly, can perform complex debridement and various flaps to cover defects in the foot.
Wound Clinics: Many patients experience limb loss due to a lack of care management around diabetic ulcers; with or without underlying arterial occlusive disease. Wound management is critical to saving limbs. In a wound clinic the wound can be appropriately assessed and managed. Hyperbaric oxygen therapy has been successfully used in the treatment of non-healing diabetic and radiation ulcers. Vacuum assisted closure has been used successfully to close large wounds.
Vascular Noninvasive Lab: A noninvasive vascular lab is an important part of the center. The lab should have the capability to perform ultrasound imaging and physiological studies.
Office Based Labs/ASCs: Key to limb preservation is quick access to the endovascular suite. Office based labs/ASCs are patient-friendly, safe and efficient. Patient satisfaction runs above 95%. Care is often less expensive than the hospital and the clinical outcomes are equivalent. An efficient OBL/ASC can provide care in a timely manner.
Community outreach: The participants in the LPC should seek opportunities to participate in community activities to increase patient awareness. This can be done by participating in health fairs, vascular screening sessions and other community outlets using print audio visual and digital media.
A significant number of patients undergoing major amputations never have their vascular status checked prior to an amputation. We could prevent a lot of unnecessary amputations by having a multidisciplinary approach in treating patients with diabetic ulcers and other limb threatening conditions. Limb preservation centers provide comprehensive management of these patients.
Vascular Screening: I’ve found that screening for diabetes-related complications such as PAD is one of the key factors that enable optimal care through this model. I particularly like the Biomedix products like PADnet and PADnet Xpress, because they have a technology platform that enables community-based collaborative care. I recommend all patients presenting with underlying risk factors be screened for PAD.
About the Author:
Dr Krishna Jain is a vascular surgeon who has been intimately involved in the growth of office-based endovascular centers throughout the country since 2007. He is the past president of Advanced Vascular Surgery and Paragon Health. He is a founding member of the Outpatient Endovascular and Interventional Society and South Asian American Vascular Society (SAAVS) and served as its first president. He is a distinguished fellow of the Society for Vascular Surgery (SVS), and the recipient of Excellence in Community Service award given by the SVS. He is also a clinical professor of Surgery at Western Michigan University, Homer Stryker MD school of Medicine, and the author of multiple scientific papers and book chapters. He is the CEO of National Surgical Ventures LLC, the founder of Limb Preservation Centers of America and the Chief Medical Officer for Amputation Prevention Experts Healthcare Network LLC.
Ready to learn more? Watch a webinar hosted by Dr. Krishna Jain and Dr. Lee Rogers on September 27th at 7 PM CST. Register here: https://bit.ly/3qQDTyO.