Saving limbs and improving lives: The Center for Limb Salvage

Keeping our feet strong and healthy is an important goal for us all. For people with diabetes, good foot health is even more important. That’s because people with diabetes are at an increased risk for developing problems with their feet. Without the right treatment, diabetic foot problems can lead to serious consequences, including amputation.  

We never want to see patients deal with the loss of a body part. That’s why my colleagues, Dr. Christopher E. Attinger and Dr. John S. Steinberg, work to save patients’ feet as part of our Center for Limb Salvage. I oversee this program in my role as regional chief of MedStar Plastic Surgery.  

Diabetes and its risk to the feet

Diabetes affects the body’s ability to process glucose. Glucose is a type of sugar that the body creates from food to fuel the body’s cells.  

If you have diabetes, your body has too much glucose in the bloodstream. These high glucose levels can lead to nerve damage in patients with diabetes. This condition, called diabetic neuropathy, makes it hard or impossible to feel pain in the feet. People who have diabetes are at higher risk for a number of foot conditions or injuries, such as:

  • Bunions, corns and calluses
  • Cuts and sores
  • Ingrown toenails
  • Fungal infections
  • Hammertoes  

Without pain, even small injuries to the foot of someone with diabetes can turn into major issues. Maybe you step on a tack or nail, or your shoe doesn’t fit properly and causes a sore on your toe from rubbing. You don’t feel pain, so you don’t treat it. The injury grows and becomes infected. Diabetes lowers the body’s ability to heal properly, so this infected wound doesn’t get any better. 

Even small injuries to the foot of someone with #diabetes can turn into major issues. via @MedStarWHC

By the time patients notice these sorts of wounds, they’ve often developed into a foot ulcer. Diabetic foot ulcers can involve:

  • Ascending infection, or an infection that spreads up the leg
  • Exposed bone or tendon from the wound
  • Gangrene, or the death of skin and tissue  

Request an appointment with one of our doctors if you have diabetes and you’ve noticed any of these symptoms of diabetic foot ulcers.

Amputation: The worst-case scenario for diabetic foot problems

The average surgeon who sees a patient with a bad diabetic foot ulcer will immediately begin thinking about amputation. Depending on how far the patient’s infection has spread, amputation could involve:

  • A portion of the foot
  • The entire foot
  • The foot plus part of the leg  

Diabetic foot ulcers frequently lead to what’s called a below-knee amputation (also known as a transtibial amputation). A below-knee amputation involves removing the leg at some point along the tibia, one of the two bones that run from the knee to the ankle. This can be a devastating loss for patients. With the loss of that much of the leg, patients have to work much harder to do what they were able to do before their amputation—expending 50 to 125 percent more energy just to maintain their previous activity levels.

In addition, below-knee amputations have been linked with an increased risk of death following the surgery. One study conducted in the Netherlands found that the median survival time after having a below-knee amputation was just 27.8 months—a little more than two years.

Amputation can lead to a sort of vicious cycle for patients. Because it’s harder to walk after an amputation, patients often are less mobile afterward. This can increase the risk of more infections, which can lead to more amputations. More amputations can lead to different prostheses as more of the leg is removed, which can make it harder to walk. It’s a painful series of events we try to avoid for our patients.

How we save diabetic feet

We try to avoid these sorts of problems through limb salvage, or treating diabetic foot ulcers before amputation is necessary. Dr. Attinger and Dr. Steinberg are internationally known experts in the area of limb salvage. More than 1,000 patients per year benefit from their expertise. The Center for Limb Salvage brings together a team of doctors from a variety of medical disciplines, including:

  • Diabetology, or the study of diabetes
  • Plastic surgery 
  • Podiatric (foot) surgery
  • Radiology, or medical imaging
  • Rheumatology, or the study of problems affecting the joints, muscles and bones, as well as the immune system
  • Vascular surgery  

The best case is when we can treat foot problems before surgery is needed. We use a number of advanced treatments to make this possible, including:

  • Braces or orthotics, which can help protect and support the foot and leg
  • Gait evaluation, or a specialized analysis of a patient’s walking pattern to correct problems
  • Hyperbaric oxygen therapy, which can stimulate the body’s natural healing processes

If surgery is needed, we can transplant tissue from other areas of the body to save a patient’s toe, heel, hindfoot or the entire foot. In other words, we can save patients’ feet when other surgeons can’t. This requires advanced microsurgical skill to remove dead or diseased tissue while preserving as much healthy tissue as possible. If tissue transplants aren’t possible, we may be able to use skin substitutes temporarily or permanently to correct wounds. We also may be able to improve blood flow to the foot with vascular surgery, which can promote healing.  

The benefits of limb salvage

Saving the foot increases mobility, which leads to a higher quality of life. When it’s not as hard to walk, you’re much more likely to be active and fit. This means limb salvage can help patients be healthier and live longer.  

On top of all that, limb salvage tends to be less expensive than amputation over the long run. If we can save your foot with one or two surgeries, that’s the end of the surgical process. But if we have to amputate, it tends to start that vicious cycle of developing more infections and needing more amputations. The costs of amputations—in terms of both money and quality of life—can be crushing to patients.  

No one wants a patient to go through the pain and difficulty of an amputation. I’m hopeful that our limb salvage expertise will help more patients stay mobile, active and healthy.  

Summer: Taking a toll on your soles?

It’s August—the height of summer—and many of us are taking advantage of the longer days to cram in more outdoor activities. For many, it just seems easier, and definitely more enjoyable, to go for an early morning run when it’s already light outside versus the dark days of winter.

But that increased activity also increases the risk of foot and ankle injuries, particularly among weekend warriors.

Aching Ankles

Sprains, which can vary widely in severity, are among the most common foot and ankle injuries. For minor problems, time-honored home remedies like icing, elevating, resting the foot and over-the-counter (OTC) anti-inflammatories are often all that’s needed. But if you don’t notice much relief after a few days of self-care, you should seek a professional opinion from a podiatrist, a doctor who specializes in foot and ankle care.

It may be that you need an ankle brace to support and protect the ligaments that were stretched or torn during the injury. More severe sprains may require a device called a CAM boot—basically a walking cast that relieves the ankle from bearing weight while it heals.

The good news is that most sprained ankles will getter better in a month or two.

Sometimes, however, what first seems like a badly sprained ankle may actually be a broken metatarsal—one of the long bones in the middle of the foot. Because the symptoms of a break, especially a Jones’ Fracture, and a sprain can be so similar, some fractures don’t get the early medical attention they may need, including surgery.

Individuals with chronic lateral ankle instability may also benefit from surgery to repair the damaged ligaments and return to a more active lifestyle. The condition is the result of cumulative injuries to the ligaments from frequent sprains, mostly due to overuse. That leaves the ankle more susceptible to chronic swelling, pain, tenderness and weakness, leading to even more sprains in the future.

Healing Sore Heels

Another quite common injury is plantar fasciitis, which occurs when you strain the ligament that connects the heel bone to the metatarsals. In 95 to 99 percent of people, it goes away with simple, conservative treatment like stretching, OTC inserts and physical therapy. If such steps don’t provide relief, however, I’m a big proponent of a promising new treatment called PRP.

PRP, or platelet-rich plasma injections, can often decrease or completely eliminate the pain of plantar fasciitis and other conditions, contributing to a speedier recovery. In the 30-minute procedure, some blood is withdrawn from the patient and then placed in a centrifuge to separate out the platelets, the component that helps with clotting, healing and tissue growth. Then the platelet-rich plasma—now containing three to five times more growth factors than normal— is injected into the affected area.

Most patients can get back on their feet within a few days and can resume regular activity within a month.

If the Shoe Fits…

Feet are the foundation of your fitness. If they’re in pain or stressed, you can’t do much of anything. But properly supported, your feet can conquer miles in comfort.

That’s where the right shoes come in to play. And it’s tricky. Some lucky people are born with a perfectly normal foot; however most of us need some sort of assistance to help achieve the right mechanical balance. For instance, a bunion, flat foot or a really high arch can put extra strain on different tendons and ligaments, leading to arthritis, pain and degeneration.

But finding that sweet spot is a matter of trial and error. Sneakers that I regularly recommend to my patients don’t work at all for my wide, highly-arched feet. You need to take time to find that brand and style that is going to be the best fit for your foot’s particular structure.

Orthotics can also help. I typically recommend that patients first try out an OTC support with a rigid sole, something like a piece of plastic, to see if that helps. In some cases, that may be all the arch support they need, while others may benefit more from a custom-made orthotic. Just be sure to avoid inserts that you can bend in half, which provide cushioning versus support.

The bottom line: Enjoy your summer activities, but don’t beat up your feet in the process. And always see a doctor in the event of any significant swelling, bruising or pain.

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