A Multidisciplinary Approach to Limb Salvage and Amputation Prevention

Purpose: Peripheral arterial disease and infection have a significant impact on healing rates in diabetic foot infections and are the leading causes of lower-leg amputations in patients with diabetes. When aggressive surgical management is emphasized, a reduction in major amputations, length of stay, and cost of care are reported. This case report highlights the collaboration between multiple specialties in prevention of major amputation in a high-risk patient.Case Study: A 48-year-old male with a history of diabetes mellitus, hypertension, hyperlipidemia, alcohol and substance abuse, and 30 pack-year smoking history initially presented to the emergency department with foot pain and an abrasion to the left second toe. An arterial ultrasound showed likely acute on chronic short segment occlusion of the distal SFA. Thrombolysis was performed. Hematologic consultation and workup to investigate his self-reported family history of thrombosis revealed a heterozygous prothrombin gene mutation. He was discharged with Warfarin but was noncompliant. He presented again four months later with worsening leg pain and was found to again have again occlusion of the distal SFA. He was discharged on warfarin and informed of the risk of limb loss. He then presented to the ED about a week after noninvasive testing with worsening of a left second toe wound for several weeks as well as subjective fevers. Radiographs and MRI showed osteomyelitis at the distal phalanx. A CTA performed revealed occlusion of the left proximal SFA with reconstitution of the popliteal artery distal to the stent. He underwent a common femoral artery to posterior tibial artery reverse ipsilateral great saphenous vein bypass with restoration of a palpable posterior tibial pulse postoperatively. He then underwent left second toe partial amputation. The amputation site healed after follow-ups at the wound care center.Analysis & Discussions: This case displays the importance of a multidisciplinary approach to limb salvage including involvement of vascular surgery, podiatric surgery, infectious disease, hematology, and internal medicine and interventional radiology. With a multidisciplinary approach and lower extremity bypass, the left limb was revascularized and the patient was able to avoid major amputation with continued outpatient podiatric care following his partial second toe amputation.