1	Emerging Role of Podiatry in Limb Salvage: The Team Approach Model John S. Steinberg, DPM Assistant Professor, Department of Plastic Surgery Georgetown University School of Medicine
2	Georgetown University Limb Salvage Team Vascular Surgery Plastic Surgery Podiatric Surgery Orthopaedic Surgery Infectious Disease Endocrinology Nephrology Nurse Practitioners Prosthetist / Pedorthotist Physical Therapy
3	Limb Salvage Team Goals of Concept Raise awareness of limb salvage Increase service Diabetics ESRD – pessimism the rule Venous disease Become a referral source for the community Improve financial viability Streamline care > 50% of patients are Medicare Decrease the “steps” required for care Limb salvage is less expensive than amputation
4	Stating the Obvious…?
5	Causes of the ‘Problem’ Wound? Ischemia Infection Nutritional Pressure / Biomechanics Bacterial Burden Loss of Cellular Signaling
6	Etiology of Diabetic Foot Pathology
7	“Amputation as a marker of the quality of foot care in diabetes” Jeffcoat, WJ et al., Diabetologia. 2004 Dec; 47(12):2051-8. High Incidence of Amputation Higher disease prevalence Late referral Limited resources Interventionalist approach by team Low Incidence of Amputation Lower disease prevalence Primary diabetes care Conservative approach by team
8	“Reducing amputation rates in patients with diabetes at a military medical center: the limb preservation service model.” Driver, VR et al. Diabetes Care. 2005 Feb;28(2):248-53. RESULTS: Diabetes increased 48% from 1999 to 2003 LEAs decreased 82% from 1999 to 2003 Amputations of the foot, ankle, and toe comprise 71% of amputations among patients with diabetes
9	Change in the amputation profile in diabetic foot in a tertiary reference center: efficacy of team working. Aksoy et al. Exp Clin Endocrinol Diabetes. 2004 Oct;112(9):526-30. Overall amputation rate was 39.4 % vs. 36.7 % before the team was established Ray amputation (35%) Below-knee amputations (30%) Data suggest that amputation is still a frequently encountered outcome Amputation profile changed to distal The implementation of a diabetic foot care team has relatively decreased the rate of major amputations
10	Case Study: Clinton R. 69 year old African American male Chief Concern: Failing hallux amputation site with gangrene PMH: Diabetes Type 2, CHF, ESRD, PAD, Anemia, Hypercholesterolemia, Cataracts PSH: laser surgery to both eyes Meds: Coreg, silvadene, glyburide, aranesp, renagel, lipitor, lasix
11	Case Study: Clinton R. Problem List: Gangrene Contaminated, non healing wound Poorly controlled DM Severe PAD Worsening CHF with EF 15% Nearing Dialysis Suspected osteomyelitis
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13	Case Study: Clinton R.
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16	Case Study: John K. 70 year old white male Transferred to Georgetown with multiple non healing wounds Right LE. Previously scheduled for BKA. PMH: DM, MI, PAD, Hypothyroidism, HTN PSH: L BKA 2002, R TMA 3 weeks ago, Pacemaker Meds: Protonix, ASA, atenolol, lisinopril, doxazosin, Lopressor, Synthroid, Lasix, Coreg, linezolid, ciprofloxacin.
17	Case Study: John K. Problem List: Poorly Controlled DM Multiple Wound Sites Severe PAD Osteomyelitis MRSA Contralateral Limb Loss
18	Debridement and Revascularization
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22	Charcot Ulceration 52 y/o female Open wound with Charcot, diabetes and osteomyelitis, left midfoot.
23	6 months post-op:
24	Peak Pressure for Ulcers Under the Great Toe
25	Plantar Pressure Assessment
26	Classification System for Diabetic Foot Surgery Class IV - Emergent acute limb salvage Class III - Curative address active pathology Class II - Prophylactic treat risk factors for ulceration Class I - Elective relief of pain
27	Case Study – Surgical Offloading Patient Information: 55 y/o WM Medical History: Diabetes Type 2 x 15 yrs Surgical History: none Wound History: none, but worsening plantar lesions despite shoegear and debridement
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29	Post Op Result
30	Case: JA 40 y/o M Type 1 Diabetes Advanced LE Sensory Neuropathy Semi-rigid cavus foot Chronic ulcers sub 1^st and 5^th metatarsal heads Failed all conservative care. PMH: DM, Sensory and motor neuropathy PSH: none. SH: Real estate investor
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35	Prevention of Recurrence? Patient Education Accommodation of Deformity Recognize Etiology
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38	Conclusions