We did Everything to Save that Leg

COVER STORY

We Did

Everything

To Save That Leg

Professionals from across the health-care spectrum share their thoughts on gait salvage and amputation decisions

Health-care professionals involved in amputation decisions

must take a number of factors into account in determining when and how to proceed. There has been much discussion over the years regarding when it’s appropriate to pursue limb salvage versus when a patient will benefit from amputation, which may lead to gait salvage. Perhaps the most important part of the decision process involves ensuring all individuals on the health-care team and their patients are fully educated about amputation, rehabilitation, and prosthetic advancements.

O&P News asked five experts on this topic—Michael Dillon, PhD, BPO (Hons); Stefania Fatone, PhD, BPO (Hons); Grace Wang, MD, FACS; Eric Burns, CO; and Mallory Lemons, CPO—to weigh in with their expertise and insights on this important subject.

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Shared Decision Making Michael Dillon, PhD, BPO (Hons) La Trobe University’s National Centre for Prosthetics and Orthotics, Victoria, Australia; and Stefania Fatone, PhD, BPO (Hons), Northwestern University, Chicago, Illinois

Decisions about amputation surgery are always difficult. Often these decisions come at the end of a protracted period of ill health, where regular visits to wound care or high-risk foot clinics often occur in parallel with treatments for other health conditions such as diabetes or kidney disease. Unfortunately, at some stage, when the recalcitrant foot ulcer just won’t heal, or the foot is black and gangrenous, amputation is an inevitable next step.

In our interviews with people about their experience of partial foot amputation, this is a familiar tale. Some people describe being in this “limbo-land” for months or even years in extreme cases, with their lives put on hold. Given this intense exposure to the health-care system, we have been surprised by how poorly informed many people seem; it is as if people had never considered the prospect of amputation, or the likelihood of wound failure and amputation had never been discussed as a possible event someday down the road. As a result, many people describe being blindsided when the discussion turns to amputation surgery.

Of course, there are lessons to be learned from these experiences. Having interviewed people at the end of this journey, often years after living with an amputation, many wished they had had the opportunity to engage in meaningful discussions about the path ahead, even if the likely outcome couldn’t be predicted exactly. In other areas of health care, such as cancer treatment, research shows that just knowing what the path ahead might look like can help people prepare for the inevitable hiccups along the way, irrespective of the outcome. Participants

A decision aid for people facing partial foot amputation due to peripheral arterial disease

Authors:

Michael Dillon, PhD, BPO (Hons)1 Stefania Fatone, PhD, BPO (Hons)2 Matthew Quigley, MCPO (Hons)1

Graphic design: Jake Eadie, MCPO, BHS, BID (Hons)

SAMPLE

1. Discipline of Prosthetics and Orthotics, College of Science, Health and Engineering, La Trobe University, Australia, 3086 2. Northwestern University Prosthetics-Orthotics Center, Feinberg School of Medicine, 680 N Lake Shore Drive, Suite 1100, Chicago, IL 60611

// 015

in our research have suggested that conversations with health professionals could be supplemented by written material, given that many of the narcotics used to help manage pain make people fuzzy-headed and concentration difficult. People have suggested that these written materials might include facts about the risks of complication, pain, mobility, or quality of life, as examples. Many people lamented the burden of

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2/3 reduced mobility compared to before illness and amputation

Michael Dillon, PhD, BPO (Hons) and Stefania Fatone, PhD, BPO (Hons), are co-authors of “A Decision Aid for People Facing Partial Amputation Due to Peripheral Arterial Disease,” along with Matthew Quigley, MCPO (Hons).

being in-and-out of the hospital and the time they lost. In hindsight, many wished they had made the decision to amputate earlier. However, one of the barriers to making this decision earlier was often a lack of knowledge about what life would be like living with an amputation. Typically, it was chance encounters in hospital waiting rooms with others already living with amputation that helped inform their decisions.

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It is these insights from the lived experience that have shaped our belief that shared decision making is one of the best ways we can help inform people about these types of difficult health-care decisions.

Shared decision making is a collaborative process designed to empower patients to take an active role in decisions about their health care. Clinicians can facilitate the process by encouraging participation in decision making, providing accurate information about the different treatment options, and supporting patients to reflect and deliberate on the difficult decisions they have to make. The process can be supported by resources such as decision aids that present information about the different treatment options and facts about the likely outcomes and risks in a way that helps people understand.

While the concept of shared decision making may be new to many, it is well established in other areas of health care, such as cancer treatment. In these areas, shared decision making has been shown to help clinicians and patients engage in meaningful conversations that, in turn, support patients in taking an active part in decisions about their health care. There is good evidence that patients become more knowledgeable about the different treatment options, can accurately perceive the risks and benefits of different treatment options, and, as a result, are more satisfied with the health care they receive and have less regret about the decisions they make.

It is important to reiterate that decisions

about amputation surgery are inherently difficult. All we can do as clinicians is ensure that patients have access to accurate and unbiased information about all the treatment options, engage in meaningful conversations, and are well

“Shared decision making is a collaborative process designed to empower patients to take an active role in decisions about their health care.”

Michael Dillon, PhD, BPO (Hons)

supported as they grapple with the difficult decision. In this way, we can help ensure that people make a well-informed decision about their health care, irrespective of the path they choose.

Multidisciplinary Intervention Grace Wang, MD, FACS (Vascular Surgeon), University of Pennsylvania, Philadelphia, Pennsylvania

Compounding the issue is the complexity of the disease process itself. Foot wounds are often the result of peripheral arterial disease (PAD), a condition characterized by narrowings in the blood vessels in the leg that lead to decreased circulation of the foot. The causes of PAD are multifactorial, with diabetes, end-stage renal disease, hypercholesterolemia, and smoking acting as significant risk factors for this disease.

The presence of a foot wound usually indicates multilevel, severe PAD, and consultation with a vascular surgeon or interventionalist is critical to ensure that the blood flow is optimized to ensure that the wound can heal and infectious processes can be resolved. Debridement may take place afterwards with a podiatrist to effectively drain abscesses or remove infected toes. Following revascularization and further surgical procedures, it is also critical that medical management of comorbidities takes place, as glucose

control plays a role in wound healing, and smoking cessation has been shown to increase the patency rate after surgical bypass or interventions. This highlights the need for a multidisciplinary team (endocrinologist, medicine, smoking cessation specialist) to effectively address all aspects of the care of a patient with a foot wound.

In the event that revascularization is not possible, due to a lack of conduit for bypass, a lack of distal targets, or an unsuccessful endovascular intervention, primary amputation may be considered. Here, it is important that the patient understands that there are no revascularization options and amputation is likely. Having discussions with family present, and sometimes with the help of a palliative care or geriatrics consult, can be helpful, to establish goals of care in this situation. The process of dealing with the end stages of PAD is challenging and can involve multiple meetings as the patient’s plan is formulated.

Maintaining Patients’ Mobility Eric Burns, CO Hanger Clinic, Tucson, Arizona

Diabetic and vascular disease patients are some of the largest populations seen in pedorthics, orthotics, and prosthetics. The numbers have risen to epidemic proportions. Concurrently, this group has undesirable outcomes, with mortality rates rivaling many cancers after above-ankle amputations. O&P can make a significant impact to these patients by making safe mobility a priority at every visit.

These patients are often in a constant state of decay and declining overall health. Loss of mobility parallels their loss of independence, stability, cardiovascular health, quality of life, balance, social isolation leading to depression, inability to heal, increased pain, and mortality rates. At the same time, safe mobility can positively influence all of these factors. Gait speed is a predictor of future health-care costs and longevity. In

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O&P, our contributing role to improved outcomes of this population is the concept of gait salvage.

Diabetes mellitus and vascular patients are life-long O&P patients. We can be the “first responders” to prevention, with pedorthics providing both medical devices (shoes and inserts) and education to change the current outcome trajectory. Educated patients can make behavioral changes to slow and even reverse the advancement of these diseases. As patients progress, orthotists must pick up the baton to provide orthotic devices for wound care and safe ambulation, with safe ambulation defined as stable, reduced peak pressures, reduced shear, protection, and addressing any deformities causing any of the above.

Prosthetists should limit the number of days between amputation and fitting the initial prosthetic fitting via post– operative protectors, postop follow-up, and providing an environment for safe ambulation. All disciplines should work together maximizing active, safe, weight-bearing days between medical interventions.

Gait salvage is simply an added goal. Research is extremely clear that maintaining patients’ mobility will dramatically improve the outcomes of tens of millions of patients. Adding gait salvage as a goal during a patient’s decline, from the initial ulcer to major amputation, will benefit the patient’s overall health, stability, quality of life, and independence.

A patient who is able to walk consistently for 20 minutes a day will reduce their risks of a future ulcer, have reduced pain, suffer less depression, and report a higher quality of life, slowing or reversing the symptoms of this disease. When the health-care community provides a safe platform for these patients to move independently through their environment, their decay can dramatically slow.

Education on the value of mobility at every stage of care will improve outcomes at each corresponding step. It is much easier to maintain mobility and independence than it is to regain. Driving the importance of maintaining gait is a valuable goal for this population, and O&P can make a valuable contribution.

“Adding gait salvage as a goal during a patient’s decline, from the initial ulcer to major amputation, will benefit the patient’s overall health, stability, quality of life, and independence.”

Eric Burns, CO

Functional Outcomes Mallory Lemons, CPO Hanger Clinic, Oros Valley, Arizona

When a patient goes to a doctor or is admitted to the hospital, they want to understand their underlying diagnosis. This includes understanding what they need to do to help lessen their symptoms, and understanding how their diagnosis will affect them and their long-term outcomes. This can be overwhelming even though the patient’s behavior can directly impact their personal results. But often, health-care providers don’t put a strong enough priority on mobility. Focusing on increasing standing and walking time can have a dramatic positive impact on the patient’s overall

health and well-being. Salvaging gait, or maintaining safe mobility during these multiple interventions, will usually have a positive effect. A focus on achieving mobility can have a positive impact on a patient’s physical health and help slow the effects of a sedentary lifestyle.

There are multiple considerations of which a patient, their family, and the health-care provider should be aware. These include the time that the patient will be non-weight-bearing following a below-knee amputation versus a partial foot or limb salvage operation, the amount of rehabilitation needed during the patient’s recovery period, and possible re-hospitalization or revision over the first year, postamputation, that might be needed. All of these factors should be taken into consideration because they can affect a patient’s recovery time, which in turn affects their short- and long-term mobility. After an amputation, patients are encouraged to be non-weight-bearing (at times for multiple months), despite the level of their amputation. These long periods of inactivity have been shown to decrease a patient’s functional capability.

We need to think of any form of amputation in regards of functional outcomes. We need to keep our patients up and mobile, not sedentary and chairbound. Mobility and function essentially save or prolong lives. Recovery from an amputation should not be more bed rest, but should be a step toward functionality.

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