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The Role of Technology in Managing Vascular Wounds 35
Amputations in the Ischemic Limb
The risk of amputation for patients with CLI is affected by many factors. Geographical factors with respect to medical resources available also play a role. Some
studies show a 1-year limb loss rate of 20%, and even higher if the patient also has
diabetes simultaneously (Rooke et al. 2011; Liew et al. 2011). Ischemic pain alone
can be an indication for amputation.
Arterial ulcers are commonly situated on the toes. However, simple toe amputations are usually not feasible due to poor microcirculation. It is generally accepted
that it is contraindicated to try to amputate a toe when the ABI is >0.5 or a toe
pressure <30–40 mmHg. Presently, there is also use the concept of angiosomes–
that is, having a low toe pressure in the greater toe does not necessarily mean that
the circulation of the little toe is equally impaired as this is supplied by a different
artery (Carabott et al. 2021).
Nonetheless, before any amputation is considered, whether it is at toe-level or a
major amputation, a vascular assessment should always be done prior to this and
whenever possible a revascularization should be performed prior to any amputation
attempt.
Following a successful revascularization, it is typical to see a reactive hyperperfusion and often significantly increased edema. It is essential to let this edema
subside before an amputation is attempted. This usually happens over two–three
weeks following revascularization.
Even when a successful revascularization has been done, the result of isolated
toe amputations are usually very disappointing and the complications can lead to a
premature amputation at a higher level. Minor amputations have high rates of
complications such as non-hea ling and reported re-amputation rates of 20%–60%.
The reason for this is that even though larger arteries in the leg may have become
revascularized, the micro perfusion of the toes may still be poor.
It is considered mandatory to measure the TBP before attempting a toe amputation. In a recent study the minimal TBP threshold for healing in diabetic patients
was higher than that for nondiabetic patients. The minimum TBP for the diabetic
patients was 65 mm Hg and for the nondiabetic patients was 45 mmHg (Stafford
et al. 2021). However, a syst ematic review from 2020 showed that healing occurred
in diabetic patients at TBP >30 mmHg (Linton et al. 2020), so to date we have no
clear agreement as to which TBP is a safe threshold for attempting a minor
amputations.
If a toe amputation is attempted in a patient with severe ischemic disease, the
tissues must be handled with extreme care, trying to preserve as much of the tiny
blood vessels as possible. We never do this in a toe block anesthesia—the needle
can accidentally puncture a digital artery and the pressure from the local anesthesia
can cause irreversible ischemia. Instead, regional, spinal or general anesthesia
should be offered. As a limb-sparing procedure in cases with severe infection/sepsis
we sometimes perform a minor amputation in two sessions. In these cases, it may be
safer to do a guillotine type amputation, let the tissues calm down under concomitant antibiotic therapy and then assess the choices for the final amputation. The
36 B. E. Günther and R. Mani
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statements in this paragraph represent the author’s own expert opinion: presently no
data has been found that either complement or contradict these practices.
Major amputation (above the ankle) in patients with CLTI is recommended
when there is overwhelming infection that threatens the patient’s life, rest pain
cannot be controlled and there is extensive tissue loss (Norgren et al. 2007; Kayssi
et al. 2016). Amputation should be considered for a patient with significant necrosis
on the weight-bearing portions of the foot, or very limited life expectancy as a result
of comorbidities (Rooke et al. 2011; Hirsch et al. 2006).
Discussion
The diagnosis and management of venous and ischaemic leg ulcers benefit from
appropriate use of technology for both diagnosis and manag ement. Can wound
healing be accelerated? The beneficial effects of adjuvant treatments to accelerate
healing of lower extremity wounds, discussed in other chapters in this book, are
clear, and based on good evidence. Healing rates per se, continue to challenge and it
is time to think about combined therapy.
Prevention of such wounds needs to be addressed; this applies to VLU and ILU.
Current guidelines could be more valuable by considering wider populations such
as in low to middle income group countries. The Cochrane Wounds Group research
has offered a sound platform of reliable data from systematic reviews and
meta-analysis. During Covid-19 many patients with chronic wounds were managed
using video communications: clinical research was also more collaborative. This
sounds like a meaningful platform for development.
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The Diabetic Foot, Its Complications,
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Role of Technology in Evidence-Based
Management
Danielle Dixon and Michael Edmond s
Abstract
This chapter describes the usefulness of technology and evidence to aid the
diagnosis and management of the diabetic neuropathic foot ulcer. Technolog ical
advances have been made in the diagnosis and assessment of neuropathy, which
successfully permit the prediction of ulcers but not as yet, the prevention of
ulcers. Elevated foot pressure is an important risk factor for foot ulceration. Foot
skin temperature monitoring has permitted the early diagnosis of skin breakdown
and prevented a first or a recurrent foot ulcer in high-risk patients. Point-of-care
fluorescence imaging has aided the characterisation of infection and ulcer
healing rates have been improved. Technological advances which accelerate
healing of ulcers comprise innovative technologies in wound debridement,
wound applications, and cellular and molecular therapies, including gene therapy
and nanotechnology. Advances in the measurement of plantar pressure have
facilitated the offloading of the neuropathic ulcer and the development of
footwear which can reduce the risk of ulcer recurrence. The need for
co-ordination of treatment between community and hospital care in the Covid
19 pandemic, with the community undertaking the majority of the burden,
facilitated the development of mobile apps that encrypted messages and
photographs with patient sensitive data and thus promoted rapid communication
between health care professionals. Whilst the treatment of ulcers and thus the
D. Dixon (&) M. Edmonds
Diabetic Foot Clinic, King’s College NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
e-mail: Danielle.alicia@doctors.org.uk; danielle.dixon@nhs.net
D. Dixon
Princess Royal University Hospital Farnborough, London, UK
R. Mani (ed.), Chronic Wound Management,
https://doi.org/10.1007/978-3-031-26110-7_3
45© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
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