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Functional
Limb Salvage
The Multidisciplinary
Team Approach
Christopher E. Attinger
John S. Steinberg
Editors
123
Functional Limb Salvage
Christopher E. Attinger
John S. Steinberg
Editors
Functional Limb Salvage
The Multidisciplinary Team
Approach
Editors
Christopher E. Attinger
Department of Plastic Surgery
Georgetown University School of
Medicine and MedStar Georgetown
University Hospital
Washington, DC, USA
John S. Steinberg
Department of Plastic Surgery
Georgetown University School of
Medicine and MedStar Georgetown
University Hospital
Washington, DC, USA
ISBN 978-3-031-27724-5 ISBN 978-3-031-27725-2 (eBook)
https://doi.org/10.1007/978-3-031-27725-2
© Springer Nature Switzerland AG 2023
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
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This Springer imprint is published by the registered company Springer Nature Switzerland AG
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Foreword
Diabetes: TheTwenty-First Century Epidemic
It was a few years ago that I had the honour to share the stage at a large
Diabetes conference in Bangalore, South India, with the then Prime Minister,
Sri Narendra Modi. He spoke passionately about the problems facing the
health of the Indian population, but of greatest relevance to this book was his
comment that the biggest threat to the health of the Indian population and
indeed the world was no longer communicable diseases such as tuberculosis,
malaria, and others, but it was now non-communicable diseases such as diabetes. He was, of course, entirely correct in this statement: indeed, lower
extremity complications of diabetes contribute greatly to the morbidity, mortality, and costs of diabetes across the world. At the time of writing this introduction early in 2021, the world is in the midst of the COVID-19 pandemic.
Understandably, there has been a massive global effort in devising new treatments for this all-too-often fatal viral illness as well as rolling out a mass
vaccination programme. My fear is that this might detract from recent
increased interest in the importance of non-communicable diseases such as
diabetes, cancer, and heart disease across the world. Early during this pandemic in 2020 there was evidence that the management of the numerous very
ill patients had necessarily led to the neglect of many conditions, particularly
non-communicable diseases [1]. In the area of diabetic lower limb disease,
the threat to routine diabetic foot care has been outlined in several publications [2–5].
At the same time, we are experiencing a global epidemic of diabetes with
approximately 500 million people with the condition across the world in
2021. The most recent edition of the International Diabetes Federation (IDF)
Atlas published at the end of 2019 estimated that this number would increase
to more than 700 million in the next 20 years or so [6]. Data from this publication suggest that the prevalence of diabetes in the United States is 13.3%,
affecting approximately 34 million individuals. It is well recognized that certain groups such as native Americans, Hispanics, and Blacks have higher
prevalences of diabetes, although recent evidence suggests that in certain of
these groups, the prevalence has decreased in recent years [7, 8]. The average
expenditure on diabetes per patient per year in the USA is approximately
$10,000, one of the highest in the world. Other parts of the world have even
more frightening prevalences, with Mauritius at 25% and rising in some of
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the Polynesian islands to 33% [6]. A recent study from Pakistan [9] reported
that 26.3% of all adults in Pakistan had diabetes. Thus, there are a number of
reasons why it is vital to raise the global prole and importance of diabetes.
One such reason is the grim statistic that was recorded for diabetes in 2019
when it, for the rst time, was listed in the top ten causes of death across the
world [10]. At a time when one of the largest declines in the number of deaths
witnessed was from infectious diarrhoeal diseases, diabetes entered the top
ten with a signicant percentage increase of 70% since 2000. Diabetes also
represented the largest rise in male deaths among the top ten, with an 80%
increase since 2000.
Diabetic foot ulceration (DFU) and its sequelae are associated with signicant impairment of quality of life, increased morbidity and mortality, and
place a huge drain on healthcare resources [11]. DFU occurs as a consequence of the combination of factors most commonly peripheral neuropathy,
peripheral arterial disease, and some form of trauma. Foot problems are
amongst the commonest of all the diabetic complications and are associated
with very signicant morbidity, mortality, and cost to the healthcare system.
Although a decline in the lower extremity amputations (LEA) had been
observed in decades before 2010, Gregg etal. recently reported a resurgence
of diabetes complications with an increase in diabetes-related LEAs from
2010 to 2015 [12]. Similarly, Harding and colleagues reported a stalling of
the progress in non-traumatic LEAs in the very high-risk population of
patients with diabetes and end stage renal disease [13]. It should therefore be
apparent that the chapters in this book, which emphasize the multidisciplinary
team approach to functional limb salvage in diabetes, are of great importance
at the beginning of the third decade of the twenty-rst century. The editors
have assembled an impressive number of authors with true expertise in this
area, which will provide the reader with eminently practical information on
the diagnosis, medical and surgical management of these all-too-common
problems.
Foreword
References
1. Godlee F.Surviving the long road ahead. BMJ. 2020;369:m1840.
2. Shin L, Bowling FL, Armstrong DG, Boulton AJM.Saving the diabetic foot during the
COVID-19 pandemic: a tale of two cities. Diabetes Care. 2020;48:1704–9.
3. Boulton AJM. Diabetic foot disease during the COVID-19 pandemic. Medicina.
2021;57(2):97. https://doi.org/10.3390/Medicina57020097.
4. Rogers LC, Lavery LA, Joseph WS, Armstrong DG.All feet on deck – the role of
podiatry during the COVID-19 pandemic: preventing hospitalizations in an overbur-
dened health care system, reducing amputation and death in people with diabetes. J Am
Podiatr Med Assoc. 2020. [Epub ahead of print]. https://doi.org/10.7547/20- 051.
5. Caruso P, Longo M, Signoriello S, etal. Diabetic foot problems during the COVID-19
pandemic in a tertiary care center: the emergency amongst emergencies. Diabetes Care.
2020;43:e123–4.
6. IDF Diabetes atlas. 9th ed. 2019. www.diabetesatlas.org.
7. Cheng YJ, Kanaya AM, Araneta MRG, etal. Prevalence of diabetes by race and ethnic-
ity in the United States, 2011-2016. JAMA. 2019;322:2389–98.
Foreword
vii
8. Bullock A, Sheff K, Hora I, etal. Prevalence of diagnosed diabetes in American Indian
and Alaska Native adults, 2006-2017. BMJ Open Diabetes Res Care. 2020;8(1):e001218.
https://doi.org/10.1136/bmjdrc- 2020- 001218.
9. Basit A, Fawwad A, Qureshi H, Shera AS. Prevalence of diabetes, pre-diabetes and
associated risk factors: second national diabetes survey of Pakistan. BMJ Open.
2018;8:e020961. https://doi.org/10.1136/bmjopen- 2017- 020961.
10. WHO. The top ten causes of death. 9 December 2020. www.who.int/news- room/
fact- sheets/detail/the- top- 10- causes- of- death.
11. Boulton AJM, Whitehouse RW.The diabetic foot. In: Feingold KR, Anawalt B, Boyce
A, etal., editors. Endotext 2020. South Dartmouth: MDText.com, Inc; 2020.
12. Gregg EW, Hora I, Benoit SR. Resurgence in diabetes-related complications. JAMA.
2019;321:1867–8.
13. Harding JL, Pavkov ME, Gregg EW, Burrows NR. Trends of nontraumatic lowerextremity amputation in end-stage renal disease and diabetes: United States, 2000-
2015. Diabetes Care. 2019;42:1430–5.
Division of Diabetes,
Endocrinology and Gastroenterology
Manchester Royal Inrmary
University of Manchester
Manchester, UK
University of Miami
Miami, FL, USA
AndrewJ.M.Boulton
Preface
Functional Limb Salvage has been our professional passion for decades. We
have had the great fortune of building and working with a large multidisciplinary team based at MedStar Georgetown University Hospital in Washington
DC.We nd the work of wound healing, amputation prevention, and limb
salvage to be a true privilege and a hidden gem of the healthcare profession.
We are truly energized by this work and the motivated people that it attracts.
So why write a textbook on limb salvage? We have published, spoken,
taught, and researched on this topic through numerous formats and media…
but the missing piece for us has been a true reference text on how limb salvage really works and how to build a team approach to this crucial specialty.
We meet around the world several times a year at key meetings and conferences to exchange the latest ideas and innovate together, yet there really is not
a foundational text that someone new to the specialty could use as a cornerstone. We hope that this will serve to ll that knowledge gap and can be used
as a tool by many who wish to learn more about the challenges that are present in the limb salvage specialty.
Functional limb salvage is an ongoing journey, just like much of medicine
and surgery. In our short time doing this work, we have evolved from ‘saving
length at all costs’...to restoration of function as the key clinical goal.
Functional limb salvage is about getting the patient and those around them
back to functional capacity. That may mean a well-performed amputation, a
surgical wound closure, palliative care to control pain and prevent wound
infection, or advanced reconstructive options such as microvascular free tissue transfer, external xation, and surgical deformity correction. One of the
key challenges is to identify the correct course of action for the patient, the
problem, and those around them. We must remember that some of our most
grateful patients are those with a well-performed amputation and a prosthesis
or even those with a wound that we acknowledge we may never heal but that
we work to palliate with infection prevention and pain control.
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We hope that you enjoy the talented authors we have curated for this
unique text. Many are close friends and all are subject matter experts. We
hope that this text helps you establish your own multidisciplinary functional
limb salvage team, or helps you enhance the one you already have. When
done correctly and with the right motivation, this work can be some of the
most rewarding in all of healthcare.
Washington, DC, USA JohnS.Steinberg
Washington, DC, USA ChristopherE.Attinger
Preface
Contents
1 Building It from Scratch: The Team Approach
to Functional Diabetic Limb Salvage . . . . . . . . . . . . . . . . . . . . . . 1
Areeg A. Abu El Hawa, Kevin G. Kim, John S. Steinberg,
Katherine Hubley, Cameron M. Akbari,
and Christopher E. Attinger
2 Staffing and Day-to-Day Management: The Nuts
and Bolts of Running a Wound Care Center . . . . . . . . . . . . . . . . 13
Amara Ellis and Tara Wallace
3 Case Management of the Complex Limb
Salvage Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
R. N. Thalia Attinger, M. S. W. Heather Daniels,
R. N. Teodora Deperio, and Allen H. Roberts II
4 Integrating Inpatient Care to Your Outpatient Wound
Care Center: Key to Successful Patient Management . . . . . . . . . 47
Nancy R. Megas, Katherine S. Hubley,
and Margaret C. Kugler
5 Diabetic Foot Ulcers by the Numbers:
Epidemiology of Limb Salvage . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Romina Deldar, Adaah A. Sayyed, Zoe K. Haffner,
and John S. Steinberg
6 Unlocking the Mystery of Peripheral Neuropathy
in Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Andrew J. M. Boulton
7 The Science and Utility of Offloading the Diabetic Foot . . . . . . . 73
Caitlin S. Zarick, Kurtis D. Bertram, and Thomas F. Milisits
8 Medical Management of the Limb Salvage Inpatient . . . . . . . . . 87
Marie M. Alternburg, Jennifer M. Haydek, Sara Kiparizoska,
Nina K. Weaver, and Margot G. Wheeler
9 Evaluation and Examination of the Diabetic Foot . . . . . . . . . . . . 107
Michael Edmonds, Rajesh Kesavan, and Arun Bal
10 Frailty and Mobility Degeneration in Diabetes
and Diabetic Foot Ulceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Bijan Naja and Gu Eon Kang
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