Multidisciplinary Limb Salvage Service Reduces Major Amputations in Diabetic Foot Infections

Abstract

Background: Diabetic foot infections (DFIs) can lead to limb loss and mortality. To improve patient care at a safety-net teaching hospital, we created a multidisciplinary limb salvage service (LSS). Methods: We recruited a cohort prospectively and compared it to a historical control group. Adults admitted to the newly established LSS for DFI during a 6-month period from 2016 to 2017 were included prospectively. Patients admitted to the LSS had routine endocrine and infectious diseases consultations according to a standardized protocol. A retrospective analysis of patients admitted to the acute care surgical service for DFI before creation of the LSS during an 8-month period from 2014 to 2015 was performed. Results: A total of 250 patients were divided into two groups: the pre-LSS (n = 92) and the LSS (n = 158) groups. There were no significant differences in baseline characteristics. Although all patients were ultimately diagnosed with diabetes, more patients in the LSS group had hypertension (71% versus 56%; P = .01) and a prior diagnosis of diabetes mellitus (92% versus 63%; P < .001) compared to the pre-LSS group. Significantly, with the LSS, fewer patients underwent a below-the-knee amputation (3.6% versus 13%; P = .001). There was no difference in the length of hospital stay or 30-day readmission rate between the groups. Further broken down into Hispanic versus non-Hispanic, we noted that Hispanics had significantly lower rates of below-the-knee amputations (3.6% versus 13.0%; P = .02) in the LSS cohort. Conclusions: The initiation of a multidisciplinary LSS decreased the below-the-knee amputation rate in patients with DFIs. Length of stay was not increased, nor was the 30-day readmission rate affected. These results suggest that a robust multidisciplinary LSS dedicated to the management of DFIs is both feasible and effective, even in safety-net hospitals.

Ambulatory Status before Diabetic Foot Ulcer Development as a Predictor of Amputation and 1-Year Outcomes: A Retrospective Analysis

“…15 Studies have also demonstrated that hospital length of stay and 30-day readmission rates were not increased, in addition to decreasing amputations. 18 Among DLS patients, 84%-86% achieved successful postoperative ambulation, 15,20,22 which demonstrates a promising improvement after traditional amputation. 15,26 A 2014 study examined the role of premorbid ambulation on the success of DLS, defined as a stump fit for functional ambulation, and found that a higher premorbid ambulation state increased the odds of a successful DLS operation.…”

“…14 The creation of multidisciplinary diabetic limb salvage (DLS) services has led to decreased amputation rates, with significant mortality benefit. [15][16][17][18][19] A recent systematic review found that these teams have reduced major amputations in 94% of studies. 19 Studies have reported high success rates, specifically with free tissue transfer, which had previously been avoided in this patient population before advancements in microsurgical technique and perioperative care.…”

“…[11][12][13][14] The implementation of multidisciplinary DLS services has led to decreased amputation rates and significant mortality benefit. [15][16][17][18][19] Studies have reported high rates of success, specifically with free tissue transfers, with improved postoperative functional status compared with amputations. 15,[19][20][21][22] As amputation can have a significant impact on cardiovascular dynamics and energy expenditure, limb salvage may preserve quality of life and minimize the risk of deconditioning that leads to further morbidity and mortality.…”