Temple team dedicated to preventing foot amputations

At 7:30 a.m. on a frigid winter day, the amputation-prevention team gathered in a conference room at Temple University Hospital for their weekly review of the most difficult cases.

Podiatrist Andrew Meyr and blood-vessel surgeon Eric T. Choi - the "toe and flow" doctors - led a discussion with five other colleagues.

Choi used his laptop computer to project a slide showing the feet of a 68-year-old African American diabetic. The right foot had a gaping wound on the heel. The toes of the left foot were black and shriveled by gangrene.

Doctors in the man's hometown, more than two hours away, had recommended double amputation above the knees.

The question before the Temple team: How could they save his legs?

Meyr and Choi are key members of Temple University Hospital's year-old Limb Salvage Center. Despite the grim name, it is an uplifting initiative, the region's first multidisciplinary, hospital-based team dedicated to preventing foot and leg amputations in patients with diabetes or other diseases that damage blood vessels.

The center reflects a huge national problem with an equally huge racial disparity - and a proven way to reduce both.

Foot ulcers and amputations cost the U.S. health system an estimated $29 billion in 2007.

While medical advances have reduced amputation rates for all races, African Americans remain two to five times more likely than whites to undergo the drastic surgery, studies show. In the Philadelphia area, the ratio is almost 4-1.

Some of this gap can be explained by much-studied racial differences in income and education, insurance coverage, access to care, prevalence of diabetes, plus subtler factors. Many African Americans distrust doctors, with good historical reason.

But there is another factor, first recognized more than 75 years ago, when the introduction of insulin led to a dramatic decline in deaths from diabetic coma, yet deaths from diabetes-related gangrene kept going up:

Diabetic foot care is not as good as it could be - for any race.

The Journal of Vascular Surgery and the Journal of the American Podiatric Medical Association copublished a special issue on the problem in 2010. Patients with chronic foot ulcers usually have complex, urgent medical needs - not to mention trouble getting around - yet they wind up trekking from the foot doctor to other specialists, receiving what the report called "fragmented, variable" care that often ends with an avoidable "tragedy" - amputation.

The remedy? As the journals explained - and as Temple is showing - it is both daunting and elementary: "Working together is clearly the answer."

Twenty-six million Americans - and counting - are diabetics. Each year, about 71,000 lose a lower extremity, the vast majority after developing a foot ulcer.

The "stairway to amputation," as experts call it, has climbed during decades of poorly controlled diabetes. In simplest terms, excessive sugar and fats in the blood corrode and clog the blood vessels, with tiny ones farthest from the heart shutting down first.

As the lower legs become starved for nourishing blood, the skin becomes thin, shiny, and hairless. There may be pain and tingling as the nerves wither from a combination of poor circulation and biochemical changes.

This nerve damage can cause a loss of sensation in the feet, setting the stage for an ulcer.

The 68-year-old man was a classic example.

Diabetes had damaged his kidneys (another classic complication), so three times a week, he sat with his feet elevated while he underwent dialysis. Minor pressure on the back of his right heel broke down his fragile skin, leading to a sore he could not heal - or feel - as it worsened.

On his left foot, meanwhile, lack of circulation turned his toes into black nubs, victims of "dry" gangrene. Where the toes met the sole, the skin had a deep fissure.

The ulcer and the fissure were potential portals for bacteria, but antibiotics would be ineffective without better blood flow to the wounds.

"The good thing is, he's relatively stable, there's no sign of infection, and he's still walking," Choi told the group.

Patrick Kelly, the manager of the salvage center, added what they were all thinking: If an infection did develop, it could turn into sepsis, a deadly bloodstream toxin, practically overnight.

The group agreed that for now, the right heel could be treated with advanced wound care and a special shoe that would keep pressure off it.

The left foot, however, was a dilemma. They discussed a transmetatarsal amputation - cutting off the end of the foot a few inches above the toes. While a "TMA" is more disabling than simple toe amputations, the patient does not need a prosthesis other than a shoe filler.

"We could give him a pretty long foot to work with," Meyr said.

Rick Nissley, the physical rehabilitation specialist, added: "My plan if you did a TMA would be to keep him mobile. A lot of times these patients stop being mobile" because they must learn new ways to balance and walk.

The big question was whether he would have enough circulation to heal after a TMA. A diagram of ultrasound imaging showed his blood flow at key body points.

"Between his thigh and calf, it looks pretty good," said interventional cardiologist Riyaz Bashir. "But in his feet, we're not picking up any" circulation.

They decided that before the TMA, the patient would undergo balloon angioplasty. A catheter would be threaded into his leg arteries, then a tiny inflatable bag would widen the vessels.

The procedure turned out to be unusually arduous because his arteries were so hardened.

But it worked. And the patient kept his foot.

About three years ago, Abington Memorial Hospital podiatrist Ronald Renzi joined forces with African American churches in Philadelphia to try to prevent amputations. The Save Your Soles campaign was a great idea: ministering to souls and soles at the same time.

"I met an 80-year-old gentleman," Renzi recalled. "He stopped smoking and changed his diet, and he's wearing better shoes. I think we'll prevent him from getting an ulcer."

The campaign grew out of Renzi's research into local amputation trends.

He calculated that for every 100,000 black men in Philadelphia and the four surrounding Pennsylvania counties, there were almost 75 amputations a year, compared with 20 for every 100,000 white men. The comparable figures for women were 43 amputations for blacks, 9 for whites.

In a few impoverished, predominantly minority zip codes in West and North Philadelphia, Renzi found nearly 90 amputations per 100,000 adult residents in 2009.

While socioeconomic factors are at play, so are treatment choices. Studies suggest some blacks may undergo amputation before it is absolutely necessary.

"Blacks might face higher rates of amputation, because they are less likely to receive aggressive care aimed at preventing their amputations in the first place," concluded a University of Michigan analysis of Medicare data.

Providing prompt, aggressive care is one reason the Temple center was created. With a phone and a computer, the core team can consult or bring in other Temple specialists - endocrinologists, nephrologists, orthopedic surgeons, plastic surgeons, nutritionists - while the patient goes no farther than the center's clinic.

"It became clear that it made no sense for the patient to go see every one of us and miss appointments," Choi said.

Since opening last April, the clinic has seen its weekly patient count grow from five to 50. Clinic hours have expanded from two half-days a week to five half-days.

It is too soon to gauge the Temple center's effect. However, studies around the world have shown that hospital-based teams reduce amputation rates 50 percent or more, while reducing the costs of treating diabetics' feet.

So why aren't such teams more common? One reason, experts say, is that the U.S. health-care system has an economic disincentive: Medicare is not set up to reimburse all those involved.

Specialists who are consulted but do not see the patient "don't get paid," Choi said.

Beverly Wallace Rockemore, 64, a diminutive African American mother of four, strode into the limb-salvage clinic in early February. Wearing a track suit and black sneakers, she could have been on her way to a gym.

Her spritely step was a sharp contrast to that of her first visit last October, when the Philadelphia woman sat in a wheelchair. Her left heel had a raw, festering wound that had developed while she lay in a hospital and then a nursing home, recovering from brain surgery for a seizure disorder.

Unlike most clinic patients, Rockemore is not a diabetic. Her poor circulation is mostly the result of an ongoing vice, one Meyr gently lectured her about: smoking.

"When I started, I thought it made me look sophisticated," she said ruefully.

After leaving the nursing home, Rockemore stayed with her daughter in South Jersey. Doctors there raised the possibility of amputation.

"I told my daughter, 'I want to go back to my home and to my [Temple] doctors," she recalled.

Meyr had cut away dead and infected skin from her heel, encased the vulnerable tissue in an advanced biological skin substitute, and put her on antibiotics. She also wore a protective boot.

Now, as she sat on an exam table, Meyr poked the back of her scarred, flattened heel with scissors. He told her she may still need surgery to improve her leg circulation. But she's already back on good footing.

"In a lot of ways, we got lucky with you," he said.