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A Diabetic Limb Salvage AlgorithmNicholas Lombardo, DPM, FACFAS, CWS
Nicholas Lombardo, DPM
Born Wausau, WI 1977
B.S. Medical Microbiology and ImmunologyUniversity of Wisconsin, Madison 1995-2000
Associate Research Specialist University of Wisconsin School of Medicine, 2000-2001
Doctor of Podiatric MedicineIllinois College of Podiatric Medicine 2001-2005Podiatric Surgery Residency 2005-2008
Detroit Medical Center, Detroit MI
Madison WI 2008-2016 Wausau WI 2016-present
Credentials/Additional
Certified Wound Specialist 2008
Board Certified, Foot Surgery 2012American Board of Foot and Ankle Surgery
Board Certified, Rearfoot and Ankle Reconstructive Surgery 2013
American Board of Foot and Ankle Surgery
President, Wisconsin Podiatric Medical Association2013-2015
Diabetic Limb Salvage Algorithm
Neurotrophic
Ischemic
Venous
What percentage of each category is reflected in the pathology seen?
Neurotrophic
Usually younger age group
Uncontrolled diabetes, obese, low socioeconomic status, poor compliance
+significant neuropathy, adequate blood flow
+Deformity
charcot
Neurotrophic
Providers: PodiatristProsthetist
Treatment focus:Short term
Offloading
Long termAFO/orthotic/diabetic shoeSurgical correction of deformity
Functional amputation
è
Functional amputation?
Functional amputation levels
Unstable
1st ray amputation
Functional amputation?
Functional amputation?
Even the patient’s foot knew this was not right…..
Functional amputation
This is much better
Trans-metatarsal amputation with tendo-achilles lengthening and split TibialisAnterior tendon transfer
Ischemic
Usually older patient population
Diabetes, CAD, HTN, CVA, tobacco
Ischemic
Providers:Vascular surgery
If revascularization is possibleSurgical removal of necrotic tissue
functional amputation level not as important compared with neurotrophic group
If revascularization is not possibleGoal of wound care should shift from healing wound to keeping it stable
betadine
Venous
Usually older patient population
+/- DM, HTN, CHF, obesity
edema
Venous
Providers:PCP
Diuresis
CompressionShort term
Unna boot
Long termCompression stockings
debridement
Mixed
Combinations of neurotrophic, ischemic, and venous
Most cases will be mixed to some degree, the key is to figure out how much each component is contributing to the wound and focus your treatment plan accordingly
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2/9/17 (original date of surgery 12/8/17) percutaneous flexor tenotomy 3rd toe
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