I was reading an interesting thread on the PRESENT Podiatry website entitled “What is the best predictor for level of amputation healing?” This started me thinking about a few issues, which I’ll address in today’s editorial.

The first is the proposed question: What is the best predictor for level of amputation healing? I tend to agree with Dr Fitzgerald’s comments about the importance of blood flow. The problem is knowing just how good the blood flow is. On the extremes – strong and weak perfusion – it’s relatively easy to appreciate the strong or weak bleeding in response to our surgical insult. However, the challenge comes with the borderline cases. There are times when an amputation bleeds only a little, and I suspect it’s going to heal poorly, only to find an uneventful postoperative course. Other times, gangrene or tissue necrosis sets in, as expected, when little bleeding is noted.

Are the current technologies like skin perfusion pressures (SPP), transcutaneous oxygen measurement (TcPO2), or fluorescence angiography adequate? Despite current research demonstrating TcPO2 accurately determining tissue oxygenation¹, my experience has been variable. For example, I once had a patient with a pedal TcPO2 in the single digit range with strongly palpable pulses that were biphasic on hand-held Doppler. His transmetatarsal amputation healed uneventfully. Unfortunately, I have less experience with skin perfusion pressures due to lack of availability in my region. However, the research is reasonably strong that SPP, especially at levels above 40mmHg, are useful to determine tissue oxygenation². Fluorescence angiography is a newer promising technology³, though it is unlikely to ever be part of a typical podiatric practice due to the cost of the device. I have some personal experience with this technology and found it to be somewhat subjective and user dependent. It clearly has a future role once we understand it better. On my professional wish list are hand-held versions of these devices. I’d give one of my own toes to have a hand-held bedside SPP or TcPO2 device!

It’s also important not to forget about the power of our own hands on physical examination. Palpating pulses, feeling temperature gradients, looking at skin characteristics, etc, still have a place in helping to determine the course of therapy for our patients^4,5.

My second thought is, regardless of the technology used to assess peripheral oxygenation, without adequate vascular surgery assistance, we are unlikely to be successful with those patients that require revascularization.

The evidence is building to support the argument that revascularization to the affected angiosome is necessary⁶. Simply restoring flow to the “region” of the foot is not good enough. Telling me you reestablished flow to the foot or ankle just doesn’t cut it. I want to know that the angiosome is open for business.

The other issue I’ve experienced at various practice locations throughout the country is a lack of available vascular surgeons who are both capable and willing to do what is necessary for a successful result. Too often I experience surgeons who want to “watch and wait” (a ridiculous proposition in patients with critical limb ischemia), are unable to revascularize into the foot (stopping at the ankle), or rely solely on endovascular approaches. It appears the limb bypass is no longer an option for some of our vascular surgeons.

It’s very frustrating to have a patient in dire need of revascularization, watching a part of their body rot off, while we wait for an appointment with the vascular surgeon. Too often I find myself working around the system and sending patients to the emergency room with the intent to have them admitted and revascularized while in house. This is an unfortunate situation that wastes patient time and healthcare money. Many of these procedures can be done on an outpatient or limited inpatient basis with the right support. Given the available technology it’s an absolute travesty that our patients with PAD have to suffer the way they do.

Here’s my third thought. Hang on; it’s a doozie!

It would be optimal if podiatrists could create a lower extremity vascular fellowship in which we are trained to perform revascularization of the leg and foot.

I know. You’re thinking that would be absolutely crazy. We would be pitting ourselves directly against all of the vascular surgeons, interventional cardiologists, some general surgeons, and interventional radiologists, cutting into their territory. This would create the same issues we have with orthopedists who dislike our treating the foot and ankle surgically. Maybe that’s all true, but I’d support a pilot program to investigate the viability of this proposal.

What do we have now? Many of our patients are literally rotting while we wait for a vascular surgeon who may or may not have the training to help us. It appears there are decreasing numbers of young vascular surgeons every year, making it even harder to find a good surgeon. The ones we have seem great at creating AV fistulas for hemodialysis, but baulk at doing “radical” procedures like pedal revascularization. If it’s truly that hard to find someone to do this work, then why not enter this arena? I have begun sending my patients to interventionalists up to 70 miles or more away from my office. How is that beneficial?

Clearly, this hypothetical fellowship would require training in specific and some general vascular surgical skills. Our fellow would have to be trained in open vascular repair techniques, endovascular methods, and pertinent patient medical management issues. The scope of practice would also need to be very clearly defined to decrease the uproar that would inevitably occur. I’m sure we would be criticized as wanting to become thoracic surgeons next.

Despite these challenges, podiatrists are currently hostage to a disease that we cannot directly treat - regardless of how accurately we diagnose it – and hostage to other doctors who are variably able and willing to help us. In the end, it’s about what’s best for our patients. To that end, I vote for the creation of the subspecialty of interventional podiatry. Just don’t hold your breath for this to happen.