Recognizing the Warning Signs of Limb Loss

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. This podcast will explore disease prevention, testing, medical and surgical treatments, new innovations and more. Enjoy.

Courtney Hanak, MD:

We are here today to talk about amputations. My name is Courtney Hanak. I'm a staff vascular surgeon here at Cleveland Clinic.

Ravi Ambani, MD:

Hi guys. I'm Ravi Ambani. I'm also one of the staff at Cleveland Clinic at the main campus. Yeah, we're excited to be discussing amputation prevention and how we look at this from a vascular disease perspective, what to consider before amputation and what to consider after having an amputation. I think with that being said, Dr. Hanak, if you want to tell the people what amputation means to you and what the most common reasons are that people end up needing one?

Courtney Hanak, MD:

Sure. Amputation in general is when you have something that's considered non-viable or non-functional. Just a portion of your body; it can be your fingers, your toes. It can be a higher amputation, which can be your lower extremity or your leg, above or below the knee. That can be a very serious condition and something that can be very life-changing. We take it very seriously when counseling you and counseling additional patients. What should be considered reasons why you may need an amputation? Again, if the limb, your digit, or your toe is nonfunctional or you have an infection that could threaten your life. Those are the most common reasons.

Dr. Ambani, what conditions or risk factors most commonly lead to amputation, such as diabetes or poor circulation?

Ravi Ambani, MD:

So I think when you think about amputations, it's really a lot of factors that play into the whole decision to get an amputation and what leads to an amputation. Medical conditions like really bad diabetes can lead to wounds or infection of the feet that can kind of force you almost to need an amputation because it's a matter of saving your life over saving your limb. Other conditions, usually caused by smoking or bad cholesterol disease, can cause blockages or tightening of the arteries in your legs. This can lead to less blood flow as it comes down to your foot, which can again lead to wounds, lead to pain that's really tough to deal with and eventually, unfortunately, we know that these patients with these untreated conditions can lead to amputations. We try everything we can to save the extremities, but sometimes that kind of fight is hard to win.

When you're thinking about it, Dr. Hanak, when you're looking at a patient, what are those early signs that can say, "Hey, we're dealing with a serious problem or this is going to become something that can lead to an amputation"?

Courtney Hanak, MD:

As we all age, we have aches and pains and things like that. But if you have constant pain in your fingers, toes or leg, those are definitely reasons to seek care. If it starts with your primary care physician, that's good. Then they can kind of get you to the right place. But we want to make sure that we address pain that's there constantly all the time when you're awake, when you're sleeping, when you're active. That's an early warning sign.

Then most definitely, if you develop a wound or sore somewhere that doesn't heal in a normal healing time. It should be getting better each day over a period of time. If there are any signs of infection, you feel poorly, you have fevers, those are early warning signs. Then another sign that can commonly be dismissed or missed in general is if you have discoloration of any of your toes or fingers, or the skin on the top of your foot starts to become darkened or you start to get that purple color. That's definitely a reason to seek care.

So, Dr. Ambani, when should patients seek care and speak to their provider about their concerning symptoms?

Ravi Ambani, MD:

I think that is a great question. My counseling would be not to wait too long. As Dr. Hanak mentioned, if you're getting pain that's kind of becoming constant, if you're getting discoloration of your toes, if you've developed a wound that's really taking a while to heal, these are reasons to go see your physician, go see your primary doctor, go see a specialist.

I think when you're really looking at it, if you wait too long, that's when it becomes challenging to really save your legs, save any kind of toes or any part of your foot that we can. The longer we wait, the less likelihood of a good limb salvage operation or a limb-saving procedure. I think if you're ever concerned, there's no harm in going to see your doctor and at least talking about it.

With the space of the peripheral arterial disease or these chronic limb-threatening ischemia patients, we know that there are a lot of ways to treat them. Who are the physicians or people that are treating these patients, and how do they work together?

Courtney Hanak, MD:

I think the most important in all of this is the primary care physician. The person that you trust, that you see, that gives you medications and sees you multiple times a year for different reasons. They know you best, and then they can see you and direct you to the right person.

The other physicians that are really involved are the podiatrists. A lot of older patients will seek care for nail clipping and just overall hygiene of their feet. A podiatrist can really get on the front lines if there's a wound or discoloration or even when they do their exam, if they notice that they can't feel your heartbeat in your feet, then they usually will refer you to someone like a vascular surgeon who does procedures or they'll refer you to something called a vascular medicine physician who is really good at sifting through whether this is something that would need a procedure or something that could be managed medically.

Dr. Ambani, when does amputation become necessary and how do doctors make that decision?

Ravi Ambani, MD:

Like Dr. Hanak said, this is a condition that we treat from a lot of different physicians and partners. We have the primary doctors. We have the vascular specialists. We have the interventional cardiologists, the interventional radiologists, kind of everyone working together. But unfortunately, sometimes when the amount of the wound or, like I said before, infection creeps in, then it's challenging to save someone's leg when their life could be in jeopardy.

I think we all try, all of us across the board try to save as many extremities as possible. But when that wound becomes too severe that the foot doctors and surgeons are saying, "Hey, I'm not sure this patient can really keep this foot with a good functional outcome," because at the end of the day, that's what it's about. It's about getting you to walk again. I think when that happens, or again, there's an infection that we can't control, I think amputation is necessary.

I think all physicians across the board are trying to avoid doing an amputation because we know that makes it harder for people to recover and walk again. But when push comes to shove, if it's about saving someone's life over saving their leg, I think we're always going to make that decision.

When patients are asking about amputation or hearing that word for the first time, what are the questions they should be asking their providers, and how do you lead that discussion?

Courtney Hanak, MD:

Yeah, so I think that's a really important question. First off, when you're talking to your provider about amputation, you want to know, "Is there anything to prevent this? Is there anything that can prevent me from requiring this amputation, or is an amputation needed now?" So, that's kind of the first question that you want to ask. Then after that, you want to know how much amputation is required. Is it just a toe? Is it all of your toes? Is it further up your leg, above or below your knee? And that's really important because then your follow-up question should be, "What sort of functional status will I have? Will I be able to walk? Will I need inserts in my shoes? How long until I'll be able to walk? And am I a candidate for a prosthetic?" Which is an artificial leg or artificial toes that allow you to wear a normal shoe.

Then after that, if you are facing an amputation, you want to know what your recovery time looks like, how long until you're able to get your prosthetic. Then, if you're in the hospital, what does it look like for discharge? Are you somebody that is going home or do you need to plan on going to a rehab facility where they can do intense physical therapy and get you home safely as soon as possible?

What should patients expect in terms of recovery and life after amputation?

Ravi Ambani, MD:

Yeah, I think you touched base on some of these things. I think the recovery can be challenging, but it's all about motivation. We know that the most likely outcome of a good patient outcome after amputation is their ability to walk beforehand. Those people who are ambulating and walking, you just need to stay motivated. The thing I tell all my patients when it comes down to this point is that an amputation is not the end of everything. It's the start of a process of making you feel better and getting you to walk again. I think as long as you stay motivated, you work with our physical therapists and our rehab specialist to get those exercises, get the strength built back up, then you usually have a good outcome.

We fit people with prosthetics. We work with great companies so that they can have functional outcomes. There are newer prostheses with mechanics and computer-generated technology in them that are really helping people get back to the life that they were at beforehand. I don't think that we should look at this as, "Hey, I have an amputation now and there's not much more that I can do." It's not. It's a start of you feeling better and you getting back on your feet.

As we wrap up, I think the one important thing to talk about is what we think our take-home message is for patients and families when they're hearing about this. What do you feel like is the main thing that they should take from this, Dr. Hanak?

Courtney Hanak, MD:

I think the main thing is it's normal to feel like this is a big decision when you're faced with an amputation. It's normal to feel that it's life-changing because it absolutely is, but it doesn't mean that it's life-changing in a bad way. The most important thing is to just be positive like Dr. Ambani was saying, and then also to realize there is life after amputation. Our goal is to get you functional, living the life and doing the things that you want to do and keeping you active for as long as possible.

Ravi Ambani, MD:

So, I think with that, I want to thank you all for listening to Love Your Heart. Dr. Hanak and I are privileged to participate in this podcast, and we hope you learned something. We're always here for you guys if you have any questions.

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