September 2018

Office-based Toe Amputations Are Safe and Efficient

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By Nicole Wetsman

As patients seek more affordable care options, moving surgical procedures from the hospital-based operating room to less expensive, more convenient locations is one tactic being explored. But can such procedures be done safely in these outpatient settings? New research from Podiatrists in the Department of Surgery at the Southern Arizona Veteran Affairs Health Care System provides evidence that they can…and that patients like the convenience.

In their poster, Is the Operating Room Always Necessary? Office Based Toe Amputations for Osteomyelitis,4 the researchers presented case reports of four patients with diabetes who required toe amputations due to osteomyelitis. All 4 patients and their caregivers chose to have the procedures done in the doctor’s office, rather than in the hospital or surgical center. All patients had successful procedures without complications.

Performing surgical procedures in-office is safe, with lower rates of complications, and can have a significantly lower price tag than those done in a hospital. Toe amputations done in an office are only 7 percent of the cost of an in-hospital procedure, according to the authors.

The authors described four diabetic patients with osteomyelitis, each presenting with a variety of co-morbid conditions. In the first, an 82-year-old man with chronic kidney disease, atrial fibrillation and other comorbidities presented with chronic diabetic foot ulcerations on two toes; he had failed a 6-week trial of antibiotics. Rather than undergo the potential complications of full anesthesia, he chose to have the toes amputated, three weeks apart, with both procedures done in-office. Healing was complete at 7 weeks for both surgeries (delays attributed to extensive peripheral vascular disease).

In the second case, a 54-year-old man had an infected toe that did not respond to an 8-week course of antibiotics and offloading. The patient elected to have the amputation performed  in-office to make scheduling of the procedure easier.

A 90-year-old man with dementia and peripheral vascular disease presented with osteomyelitis resulting from vascular disease in his third toe.  Given the physical and emotional disruption traveling can create in people with dementia, the family opted to have the amputation performed in-office the same day as his original appointment.

In the fourth case, a 58-year-old man with diabetes and HIV had two toes removed in-office, seven months apart; both had shown signs of osteomyelitis.

All patients reported high levels of satisfaction with their procedures, and had complete healing without complications.

“Office-based toe amputations are safe, economical, efficient, and offer a high degree of patient satisfaction for the treatment of diabetic toe ulcerations with osteomyelitis,” wrote the authors.

 

Posters presented at American Podiatric Medical Association 2018 Annual Meeting

  1. Alalwee, A, Spergel, G, Santi, L et al. The Outcomes of Local Flushing of Insulin on Wound Healing in Patients with Diabetic Foot Ulcers.
  2. Moisan, G, Descarreaux, M, Cantin, V, et al. Effects of Two Types of Foot Orthoses on the Biomechanics of Participants with Cavus Feet During Walking.
  3. Schick, F, Taweel, N. A Non-surgical Approach to Arteriovenous Malformation of the Foot.
  4. Brock, K, Walters, J. Is the Operating Room Always Necessary? Office Based Toe Amputations for Osteomyelitis.
  5. Cole, W. Management of Small, Lower Extremity Wounds in the Ambulatory Setting Using a Disposable, Mechanically Powered Negative Pressure Wound Therapy System.

2 Responses to Office-based Toe Amputations Are Safe and Efficient

  1. Tim Nichols says:

    Sounds a LOT like this author is more concerned with low cost than patient care. I once had a stent placement in my heart arteries, I had a heart attack during the procedure. Fortunately it was done in the stent lab of a regional general hospital. That ‘s when I learned my lesson: don’t skimp on price! I might have died if my stent were placed in the doctor’s office. Now i’m told that my right big toe might need amputation.. I have told the doctor that under no circumstances will it be done outside of a hospital operating room. I am adamant in this.

    Here’s the question. Is the surgeon paid any less for doing the surgery outside of a hospital? Nurses, physical therapists, custodians? They are uncompromising. We as patients need to demand that surgery be done safely, in a hospital! Patients are the only parties asked to compromise their safety. for MONEY!

    Demand your rights! Insist that any surgery be perormen safely, in a hospital.

  2. Tim Nichols says:

    Cost and convenience??? Those are your reasons?

    When were adequate medical care and best practices eliminated?

    Surgery belongs in an operating room! Period! Q.E.D.

    BTW, I’m facing a right big toe amputation.

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