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Interdisciplinary Leg Initiative 13-14 October 2009 Munich, Germany |
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Highlights from ilegx 2009
A systematic approach to the underlying causes of leg/foot tissue loss
Michael Edmonds, diabetologist, London, UK, and ilegx programme director, reviewed together with Marco Romanelli, dermatologist, Pisa, Italy, and immediate past president of the European Wound Management Association (EWMA), the more than 44 causes of leg/foot tissue loss, using the ilegx wheel as a systematic guide, dividing causes into vascular and non vascular types as well as highlighting arterial and non arterial causes.
Steven Kravitz, president of the American Professional Wound Care Association, educated delegates on the benefits of microvasculature assessment with skin perfusion pressure and pulse volume recording, which he judges to be a reliable predictor of wound healing and importantly also also a reliable predictor of peripheral arterial disease and critical limb ischaemia.
Knut Kröger, angiologist, Krefeld, Germany, board member of the "Initiative chronische Wunden" turned the spotlight to Germany by reporting the latest amputation rates. In 2006 a lower limb was amputated in 55,689 cases, a major amputation was executed in 22,003 cases compared to 22,619 in 2005. The number of minor amputations over the same period has increased to 33,702 versus 33,070 in the previous year. Kröger put the question to the audience whether every minor amputation avoids a major amputation and showed that among the oldest patients with diabetic feet the number of minor amputations declines while the number of major amputations increases, very much in line with Transatlantic Inter-Society Consensus guidelines.
Benjamin Lipsky, internist, Seattle, USA, gave an insight into the complexities of ischaemia and infection, highlighting the need for early revascularisation in the ischaemic foot as antibiotic penetration is usually diminished by ischaemia.
Definitive management - today and tomorrow
For the first time, ilegx invited members of the faculty to debate controversial topics in the main plenary. 'Balloon angioplasty is enough' and 'Endovascular therapy is better than surgery' followed the example of Europe's leading vascular symposium, Charing Cross (Read more on pages 7 and 9).
Werner Lang, vascular surgeon, Erlangen, Germany, highlighted the use of omentum free flap, a new technique for covering extensive and circular arterial ulcers. "It is excellent for covering large areas and filling cavities, but it is poor for areas with mechanical stress," he said. Lang said that the use of laparoscopic harvest minimises trauma and lowers donor site morbidity.
Ulrich Hoffman explained that regular follow-up and self surveillance were vital for critical limb ischaemia patients who have undergone revascularisation. He presented on managing patients with critical limb ischaemia beyond revascularisation because such patients had high risk of restenosis. "We should also give clear instructions to patients on how to perform self-surveillance,"
he said.
Thomas Böni, orthopaedist, Balgrist, Switzerland, analysed pros and cons of total contact cast and removable orthosis, both valuable options with different indications for diabetic foot ulcer and Charcot Foot (diabetic neurosteoarthropathy). In his final message to the audience, he reccommended: "Start treatment of diabetic foot ulcers and acute Charcot-Foot Stage 0-1 in the absence of limb threatening infection or ischaemia with total contact cast. Use a removable total contact cast after ulcer healing to check compliance during fitting of the final orthopaedic footwear or orthosis. And use a removable custom made orthosis in relapsing diabetic foot ulcer despite adequate orthopaedic footwear as well as in Charcot-Foot Stage 2-3 or with unshoeable deformity."
How to implement interdisciplinary management
On day two the faculty and delegates turned their attention to the challenge of implementing the current best approach into daily practice. Different European centres were reviewed and panel discussions revealed many valuable insights into traps and shortcomings. Overall three topics seem to be crucial in successful implementation: i) a medical champion, a flagbearer for feet as Dieter Mayer, vascular surgeon, Zurich, Switzerland, and ilegx programme director, said, is required to initiate and manage an interdisciplinary team, ii) to overcome healthcare system barriers a local solution has to be identified and iii) benchmarking is critical to roll out the current best approach beyond one individual centre.
Mayer and Severin Läuchli, dermatologist, presented the open access wound clinic as it is run at Universitätsspital Zurich and iterated how important it is to treat all team members as equals while at the same time spending time and effort in educating the entire team on leg/foot tissue loss.
CME Feedback
ilegx 2009 continued to attract a balanced interdisciplinary following
ilegx 2009 met its educational vision
89.2% of all respondents considered ilegx as good or extremely good in fulfilling the educational reason for attending the conference. The three ilegx educational topics of: DIAGNOSIS, MANAGEMENT & IMPLEMENTATION met the educational needs of the attendees, whereas discussing health care system challenges was less of a reason to attend the conference.
ilegx 2009 was rated for its high educational value
The 10 min rapid-fire, thought provoking lectures delivered by international experts were perceived as excellent or very good by 96% of attendees. 88% of attendees thought that the panel discussions provided a varied clash of opinions, with some attendees having liked even more frequent and longer discussions particularly on the implementation challenges.
The ilegx algorithm was judged by 89.3% of attendees as excellent and very good. ilegx will further improve it by stressing the patient as being of the centre of the "ilegx wheel" as well as including infection control to a larger extend in the wheel.
ilegx team award winner
An interdisciplinary team from St George's Hospital, London, UK, was announced as the winner of the best interdisciplinary team award at ilegx on Tuesday 13 October 2009. They received € 1000 supported by a Cordis educational grant. Peter Holt, Keith Jones, Peter Gogalniceau, who are all vascular surgeons; Marcus Symgen, a diabetologist; and Mark Greenhill, a podiatrist, comprised the award-winning team.
The judges of the award felt that, as a regional vascular surgical hub taking referrals from the whole of southwest London, the team at St George's Hospital are a leading example of effective interdisciplinary teamworking.
The team described how they changed the patient care system in the hospital to reach the goals of the St Vincent Declaration, which aimed to reduce the international amputation rate by around 50% over a five-year period. The team began their initiative to reduce the high amputation rate in southwest London through the implementation of a limb salvage service within a multidisciplinary framework. Prior to this, the majority of patients with diabetic foot or critical limb ischaemia were offered angioplasty followed by amputation if healing was unsuccessful. The rates of surgical revascularisation were very low. Furthermore, there was no collaboration between podiatrists, orthopaedic foot specialists, microbiologists and diabetologists, and no clear patient treatment pathway through the hospital. No targets were in place and there was no system for benchmarking the outcomes of the management of the diabetic foot.
Processes were put in place so that every patient with diabetes and critical limb ischaemia would be discussed in a joint forum including microbiologists, diabetologists, orthopaedic foot specialists, podiatrists, tissue viability nurses, vascular technologists, interventional radiologists, plastic surgeons and vascular surgeons.
Every diabetic foot referred to the vascular team is now examined within four hours of referral in daylight hours, and at the start of the working day for out-of-hours referrals. Treatment pathways for these patients are expedited where patients are identified as having a limb at risk.
The new system has been in place for one year and there has been a huge increase in referrals from all specialities, an increase in the number of peripheral bypass procedures performed, and a decrease in the number of major amputations performed, despite the increase in the number of referrals.
The major learning point is that to effectively manage the diabetic foot needs a change in the traditional attitudes is needed. Aggressive, early management of diabetic foot complications under the auspices of an interdisciplinary team approach can lead to improvements in limb salvage rates. Attention to detail and a will to reduce amputation rates are key.
ilegx poster award: Early referral will save legs
The ilegx best poster presentation 2009 was awarded to Ivone Silva, Daniel Menezes, Armando Mansilha, Ruy Fernandes e Fernandes, and Joaquim Barbosa from the Sociedade Portuguesa de Angiologia e Cirurgia Vascular, Lisbon, Portugal, for their entiry, "Portuguese national prospective clinical audit on critical limb ischaemia." The €500 prize was awarded at the 2009 ilegx meeting. The study clearly reflects that lack of pathology knowledge and late referral of patients with critical ischaemia conditions the treatment and outcomes.
"In our annual meeting of our Vascular Society in 2007, Sociedade Portuguesa de Angiologia e Cirurgia Vascular decided we would like to know the reality of limb salvage in our country. We were aware that our amputation rate was high, but first we needed supported data to confirm and then we wanted to know why this happened," said Ivone Silva. The aim was to assess whether treatment outcomes were conditioned either by late referral, late diagnosis or lack of pathology knowledge, or if the results were conditioned by the high volume of patients and lack of responsiveness.
Clinical audit is an important strategy in maintaining continuous improvement in healthcare by promoting evidence-based best practices. The first step is the observation of existing practice, Silva explained. "In Portugal we prioritised critical ischaemia to be audited, as evidenced by its frequency, severity and procedural variability. Based on these parameters, we developed a programme for national prospective clinical audit to assess the clinical strategy of all vascular surgery services in the treatment of patients with critical limb ischaemia."
Ten hospitals were audited, 220 patients were selected randomly, and the results were analysed. Analysis of the data showed that 73% were referred in a late stage of disease evolution, presenting with a foot or leg ulcer. In patients with only rest pain smoking was the predominant risk factor while in patients with ulcers, diabetes was more common. Also, 38% of our patients had aorto-iliac disease and 71% femoro-popliteal. Aorto-iliac TransAtlantic InterSociety Consensus D and Femoro-popliteal TransAtlantic InterSociety Consensus D localisation was more common. In total, 61% were submitted to conventional surgery, 19% to endovascular surgery and 25% to hybrid surgery.
A 33% amputation rate (primary and secondary) was registered. This is a higher rate than recommended by TransAtlantic InterSociety Consensus II (25%). Silva and colleagues concluded that patients came too late to the hospital (late referral). This was due to a lack of knowledge of critical limb ischaemia in primary care, and a lack of education of patients.
Over the next few years, the two goals of the project are to invest in training in primary care and to promote patient education through educational posters and leaflets. A re-audit will then be conducted to examine whether the scenario has been improved, and limb salvage increased in Portugal.
