Christopher E. Attinger, M.D., is director of Georgetown University Hospital's Center for Wound Healing. The center combines the expertise of many different specialists in the same building to help save patients' limbs. The center had an initial 97 percent success rate at saving the limbs of patients referred to them for wound healing in the first year.

1) How did the idea for the center come about?
It had to do with the complexity of the wounds we treated. I had to contact other professionals to help me solve problems. [Over time], as the referred wounds become more complex, we realized that most of these problems required the input of two or more physicians. We needed to call more and more people in.

It turns out that for wound healing you need an orthopedist, a podiatrist, a vascular surgeon, a plastic surgeon, infectious disease [specialist], rheumatologist, neurologist, endocrinologist, internist, prosthetist and pedorthist, specifically for diabetic foot wounds. You need all those people—and then some—just to help you get the best possible outcome.

2) What makes the Wound Healing Center’s approach so effective?
If a diabetic ends up in the emergency room with an ulcer, his chance of losing the leg during that hospitalization is 23.8 percent.

With a team approach, the chance of losing a leg immediately is 2.7 percent, [based on] the first thousand patients we saw. So it’s about a tenfold decrease in limb loss.

Whenever we see a new patient in the clinic, we say, “This person needs to see x, y and z.” Each specialty is just taking care of a piece of the puzzle, and you need all the pieces to be solved before the patient heals. Some of them need blood supply. Some of them need the skeletal framework to be stabilized. Some of them need to be on appropriate antibiotics. That has to be done before we can address the wound. And then once we have all the answers, we can go ahead and solve the problem.

3) What were some unlikely cases where you’ve been able to save a limb?
We’ve had people come in with no blood flow below the ankle, and gangrene over the entire foot. There was [one patient with] a black plantar foot, and by using hyperbaric [therapy], by debriding him and by using cultured skin, we were able to get the wound closed. The patient’s still walking on his foot seven years later.

We’ve had people who’ve been deemed non-reconstructable by other professionals, and every one we [heal] is a big victory.

4) Is there a way that orthoses can be designed as a tool for prevention rather than as a step toward losing a limb?
Orthoses are the key to the whole ballgame. The minute that a diabetic knows that he has diabetes, his progress should be followed by a podiatrist. [He should] have appropriate orthoses to prevent any wounds from breaking down. If he does get an ulcer, then he needs orthoses even more, because the chances of having a recurring ulcer are about 80 percent at two years after the wound heals. If he gets an appropriate orthosis to offload the plantar foot afterwards, then his chances of having a recurrence fall dramatically.

Orthoses should redistribute the weight evenly away from the area of the wound so that no breakdown occurs over the high-pressure points.

Most of the patients we see with open wounds are initially offloaded with a Cam walker. Those have a sort of a built-in orthotic device that offloads the foot uniformly. Once [the patients are] healed, they’re fitted with an orthosis that they can fit in their shoe. They may or may not need a custom-made shoe as well.

5) How can the O&P practitioner play an even greater role in preventing amputation?
The key is to prescribe the correct orthosis for the given deficiency. Then once the orthosis comes in, make sure it does what it’s supposed to do by pressure testing. Sometimes these orthoses don’t actually offload the foot evenly, even though they were designed as such. Then make sure that the patient knows that these orthoses only [last] three to six months and need to be changed frequently, so that they remain effective in offloading the patient adequately.

The person that’s giving the orthosis needs to follow up with the patient carefully, as carefully as the podiatrist. The patient and the orthotist should be checking up on each other every three to four months.

Interview by Heather Benjamin, assistant editor of the O&P Almanac.