Oct 14, 2018
Amputation Prevention

Dr. Bill Releford - The Toe and Flow Model Used In Amputation Prevention


ello, it’s Dr. Bill Releford from The Releford Foot and Ankle Institute “Where amputation is not always the answer”. Amputation prevention strategies are more critical today than ever before.  Today we are talking about

"The Toe and Flow Model” to prevent diabetic amputations

I recently read an amazing article that talked about “The Toe and Flow Model” to prevent diabetic amputations. Here is some of what the article discussed:

The “Toe and Flow” model is essentially an Alternative to Leg and Foot Amputation.

As you know, Our limb preservation team at The Releford Foot and Ankle Institute provides a full spectrum of diagnostic test and interventional treatments to fix both arterial and venous blood flow in the lower extremities. We specialize in managing simple as well as complicated non-healing wounds by using the latest technologies to restore blood flow and improve wound healing.

Dr. Releford uses "Toe and Flow Approach" to amputation prevention.

You could do this with a headline or slogan (such as VW’s “Drivers Wanted” campaign), color or layout (Target’s new colorful, simple ads are a testimony to this) or illustration (such as the Red Bull characters or Zoloft’s depressed ball and his ladybug friend).  All good advertising copy is comprised of the same basic elements. 

A recent article I read said that Every 20 seconds a diabetic experiences an amputation which results in approximately 2,500 limbs being lost every single day due to infection and a poorly controlled blood sugars.

Twenty-five percent of those living with diabetes will have a lifetime risk of developing a lower extremity wound or sore with more than 50 percent of those becoming infected requiring hospitalization.

Dr. Bill Releford, Medical Director of the Releford Foot and Ankle Institute performing surgery to prevent an amputation.

Once a person has had a lower extremity wound, the risk of re-ulceration is as high as  68 percent if that person does not take immediate action to make the necessary lifestyle changes. Those that remain in a state of denial, which I’ve called “Denia-Betes” will ultimately be at risk of amputation.

This can all be prevented with a team approach toward care and a focus on prevention. One of these approaches is what they call

Amputation Prevention with The “Toe and Flow” Model

Which basically means that the best approach to preventing amputations is the adoption of a 2 pronged model, “Toe and Flow”. This model primarily includes “Podiatric Surgery and Vascular Surgery” working hand in hand to prevent a major amputation.

Podiatric surgeons are the first to notice the signs of peripheral artery disease (PAD) in patients, therefore it makes perfect sense that vascular surgeons work together with us as they deal with restoring circulation. Our amputation prevention team at the Releford Foot and ankle institute are uniquely experienced and qualified to treat patients with chronic non-healing wounds that can lead to amputation. We not only attract patients from the Los Angeles area but also from around the world.

The “flow” component relates to the importance of good blood flow in order to heal a wound or to prevent the development of a wound. The “toe” component relates to the importance of incorporating advanced foot care and procedures required to heal a wound and ultimately prevent an amputation.

Lower extremity arteriogram image showing severe ischemia to the left foot.

Symptoms and Risk Factors for Amputation

There are several important factors that increase the risk of developing peripheral artery disease:

  • Those suffering from uncontrolled diabetes with elevated Hemoglobin A1C levels
  • Those people suffering from kidney disease for an extended period of time.
  • Those who are currently heavy smokers or who have had a history of heavy smoking
  • Those with chronic non-healing wounds on their feet
  • Those over the age of 55
  • Those who have leg pain and leg cramping while walking several blocks or while cramping at night time also called “Claudication.”

Individuals with a history of diabetes, smoking as well as inactivity are more likely to have issues with high cholesterol, high blood pressure, and peripheral artery disease.  Those who have pain in the calves while walking only a few blocks or those that have constant leg cramps at night should see a physician immediately.

Here’s how we diagnose and Treat the Diabetic Foot

Initial evaluation involves simple yet highly advanced tools that measure the blood flow at the level of the foot, ankle, and toes; low blood flow in this area implies obstruction or blockage of blood flow. Using ultrasound-guided technology, we at the Releford Foot and Ankle Institute can also look at the inside of arteries and provide a more in-depth evaluation by finding exactly where there are obstructions along the arteries. If needed, we can also use advanced imaging, such as CT scans or MRIs, that give more detailed information about the degree and location of the disease, which helps plan an intervention if needed.

When it comes to intervention, vascular surgeons have moved away from open vascular surgery to using less invasive catheter-based procedures, which can be done under local anesthesia and can be done on an out-patient basis.

New catheter-based interventions have given surgeons more alternatives to treat those who previously were too sick to have open surgery. These patients now have a less invasive option to treat peripheral artery disease and ultimately heal a chronic wound and prevent amputation.

As for Podiatric Procedures, here is how we diagnose and treat the diabetic foot. We use:

  • State-of-the-art advanced podiatric surgical approaches to preserve and reconstruct lower limbs afflicted by vascular disease: Stay tuned to my other segments when I talk about regenerative medicine used to improve peripheral vascular disease.
  • Debridement and drainage
  • Advanced wound healing techniques
  • Use of advanced wound care products
  • Offloading devices and support
  • Education
The Releford Foot and Ankle Institute, based in Los Angeles, is dedicated to decreasing the diabetes-related amputation rates both domestically as well as internationally.