Complex Limb Reconstruction

Dr. Pereira is a strong proponent of Limb salvage through a comprehensive multidisciplinary team approach. His team usually is inclusive of the patients primary care physician, endocrinology, infectious disease, vascular surgery, endovascular specialist, radiologist, plastic surgeon, and physical therapist. Once the patient is identified as patient at risk for limb loss via a thorough medical exam, Dr. Pereira will head the entire salvage team effort. Once limb salvage is attained these patients are then fitted for custom orthotics and prosthetics. Finally a physical therapy program is then started to attain complete functional rehabilitation.

Orthoplastics & Microsurgery
The field of Orthoplastic surgery is a ‘marriage’ of conventional orthopedic surgery and plastic surgery in the operating room. In general, conventional orthopedic surgery focuses on the treatment of musculoskeletal problems. Plastic surgery focuses on the treatment of soft tissue problems. Orthoplastic surgery is best defined as “the principles and practices of both specialties applied to a clinical situation, either by a single provider, or teams of providers working simultaneously for the benefit of the patient”.

The surgical component of lower limb reconstruction and diabetic limb salvage is inherently complex. This is further compounded by a patients overall medical condition. Limb salvage patients have one chance for limb salvage. The appropriate surgical intervention must be performed at the appropriate time. Short of this, most patients end up loosing a limb.

Dr. Pereira is adept at combining a variety of advanced foot and ankle reconstructive procedures to obtain his orthopedic reconstruction. He is then able to augment those procedures at the same time in the operating room with complex plastic surgical techniques. This ultimately allows him to obtain a stable orthopedic and biomechanical foundation that then maintains his soft tissue reconstruction.

Overall Dr. Pereira has had an 85% success rate reconstructing and salvaging limbs once said to be non reconstructible and recommended for amputation.

Amputation Prevention
The estimated risk for major amputation in the individual with diabetes is 15-40X higher than the general population. This risk can be reduced by awareness, tight blood sugar control, lifestyle modification, good skin care and pressure reduction footwear.

Despite these preventive measures limb threatening wounds and infections do develop. A coordinated surgical approach optimizes the prospects of limb salvage in these difficult situations.

Amputation may be unavoidable in some patients. However, Dr. Pereira’s multidisciplinary team is able to preserve length and number of functioning joints to maximize motion in the affect extremity. Individuals with amputations of the distal third of the foot (transmetatarsal level) often achieve near normal mobility with the aid of a custom insole. As the amputation level rises so does the energy expenditure necessary to walk. A below knee amputation (BKA) requires a 25% and an above knee amputation (AKA) requires 65% more energy expenditure in order to ambulate. Therefore reducing the level of amputation is essential for an individual’s long-term function.

Complications of Diabetes
More than 2 million of the estimated 14 million Americans living with diabetes will develop foot ulcers at some time in their life. Without appropriate treatment these wounds rapidly become limb threatening. In fact more than 45% of all non-traumatic amputations are performed for diabetes and its related problems.

The causes of diabetic foot ulcers are multi factorial. Poor circulation (PAD), loss and lack of sensation (neuropathy) and an impaired immune response system are some of the major contributing factors to the development of diabetic foot ulcers. Local problems such as calluses, deformed nails, inadequate foot and ankle hygiene and poorly fitting shoes also play an important role.

Individuals with diabetes are educated to take an active role in their overall health and ulcer prevention. Daily inspections of the feet can be performed with a hand held mirror. Their feet can be washed daily in lukewarm water that has been tested with the more sensitive part of the hand. Mild lotions are utilized to keep the skin well hydrated. Calluses and nail abnormalities should be under the careful watch of a podiatrist.

Tight blood sugar control can further decrease risk of ulcer formation. Close monitoring of high blood pressure with lipid lowering therapy, in conjunction with proper diet and discontinuing smoking can all decrease the development of PAD and neuropathy. Customized insoles and shoes can be fashioned to off-load regions of concern and accommodate bony abnormalities.

Generally a healthy lifestyle with a weight reduction and a moderate exercise program guided by the primary physician are beneficial in further reducing risk of diabetes related foot and ankle complications.