A Limb is a Peninsula- and No Clinician is an Island: Introducing the American Limb Preservation Society (ALPS)

According to a well-known proverb: “if you want to go fast, go alone; if you want to go far, go together.” When caring for the at-risk lower limb, going it alone may lead to the express lane to an amputation. Unfortunately, once an amputation is performed the next stop on the express lane is often death; the 5-year mortality is 46.2% following a diabetes-associated minor amputation and 56.6% following a diabetes-associated major amputation¹. In 2014 the Society for Vascular Surgery published the WIfI (Wound, Ischemia, and foot Infection) classification system for staging lower extremities at-risk for amputation² and a subsequent meta-analysis of WIfI publications confirmed it to be predictive of one-year amputation risk³. The three risk-factors of WIfI inherently suggest the need for interprofessional collaborative efforts if at-risk limbs are to be preserved. In fact, before the publication of the WIfI classification system, several of its authors initiated concerted efforts to promote a podiatric and vascular surgery (‘Toe and Flow’) team approach to limb preservation⁴. This effort to extend the mileage traversed by at-risk limbs was a nascent recognition of the need to work collaboratively to save such limbs. The following searches, conducted on March 5^th, 2021 in PubMed, and yielding only 56 and 54 publication hits, respectively (many duplicative), confirm the historical lack of a team approach to limb preservation.

Search 1: ((interprofessional relations[MeSH Terms]) AND (amputation[MeSH Terms])) NOT (trauma)

Search 2: (diabetic foot[MeSH Terms]) AND (interprofessional relations[MeSH Terms])

With the possible exception of 3 publications prior to 1975, all publications of relevance from those searches were published in the twenty-first century. Despite the emphasis on interprofessional practice features of interdependence and shared decision making⁵ being relatively new in limb preservation, outcomes from individual studies and meta-analyses have been strong and consistent in suggesting that these teams improve care and commensurately reduce risk for amputation^6–8.

With the recent advent of the team approach to limb preservation, investigational and clinical efforts to promote an interprofessional approach to limb preservation are accelerating globally^9–15. While podiatric and vascular surgery are indisputably key components to amputation prevention teams¹⁵, unnecessary amputations remain a substantial challenge and a correspondingly substantial team is required to meet this foe. Diabetes educators, endocrinologists, infectious disease specialists, interventional radiologists and cardiologists, nurses, pathologists, pedorthists, physical therapists, plastic surgeons, clinical scientists, and many others are valiantly working to save limbs. However, the individual efforts of each respective profession in the US and abroad have previously remained largely isolated in silos and lacked a dedicated interprofessional entity tasked with pooling resources and efforts. In 2020, such an organization, The American Limb Preservation Society (ALPS- https://limbpreservationsociety.org/), was founded to advance the science and clinical care of limb preservation and to develop the next generation of clinicians, scientists and clinician scientists in the field. Its ambitious collective goal is to eliminate preventable amputations over the next generation. In the short time since its inception, ALPS has made significant progress in bringing together varied organizations with a vested interest in limb preservation. These parties are now working together collaboratively for the benefit of those facing the potential tragedy of limb loss. Having adopted the well-established diabetic foot conference DFCon (https://www.dfcon.com/) as its official annual conference; ALPS has ensured from its inception that it will have not only a national, but a global platform for promoting its initiatives. With momentum rapidly building, ALPS remains committed to seeking the broadest possible coalition in the fight for the preservation of limbs and lives. Much like Uncle Sam ‘wanting you’ to sign up to protect the USA, ALPS ‘wants you’ to join in the preservation of limbs now and in the future.