Written for attorneys evaluating lower-extremity cases. This is general education about how these matters are assessed clinically. It is not medical advice, not legal advice, and not an opinion about any particular case — every case turns on its own record.
Diabetic limb-loss cases are among the most common podiatric claims and among the hardest to evaluate. The patient is usually sick before anyone did anything wrong, which gives the defense a real causation argument from day one. The cases that hold up are the ones where the record shows a specific, datable failure and a plausible different outcome.
The clinical chain
Most amputations in this population follow a recognisable sequence: neuropathy means the patient cannot feel a pressure point; a callus or deformity concentrates load; the skin breaks down; the wound becomes colonised and then infected; infection reaches bone; and if perfusion is inadequate, nothing heals. Each link is a place where appropriate care can interrupt the chain, and each is a place where the record either shows an intervention or does not.
Where these cases most often break down
They are the first things an amputation expert witness should check, because they are where most of these claims turn.
- Perfusion never assessed. No pulse exam, no ankle-brachial index, no vascular referral, in a patient whose wound is not healing. A wound cannot heal without blood supply, and treating one for months without asking that question is difficult to defend.
- Offloading never actually achieved. Telling a patient to stay off the foot is not offloading. The record should show a device, a plan, and whether the patient could realistically comply.
- Infection recognised late. Fever is often absent in these patients. Increasing drainage, odour, probing to bone, or a wound that suddenly enlarges are the signals; a chart that records those findings and does nothing is a problem.
- Osteomyelitis not investigated. A wound that probes to bone, or that sits over a bony prominence and will not close, raises the question. Whether imaging or biopsy followed is usually documented one way or the other.
- No escalation. The same debridement and the same dressing, week after week, with a wound that is measurably not improving.
- Handoff failures. Referrals made but never scheduled, results never followed up, or a patient discharged from care without a plan.
The defense case, stated fairly
An honest evaluation has to take these seriously, because juries do:
- Advanced peripheral arterial disease that no podiatric care could have overcome
- Poorly controlled glycemia over years, documented in the primary care record
- Continued smoking
- Missed appointments, or a patient who would not wear the offloading device
- An infection that progressed faster than any reasonable follow-up interval would have caught
Where those factors dominate the record, the case may still be a departure case, but it is often not a causation case — and that distinction is worth knowing before an expert is retained rather than after.
What makes a strong file
- Complete podiatric office notes, including the wound measurements at each visit
- Photographs, if any were taken — these are often decisive
- Vascular studies and any vascular consult
- Imaging, including plain films and any MRI or bone scan
- Culture and pathology results
- Hospital records for the admission that led to amputation
- Primary care and endocrinology records for the same period
- Phone and portal messages between visits
With that set, a preliminary read is usually possible quickly: whether there is a datable departure, whether the timeline supports a different outcome, and whether the underlying disease swallows the claim.
Related reading
- Wound care and diabetic foot ulcer expert witness — how the ulcer itself was managed before it became a limb-loss case
- What a podiatric malpractice case has to prove — the four questions that decide most claims
- Records to send for a podiatric case review — including the vascular studies these cases turn on
- Case types reviewed — diabetic ulceration, infection and limb loss among them
- Expert witness services — record review, written opinions, IMEs and testimony
Have a case like this?
Send the parties, the venue and a short description. I will run a conflict check and tell you plainly whether the record supports the theory. No charge for that first conversation.
Dr. Tom Biernacki, DPM, FACFAS is a double board-certified foot and ankle surgeon in active practice in Howell and Bloomfield Township, Michigan. He reviews podiatric malpractice and lower-extremity injury cases for plaintiff and defense counsel, performs independent medical examinations, and testifies at deposition and trial.