Skin graft or amputation (edema and arthritis comorbidities)?

You are very correct to be very worried. In all truth circulatory and non-healing issues become an ongoing nightmare and I as a nurse in cardiology often thought of it as the old Chinese death sentence of "death by 1,000 cuts". Once the circulation fails to allow healing (and this was most common with diabetics but happen also with many others) it is one surgery after another.

I would discuss, as your dad is rational, his own wishes now and going forward and have as honest a discussion with doctors as you are able. In the (common, sorry) event of any sepsis that is systemic, what would you father want? Does he want a vent, and all heroic measures or would he prefer Hospice and medications with palliative care.

Your dad is an individual as unique as his own thumbprint. There is almost no way to predict what is best now, what might work best for him or what future "complication" could happen. This is a day at a time and I would ask you to tell the doctors to LEVEL with all HONESTY with you and your dad about his chances. None of this "I have seem....." and their wonderful stories, but the honest statistical facts given this patient they KNOW in terms of his ability to sustain treatment modalities of different type.

You can only make your best guesses going forward.
I hope Dad has the best docs in the world. Help him make the decision he feels is best for him. He has complications that are going to make this very tough indeed. He will not be able to have home care imho but will require SNF and possible placement if PT cannot get him back on his feet. He should be ready for that eventuality. He is 80. I am 81 facing down a new breast cancer which I will treat MINIMALLY and allow nature to take its course. That is my decision for myself. I am not a fighter. I do not fear death whatsoever, but I DO fear being caught in the medical system at the end; that is honestly worse than anything the inquisition had to offer, in some instances. I have had a good life; I am well satisfied. I recognize I am closing in on the end of it.

I wish you and your dad the best. He has your love; that's VERY important.

As a related aside on your Dads RA, you mentioned it “was reasonably under control on biologics”. So is he still on bio alone, like Humira? Or on Plaquenil? Or did he get switched back to old school Methotrexate / MTX plus prednisone? Or biologic & MTX?

My hubs has RA, was dx’d last year and went onto prednisone & MTX and around the same time had retina detachment surgery. Well MTX adversely affects healing as it slows down scar tissue growth bc it’s an immunosuppressant. For some, slow healing isn’t a huge issue, but it might be for your dad as he’s had cellulitis and edema. You don’t want him on anything that impairs wound healing if it can avoided. It’s something to discuss with his rheumatologist.

Not exactly related, my dad had an extensive skin graft, skin taken from his thigh and placed on his head, in a skin cancer treatment. He has in his upper 80’s at the time with progressive CHF. The healing was horribly slow, both on the leg and head, taking most of a year. It never looked well in either place. In my dad’s case, I found the whole thing to be ill advised, as it would have taken more than 20 years to really cause his end. My dad walked a slow, shuffling walk his last years, with multiple falls, but his wasn’t only the ill advised surgery, CHF and its accompanying fluid overload was at work. Your dad is in a different position. I’d advise the best vascular specialist you can find, along with getting the most realistic prognosis about recovery. I wish you all the best in finding the best plan

I know that you understand that no matter our histories, we none of us are qualified as doctors to advise you. Even were we doctors, we do not know this patient, and that is CRUCIAL. I am an OLD RN, long retired, more than two decades, so I want you first to understand that ANYTHING I say here is to be taken with a grain of salt. Your best advice now comes from doctors. Ask for specialists. You are dealing with someone with vascular insufficieny of the lower extremities and with edema that may be indicative of some modicum of heart failure. There has already been a DVT, and these are DEADLY when thrown to the lungs. This is a very ill man and WHATEVER choice is now made, I know the doctors will inform you, will mean that outcome is touch and go, perhaps for the rest of his life.

You do not mention under co-morbidities any diabetes.
I hope that is the case, for I would be truly worried to hear that added onto these problems.

Again, this is touch and go stuff and you want the opinions of a GOOD VASCULAR specialist, a good and thorough heart exam with testing, and to know conditions of lungs, and etc. You already will know that there is a danger to anesthesia due to age and due to condition. An amputation MAY be longer duration than skin grafting and with need for longer and more potent sedation. A lumpectomy was recently recommended for my cancer rather than a mastectomy simply because I am 81 and the difference in a 1 1/2 hour versus a 4 hour surgery can mean a lot for outcome without any danger of dementia due to anesthesia.

I am trying to give you all the things that need to be considered here, and the next thing for consideration, other than your loved one OWN WISHES is what amputation means. Often they do not heal. Especially in aged. As an RN I often saw amputation patients many times due to their need for revision of stump, due to non-healing and infection, and often for further, higher amputation.
Skin grafts in this area will be difficult to heal if there is not wound care specialist followup. That may mean SNF for some months. That means painful dressings. That means that any edema could ruin the grafting no matter the care taken.

I am sorry to lay all the bad news upon you but people do fail to know that the sloughing of skin due to edema can have terrible consequences. You are there now, and likely this could not have been prevented even with diuretics and good elevation of limbs. But it is tough now and I must tell you to make the best decisions you can after having doctors DISCUSS ALL OF THE RISKS with you. If they don't have time to talk with you at length then you need another opinion, as this is a must.

I am so sorry you are facing this down.
I hope you will update us on your decision.
I hope I haven't scared you too badly and I just want you to know all that COULD BE involved here. I truly do wish you the very best of luck.