Below the knee amputation for ischemic gangrene. Comparative results of conventional operation and immediate postoperative fitting technic

Two technics of below the knee amputation-rehabilitation are presented. The results of a standard operative technic are compared with those of amputation with immediate postoperative fitting of a prosthesis. In every parameter of comparison the group receiving an immediate postoperative prosthesis was superior as evidenced by a zero mortality compared to 15 per cent in the standard group, an 85 per cent primary healing rate compared to 53 per cent, and 100 per cent rehabilitation compared to 85 per cent. The time from amputation to fitting of a permanent prosthesis was 32 days in the group with an immediate postoperative prosthesis as compared to 125 days in the standard amputation series. A combination of factors comprising the immediate postoperative prosthesis program, including a long posterior flap, rigid dressing, and immediate ambulation, seems to account for the improved results in this amputation series.     

Open transmetatarsal amputation in the treatment of severe foot infections

Severe forefoot infections may lead to limb loss, even if addressed aggressively. Infection or gangrene that compromises the plantar skin flap may preclude a standard transmetatarsal or midfoot amputation, thereby culminating in a below-knee amputation. We report a series of forefoot infections with loss of the distal plantar skin. Open or guillotine amputation at the mid-metatarsal level led to a high rate of healing and a durable stump, provided that the level of infection did not extend beyond the metatarsal heads. Wound closure was obtained by wound contracture alone or by use of partial-thickness skin grafting. Rehabilitation was dependable. The association of diabetes mellitus or gangrene did not adversely affect outcome. Open transmetatarsal amputation is a safe surgical option preferable to midfoot or below-knee amputation for the treatment of severe forefoot infection that does not extend proximally beyond the metatarsal heads.     

Influence of transmetatarsal amputation in patients requiring lower extremity distal revascularization

When a transmetatarsal amputation (TMA) is required, successful long-term limb salvage is questioned. We evaluated the influence of TMA on limb salvage in patients undergoing lower extremity revascularization. Patients who had distal bypasses extending to the infrapopliteal arterial tree and adjunctive TMA were retrospectively reviewed. Limb salvage was determined with life-table analysis. Twenty-four patients (29 limbs) were evaluated: 15 male and 9 female. Average age was 64.2 years old. Gangrene was the indication for bypass and TMA in 25 (86.2%) patients. Seven limbs were lost to follow-up. Nine of the remaining 22 limbs required below-knee (8) or above-knee (1) amputations, seven limbs within the first 3 months. In the group of patients who had major amputations within the first 3 months, graft thrombosis was the cause of leg amputation in six (85.7%) cases. No significant predictors of early major amputation were identified. Limb salvage was 62 per cent at 1 year in the TMA group. In comparison, among historical controls requiring distal revascularization and no adjunctive toe or foot amputations, limb salvage was 76.5 per cent (P = NS). Long-term limb salvage is dependent on successful lower extremity revascularization. Requirement for TMA should not influence the decision for limb salvage.     

Two stage amputation for diabetic gangrene of leg

In summary, the simplest amputation that provides drainage and undisturbed vascular distribution is offered as a means of controlling the deathrate in diabetic gangrene.     

Medial forefoot fillet flap for primary closure of transmetatarsal amputation: A series of four cases

Amputation of the forefoot is a salvage procedure for several forefoot acute or chronic infection. A good, sensate and durable skin cover is important for quicker and better rehabilitation. The use of filleted flaps (or “spare parts technique”) has been published in the past as a creative technique. The purpose of this article is to introduce a reproducible, pre-planned, technique that requires less creativity for the use of the “spare parts”.The authors describe a case series of 4 patients with deep infection and osteomyelitis of the forefoot, without involvement of the medial skin that underwent two staged procedure for transmetatarsal amputation with medial forefoot fillet flap.The first procedure was amputation of the 4 lesser metatarsal and the wound was left open. After a few days the second operation was done with amputation of the first metatarsal bone and using the filleted medial skin and subcutaneous tissue for closure of the wound.In conclusion the medial fillet flap is an effective method of covering large wounds after partial, lateral forefoot amputation. This method shortens the healing time of the patient, and in hospital stay. The authors recommend using the staged method when dealing with diabetic patients with partial, central and lateral forefoot deep infection and/or necrosis.     

Hemoglobin and hematocrit as risk factors in below-the-knee amputation for incipient gangrene

Summary The relationship between complication rate and preoperative levels of hemoglobin and hematocrit was investigated in 186 consecutive below-the-knee amputations for incipient gangrene. Arteriosclerotic amputations had successively higher rates of wound complications and reamputation with increasing hemoglobin and hematocrit. No such association was found among diabetics. Thus, hemoglobin 7.0 mmol/l and hematocrit 40 were significant preoperative risk factors in below-the-knee amputation for arteriosclerotic incipient gangrene.     

Hemoglobin and hematocrit as risk factors in below-the-knee amputation for incipient gangrene

The relationship between complication rate and preoperative levels of hemoglobin and hematocrit was investigated in 186 consecutive below-the-knee amputations for incipient gangrene. Arteriosclerotic amputations had successively higher rates of wound complications and reamputation with increasing hemoglobin and hematocrit. No such association was found among diabetics. Thus, hemoglobin greater than or equal to 7.0 mmol/l and hematocrit greater than or equal to 40 were significant preoperative risk factors in below-the-knee amputation for arteriosclerotic incipient gangrene.