One-stage versus two-stage amputation for wet gangrene of the lower extremity: a randomized study

Although the two-stage amputation technique entails an additional operation, several authors have advocated this approach to deal with wet gangrene because it allows primary wound closure with a reduced chance of wound infection. To examine this issue, 47 patients with necrotizing wet gangrene of the foot were randomized prospectively to receive either a one-stage amputation (definitive below- or above-knee amputation with delayed secondary skin closure in 3 to 5 days) or a two-stage amputation (open ankle guillotine amputation followed by definitive, closed below- or above-knee amputation). Antibiotic coverage was standardized with clindamycin and gentamicin used in all patients. Preoperative blood cultures and intraoperative foot cultures were obtained, as well as cultures from the deep muscle and lymphatic area along the saphenous vein to determine the presence of bacteria at the level of initial amputation. Twenty-four patients (11 diabetic and 13 nondiabetic) were randomized to the one-stage procedure. Twenty-three patients (14 diabetic and nine nondiabetic) were randomized to the two-stage procedure. Five of 24 patients in the one-stage group (21%) had positive muscle cultures vs 10 of 23 patients in the two-stage group (43%). Two of 24 patients in the one-stage group (8%) had positive lymphatic cultures vs 7 of 23 patients in the two-stage group (30%). Five of 24 patients in the one-stage group (21%) had wound complications attributable to the amputation technique vs none of 23 patients in the two-stage group (p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

A reappraisal of a modified through-knee amputation in patients with peripheral vascular disease

BACKGROUND: Through-knee amputation provides a longer lever arm and improved muscle control of the limb compared with above-knee amputation. Through-knee amputation also allows use of a total end-bearing prosthesis, which avoids the ischial pressure and suspension belts required of the above-knee amputation prosthesis. Several reports in the European literature tout the superiority of the through-knee amputation over the above-knee amputation in the patient with vascular disease. Through-knee amputation has received little attention in the United States, however, owing to the belief that the long flaps necessary to close a standard through-knee amputation are associated with an unacceptable rate of wound problems and offer no functional ambulatory advantage to above-knee amputation. We reviewed our experience with a modified technique of through-knee amputation in a group of patients with severe lower extremity ischemia who were not candidates for below-knee amputation to determine the incidence of wound complications and their functional outcome. METHODS: Since 1996, 12 patients with severe lower extremity arterial insufficiency have undergone through-knee amputation utilizing a technique designed to limit flap length and facilitate the fit of a suction prosthesis. Two patients died of myocardial infarction in the immediate postoperative period and were excluded from the study. In the remaining 10 patients (1 man, 9 women; mean age 63 years (range 40 to 86), the below-knee amputation level was precluded because of gangrene or nonhealing wounds of the mid leg in 5 patients, failure of a previous below-knee amputation attempt in 4 patients, and severe ischemia that would compromise below-knee amputation healing in 1 patient. Nine patients had at least one failed vascular reconstruction procedure. RESULTS: Mean follow-up is 25 months (range 6 to 41). Six (60%) patients had primary healing of their amputations. Two (20%) patients had delayed healing (6 weeks and 8 weeks). Two (20%) patients developed wound infections, which required amputation revision to the above-knee level. Seven (70%) patients were fitted with a suction socket prosthesis and are fully ambulatory. One patient healed but has not ambulated because of ischemia and subsequent ulceration of the contralateral limb. CONCLUSIONS: These data show that through-knee amputation is associated with an acceptable primary healing rate (80%) and satisfactory functional outcomes (70% ambulation) in a high-risk vascular population. The functional advantages of through-knee amputation over above-knee amputation make it the preferred alternative for patients with vascular disease.     

Segmental amputation for recurrent malignant bone tumors of the distal femur

We describe an alternative method for lengthening a short femoral stump after wide amputation of a malignant bone tumor of the distal femur in two patients. The method consists of two procedures during the operation. The first procedure is amputation of the affected cylindrical segment of the involved limb. The second procedure is elongation of the amputation stump using the tumor-free segment of the ipsilateral lower leg as a free composite osseous myocutaneous graft. Both patients had good function and were satisfied with the results with no complications or tumor recurrence 4 years postoperatively. We think the segmental amputation is a good procedure that results in a longer functional stump in patients who have above-knee amputation.     

Occult femoral artery injury in a case of closed fracture of the femur revealed during guillotine above-knee amputation: a case report

Arterial injury is most commonly seen with penetrating injuries. An arterial disruption in a closed fracture is rare. It has been reported in only 0.3% of long bone fractures. The authors report a case of femoral artery injury in a polytrauma patient associated with a closed femoral fracture. The arterial injury was not apparent until the patient had an above-knee guillotine amputation done to revise his ipsilateral below-knee traumatic amputation, which released the soft -tissue tamponade effect on the leak. Unless the possibility of this injury is kept in mind, above-knee amputation or any other open procedure on a patient with a femoral fracture can cause exsanguination of the patient.     

Gangrene of the immediate postoperative above-knee amputation stump: role of emergency revascularization in preventing death

Two hundred seventy-five lower extremity amputations were performed over a 4-year interval for end-stage peripheral vascular disease. Fourteen patients (8.5%) of a total of 165 patients undergoing above-knee amputation (AKA) either suffered acute gangrenous ischemia of the AKA stump postoperatively, or were thought to be at high risk for same, and therefore underwent prophylactic inflow revascularization prior to or concomitant with AKA. The overall operative mortality rate was 28.5% in these 14 patients and was related either to inability to revascularize (two of three patients) or to the attempt to revascularize in the presence of a frankly necrotic amputation stump (three of five patients). Lower extremity amputation may be performed with an overall acceptably low mortality rate, which for our series is 0.9% for 113 below-knee amputation (BKA) and 2.8% for 140 AKA levels. Acute postoperative gangrene of the stump carries a high mortality rate and may be prevented by inflow revascularization prior to amputation. Three situations were identified as carrying a high risk for the subsequent development of gangrene: acute thrombosis of a prior combined inflow/outflow procedure, occlusion of the superficial femoral artery with an occluded/stenotic deep femoral artery and no palpable femoral pulse, and flat pulse volume recordings at the high thigh level. Patients who present for AKA with one of these indications should be considered as a candidate for prophylactic inflow revascularization prior to AKA to prevent ascending gangrene.     

Hip disarticulation: factors affecting outcome

Hip disarticulation, especially in patients with peripheral vascular disease, has been associated with high morbidity and mortality rates. This report describes patient characteristics that influence the clinical outcome of hip disarticulation. The medical records of all patients undergoing hip disarticulation from 1966 to 1989 were reviewed for surgical indication, perioperative wound complications, and postoperative deaths. Fifty-three patients underwent hip disarticulation for limb ischemia (10), infection (12), infection and ischemia (14), or tumor (17). The overall incidence of wound complications was 60%, and no significant differences were found among the groups. Prior above-knee amputation and urgent/emergent operations were significantly associated with increased wound complications (p less than 0.05). The overall mortality rate was 21%, ranging from 0% (tumor) to 50% (ischemia) and differed significantly among the groups (p less than 0.02). Mortality was significantly associated with urgent/emergent operations (p less than 0.01). Age, diabetes mellitus, and previous inflow procedures did not influence mortality rates. The presence of limb ischemia influenced mortality rates to a greater extent than did infection, and a history of cardiac disease was statistically predictive of death. Wound complications frequently accompanied hip disarticulation, regardless of operative indication, and were significantly increased by urgent/emergent operations and prior above-knee amputation. Hip disarticulation can be performed with low mortality rates in selected patients. Both limb ischemia and infection substantially increase operative mortality rates.     

Management of ischemic heel ulceration and gangrene: An evaluation of factors associated with successful healing

OBJECTIVE: The objective of this study was to determine the effectiveness of treatment of nonhealing heel ulcers and gangrene and to define those variables that are associated with success. METHODS: A multi-institutional review was undertaken at four university or university-affiliated hospitals of all patients with wounds of the heel and arterial insufficiency, which was defined as absent pedal pulses and a decreased ankle/brachial index (ABI). Risk factors, hemodynamic parameters, and arteriographic findings were statistically analyzed to determine their effect on wound healing. Life-table analysis was used to assess graft patency and wound healing. RESULTS: Ninety-one patients (57 men, 34 women) were treated for heel wounds that did not heal for 1 to 12 months (62% of nonhealing wounds, 3 months or longer). The mean preoperative ABI was 0.51, and 31% of wounds were infected. Of the patients, 55% had impaired renal function (Cr > 1.5), with 24% undergoing dialysis, 70% had diabetes, and 64% smoked cigarettes. Treatment was topical wound care for all patients and operative wound débridement in 50%. Infrainguinal bypass was performed for 81 patients, 4 had inflow procedures, 3 had superficial femoral artery percutaneous transluminal angioplasty, and 3 had primary below-knee amputation. Postoperatively, 85% of patients had in-line flow to the foot with at least a single patent vessel, 66% had a pedal pulse, and the mean ABI improved by 0.40, to 0.91. Follow-up ranged from 1 to 60 months (mean, 21 months), and 77 patients (85%) are currently alive. In 66 patients (73%), the wounds healed-all within 6 months (mean, 3 months). For 14 (16%) the wounds had not healed, and 11 patients (11%) underwent below-knee amputation. By life-table analysis, limb salvage was 86% at 3 years. During follow-up, 75 infrainguinal bypasses (91%) remained patent (3 secondarily) and 6 occluded, with primary assisted patency of 87% at 3 years. All wounds in patients with occluded grafts failed to heal. Variables found to be statistically significant in predicting healing included normal renal function (95% healed vs 55% nonhealed, P <.002), a palpable pedal pulse (85% healed vs 42%, P <.0015), a patent posterior tibial artery past the ankle (86% healed vs 57%, P <.02), and the number of patent tibial arteries after bypass to the ankle (P <.0001). Neither the ABI nor the presence of infection (defined as positive tissue cultures or the presence of osteomyelitis), diabetes, or other cardiovascular risk factors influenced the outcome. CONCLUSIONS: Complete wound healing of ischemic heel ulcers or gangrene may require up to 6 months, and short-term graft patency is of minimal benefit. Successful arterial reconstruction, especially a patent posterior tibial artery after bypass, is effective in treating most heel ulcers or gangrene. Patients with impaired renal function are at increased risk for failure of treatment, but their wounds may successfully heal and they should not be denied revascularization procedures.     

Negative pressure wound therapy via vacuum assisted closure following partial foot amputation: what is the role of wound chronicity?

Randomised clinical trials (RCTs) to evaluate diabetic foot wound therapies have systematically eliminated large acute wounds from evaluation, focusing only on smaller chronic wounds. The purpose of this study was to evaluate the proportion and rate of wound healing in acute and chronic wounds after partial foot amputation in individuals with diabetes treated with negative pressure wound therapy (NPWT) delivered by the vacuum-assisted closure (VAC) device or with standard wound therapy (SWT). This study constitutes a secondary analysis of patients enrolled in a 16-week RCT of NPWT: 162 open foot amputation wounds (mean wound size = 20.7 cm(2)) were included. Acute wounds were defined as the wounds less than 30 days after amputation, whereas chronic wounds as the wounds greater than 30 days. Inclusion criteria consisted of individuals older than 18 years, presence of a diabetic foot amputation wound up to the transmetatarsal level and adequate perfusion. Wound size and healing were confirmed by independent, blinded wound evaluators. Analyses were done on an intent-to-treat basis. There was a significantly higher proportion of acute wounds (SWT = 59; NPWT = 63) than chronic wounds (SWT = 26; NPWT = 14), evaluated in this clinical trial (P = 0.001). There was no significant difference in the proportion of acute and chronic wounds achieving complete wound closure in either treatment group. Despite this finding, the Kaplan-Meier curves demonstrated statistically significantly faster healing in the NPWT group in both acute (P = 0.030) and chronic wounds (P = 0.033). Among the patients treated with NPWT via the VAC, there was not a significant difference in healing as a function of chronicity. In both the acute and the chronic wound groups, results for patients treated with NPWT were superior to those for the patients treated with SWT. These results appear to indicate that wound duration should not deter the clinician from using this modality to treat complex wounds.     

Results of percutaneous subintimal angioplasty using routine stenting

OBJECTIVE: To assess the long-term patency and clinical success of subintimal angioplasty in patients with limb-threatening ischemia. METHODS: From 1999 through 2004, 29 patients with superficial femoral artery (SFA) or popliteal artery occlusion and rest pain or tissue loss underwent subintimal angioplasty. Patients had subintimal wire placement followed by percutaneous transluminal angioplasty and stent placement. From 1 to 10 stents were placed. Technical success required stenosis less than 30% by arteriography, a velocity ratio less than 1.5 by duplex scan, and improvement of the ankle-brachial index greater than 0.15. Follow-up duplex scanning was performed every 3 months for 2 years and then every 6 months thereafter. RESULTS: Initial success was obtained in 26 (90%) of the 29 patients, with an improvement in the mean ankle-brachial index of 0.25. Mean follow-up was 38 months (range, 28-54 months). During follow-up, 16 arteries reoccluded. Six of the 16 patients had recurrent symptoms, four required below-knee amputation, two required above-knee amputation, and four died with an intact limb. After treatment failure, two patients had attempted tissue plasminogen activator (TPA), and four had prosthetic tibial bypass. Overall, 15 patients died, and only 2 of the 14 who lived had a patent artery. One of the two required percutaneous transluminal angioplasty of the recanalized artery. By life-table analysis, success was 85%, 64%, 18%, and 9% at 1, 2, 3, and 4 years, respectively. Periprocedural complications occurred in four patients. Of the 13 patients with wounds, six died (four healed), two were alive with healed wounds, and five had limb loss. Of 16 patients with rest pain, 14 developed recurrent symptoms after reocclusion, 1 was alive without pain, and 1 underwent amputation. CONCLUSIONS: Subintimal angioplasty is technically successful in most patients, with few complications. Most procedures provide short-term clinical success and have allowed for successful wound healing and temporary relief of rest pain. However, late arterial patency is poor, with a high rate of symptom recurrence. Many patients will have recurrent pain, and some will require major amputation. Nevertheless, limb-salvage rates are significantly better than arterial patency. Intermediate-term patency is higher than that commonly reported for prosthetic bypass, and despite the lack of durable long-term patency, the procedure offers an additional potentially effective therapeutic option in the treatment of patients with limb-threatening ischemia and femoropopliteal occlusion.     

Management of infected lower extremity autologous vein grafts by selective graft preservation.

Between 1975 and 1991, we treated 16 patients with infected lower extremity autologous vein grafts performed for limb salvage by complete graft preservation. Traditional treatment of these infections includes immediate graft excision and complex revascularization procedures to prevent limb loss. The infection involved an intact anastomosis in 12 patients or the body of a patent graft in 4 patients. None of the patients was systemically septic. All patients were treated with appropriate intravenous antibiotics. Six patients were treated by placement of autologous tissue on the exposed graft (4 rotational muscle flaps, 2 skin grafts), and 10 were treated with antibiotic-soaked dressing changes and repeated operative débridements to achieve delayed secondary wound healing. This treatment resulted in a 19% (3 of 16) mortality rate and an 8% (1 of 13) amputation rate in survivors. Of the six patients managed by autologous tissue placement onto the infected graft, five patients had wounds that healed without complications, and one died of a myocardial infarction. Of the 10 patients treated by delayed secondary wound healing, 2 developed anastomotic hemorrhage, which resulted in death in 1 patient and above-knee amputation in the other, 1 died of a myocardial infarction, 1 developed graft thrombosis, and 6 had wounds that healed. Placement of autologous tissue to cover an exposed, infected patent vein graft with intact anastomoses may prevent graft dessication, disruption, and thrombosis, which renders graft preservation an easier, safer method of treatment compared with routine graft excision.     

Through-knee amputation in high-risk patients with vascular disease: indications, complications and rehabilitation

During a 10-year period 104 patients (mean age 72 years) had 106 through-knee amputations. Indications for surgery were: limb gangrene, 67 (64 per cent); ischaemic ulceration, 22 (21 per cent); rest pain, 9; knee contractures, 6. Thirty patients had had previous unsuccessful vascular reconstructive surgery and five had had a failed femoral embolectomy. The through-knee disarticulation used lateral skin flaps. The mortality was 21 (20 per cent). Of the 83 survivors, 59 (71 per cent) underwent uncomplicated primary wound healing; 36 (43 per cent) of the survivors were unsuitable for rehabilitation on a prosthesis. The remaining 47 (57 per cent) were walking before discharge 30-130 days (mean 68 days) after amputation. Through-knee amputation is a rapid, relatively bloodless, amputation and is a useful debridement procedure. The many surgical and functional advantages, in conjunction with the recent reports of better rehabilitation compared with the above-knee or Gritti-Stokes amputation, suggests that the through-knee amputation deserves greater consideration.     

Staged below-knee amputations for septic peripheral lesions due to ischaemia

Preservation of the knee joint is of paramount importance in lower limb amputation for ischaemia. Clinical predictors of healing are unreliable in patients with septic peripheral lesions due to ischaemia. Seventy-three patients in whom a below-knee amputation was considered likely to heal, based on the temperature and appearance of the skin and bleeding from skin and muscle flaps, were divided into two groups. Twenty-nine (Group A) had a primary below-knee (BK) amputation at the site of election with delayed primary skin closure, while 44 patients (Group B) initially had a guillotine BK amputation below the site of election, with elective amputation at the appropriate level once infection had been eradicated (4-5 days later). The groups were similarly matched with regard to level of occlusive arterial disease, nature of ischaemic lesions and operative risk factors. There was no significant difference in the overall operative mortality in Group A (6.7 per cent) compared with Group B (11.4 per cent) (P greater than 0.05). There was a significantly higher above-knee revision rate in Group A survivors (33.3 per cent) compared with Group B (7.7 per cent) (P less than 0.01) due to non-viability and uncontrolled sepsis of the BK amputation site. The presence or absence of a palpable femoral or popliteal pulse had no significant influence on healing in either group.     

Syme Amputation for Limb Salvage: Early Experience with 26 Cases

The Syme amputation is often overlooked as an alternative to below-knee amputation or above-knee amputation in cases of limb-threatening foot infections and gangrene. Even though the advantages of the Syme amputation over major amputation are well cited in the literature, many surgeons do not view this amputation as a viable option for limb salvage. We herein present our initial experience with this operation in a series of patients at imminent risk for major lower extremity amputation. This study included our initial 26 patients at high risk (92% had diabetes) with infection and/or significant peripheral arterial disease who underwent ankle disarticulation for limb salvage. Medical records were abstracted for pertinent demographic and clinical data. Variables of interest included diabetes status and duration, presence of peripheral arterial disease, infection, osteomyelitis, and gangrene. Our primary outcome variable was a healed amputation, whereas secondary outcomes included time to healing, subsequent major amputations, and complications. Despite prior recommendation for below-knee amputation or above-knee amputation in each of these patients, 50% remained healed at an average of 49.3 weeks of follow-up. Although 17 patients (65.4%) ambulated in a Syme prosthesis after healing of the original Syme operation, several patients went on to major amputation for progressive sepsis or recurrent ulcers, and 1 patient subsequently died. Because of the relatively small number of study subjects, we could find no significant predictors of success or failure of this procedure. However, all 10 patients eventually succumbing to major amputation and all 3 patients who died during follow-up had diabetes mellitus. At the end of follow-up, 46.2% (12/26) patients were functioning well in a Syme prosthesis. In this high-risk cohort of patients in whom major amputation had been recommended, we achieved a healing rate of 50% at an approximate 1-year follow-up. With the majority of patients having diabetes and peripheral vascular disease, we could not find any clear predictive factors for failure or successful outcome in this small population. Nonetheless, the Syme amputation deserves further study and consideration as a viable limb salvage option in patients threatened with major lower extremity amputation.     

Use of Doppler pressure measurements in predicting success in amputation of the leg

Fifty-five patients underwent amputation of the leg. Fifty-eight percent of the amputations were above-knee and 32 percent below-knee. Preoperative Doppler ankle blood pressure measurements and $\text{ankle}\text{brachial}$ ratios were compared and correlated with wound healing in patients with below-knee amputation. Statistical analysis documented that such measurements were significant in predicting wound healing. If blood pressure greater than 55 mm Hg at the knee, greater than 70 mm Hg at the incision site or greater than 70 mm Hg at the ankle or an $\text{ankle}\text{brachial}$ ratio of at least 0.3 is documented, satisfactory healing will follow amputation.     

Intracapsular fracture of the proximal femur in a bilateral above-knee amputee: A case report with technical tips for intraoperative positioning and literature review

Intracapsular fractures of the proximal femur are one of the most common fractures of the lower limbs. Most cases require osteosynthesis with suitable implants, and intraoperative positioning of the patient on the fracture table is a prerequisite to facilitate fracture manipulation, traction, reduction and fluoroscopy assessment. However, positioning the limbs of bilateral above-knee amputees for internal fixation of related proximal femoral fractures is a difficult task, which requires customized inventory for effective limb positioning and fracture manipulation. This study reported a rare case following a crush injury of bilateral lower limb in a road traffic accident, and described some technical tips of acute femoral neck fractures in bilateral above-knee amputation. The patient was managed with immediate guillotine amputation and later secondary wound closure followed by internal fixation of the right-sided femoral neck fracture with multiple cancellous cannulated screws.     

Improved results with diabetic below-knee amputations

This study of 100 consecutive below-knee amputations in 98 diabetic patients was undertaken to review our results and to compare them with a similar report of 20 years ago. Ninety-three limbs were ischemic, and 79% of the patients had significant infection. This finding was similar to that in our previous study group. Twenty-one percent of the patients had previous arterial reconstruction, 11% had had a toe or metatarsal amputation, and 17% required a guillotine (open) amputation to control sepsis. The below- to above-knee amputation ratio was 2.3/1. The selection of level was made on clinical grounds. None of the 100 amputations required revision to above-knee amputation. The mortality rate was 3% and the wound complication rate was 18%. Eighty-three percent of the patients were ambulatory at the time of discharge, which occurred at an average of 35 days. There has been a significant improvement in the number of successful below-knee amputations performed since our previous study. We attribute these results to aggressive surgical control of infection and to close follow-up with early recognition and treatment of healing problems.     

The Stanmore knee arthrodesis prosthesis

Knee arthrodesis is most commonly performed for failed total knee arthroplasty. Conventional arthrodesis techniques are associated with a high incidence of complications and are unsuitable in cases with extensive bone loss. We report our medium-term results using a custom-made cemented knee arthrodesis prosthesis in 10 patients with a mean follow-up of 56.4 months (range, 15-199 months). The prosthesis was implanted as a 1- or 2-stage procedure for infected revision knee arthroplasty or tumor endoprosthesis in 9 patients and as a primary procedure in 1 patient with angiosarcoma involving the knee extensor mechanism. The average combined femoral and tibial bone deficit was 170 mm (range, 56-220 mm). Implant survivorship was 90%. All patients with retained prosthesis had no evidence of residual infection or loosening and were able to mobilize independently. One prosthesis was revised though retained following a prosthetic fracture, and 1 patient underwent above-knee amputation for uncontrolled infection. We conclude that the Stanmore knee arthrodesis prosthesis provides reliable fusion in an otherwise difficult-to-treat group of patients.     

Long-term follow-up of patients with rotationplasty

Introduction and importanceRotationplasty considered a limb-salvage procedure and has a lot of advantages when comparing it with endoprostheses or above-knee amputation.Case presentationWe report two cases of young patients with osteosarcoma with rotationplasty being performed for both of them.Clinical discussionPatients with rotationplasty have less restrictions in daily life activities due to pain comparing with patients with endoprostheses.ConclusionOur aim here is to confirm that rotationplasty is an applicable, successful and alternative procedure to endoprostheses or above-knee amputation, when doing it based on an accurate indication and patients regain their previous daily life activities and satisfaction.     

The mid-distal deep femoral artery: few important centimeters in vascular surgery

The deep femoral artery is an important artery in lower-limb revascularization. Employing its initial centimeters as either an inflow or an outflow site has been advocated by many authors. The purpose of this work was to highlight the importance of the mid-distal section of the deep femoral artery, underlining its indications and advantages. From January 1998 to December 2004, we performed, at the Misericordia Hospital Vascular Surgery Unit in Grosseto, Italy, 45 bypasses employing the mid-distal deep femoral artery as an inflow or outflow site. Twenty patients (44.4%) had nonhealing ulcers and/or gangrene, while the remainder (25 patients, 55.6%) presented with rest pain or severe claudication. In 41 cases (91.1%), the mid-distal deep femoral artery was used as the inflow site for peripheral bypasses. In four cases (8.9%), the mid-distal deep femoral artery was employed as the outflow site, twice (4.4%) after aortobifemoral branch thrombosis and twice (4.4%), in the same patient, after inguinal prosthetic infection healing. When the mid-distal deep femoral artery was employed as the inflow site, primary and secondary patency at 1 and 5 years were 92.72% vs. 95.20% and 57.39% vs. 72.81%, respectively. We had two early (<30 days) failures (4.4%) in patients with posterior tibial distal anastomosis, which required above-knee amputation. In two cases (4.4%), we had to perform a transmetatarsal amputation. In one patient, after healing of the inguinal prosthetic infection of an aortobifemoral bypass, we employed the mid-distal deep femoral artery both as inflow and as outflow site. This patient required a monolateral above-knee amputation after 5 months. The mid-distal deep femoral artery is a good outflow and inflow site in patients who have previously undergone surgical interventions in Scarpa's triangle, in those having inadequate vein segment, in those with local inguinal healed infection, and in obese patients. The surgical technique is a practical, easy, elegant, and fast procedure, along with being an optimal alternative to reexploration of scarred inguinal tissue.     

Débridement and primary closure of nonhealing foot wounds

Fifty-eight chronic nonhealing foot wounds (51 patients) were treated with irrigation, aggressive débridement, and primary tension-free closure. Factors such as wound location, wound size, presence of infection, and healing outcome were recorded. In addition, medical comorbidities and preoperative laboratory test results were reviewed. Thirty-seven (64%) of the 58 wounds healed after primary closure. Of the other 21 wounds, 16 healed after repeat irrigation, debridement, and closure or local wound care; 2 patients were lost to follow-up after initial failed wound healing, 1 patient died after initial failed wound healing, and 2 cases were salvaged with amputation. Failed primary closures were thought not to increase wound size; all but 3 of these closures decreased wound size significantly. Differences between the wounds that healed primarily and the wounds that failed healing were not statistically significant. Diabetes was present in 46% of the patients whose wounds healed primarily versus 71% of the patients whose wounds failed healing (P = .06). Irrigation, débridement, and primary closure of nonhealing foot wounds can be a useful treatment option for most such patients. Complete healing or reduced wound size occurs in 95% of cases.