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

Abstract

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.

Spectrum of disease and outcome of primary amputation for diabetic foot sepsis in rural KwaZulu-Natal

“…All patients who had a failed primary BKA and re-amputation to the above knee level had either aortoiliac or femoropopliteal artery occlusive disease which would have been a major risk factor for stump failure due to ischemia. 2 Mcintyre and colleagues have also shown that a primary amputation in the setting of foot sepsis in a mixed cohort has a lower success rate than a staged amputation (78% vs. 97%) and conversion from BKA to AKA was 11% in the primary amputation group. 4 Furthermore, a revision to below knee level after a guillotine amputation has been shown to have a failure rate of 5.9% vs 33% when a primary BKA was done for diabetic foot sepsis; the cause of stump failure was attributed to stump sepsis.…”

“…Guillotine amputation for diabetic foot sepsis followed by elective stump closure is widely practiced. 2,4,[5][6][7][8] The concern with primary amputation has been the high risk of stump sepsis, necessitating re-amputation to the above knee level which has a major impact on rehabilitation and quality of life.…”

“…Patients undergoing a primary BKA (skin and muscle flap closure) had a reamputation (conversion to above knee level) rate of 33.3% while those undergoing a guillotine amputation followed by a revision within seven days had a re-amputation rate of 7.7%. 2 In view of these findings, it has become common practice to adopt a two stage approach to amputations in the setting of extremity sepsis.…”

What Is Currently the Role of TcPO2 in the Choice of the Amputation Level of Lower Limbs? A Comprehensive Review

“…It has been shown that serum albumin levels are associated with success or failure of the healing procedure [31]. Preoperative treatment of infected lesions in the relevant limb has also been shown to reduce the subsequent morbidity [32].…”

The influence of diabetes mellitus on early outcome following carotid endarterectomy

“…[5] There is sufficient evidence that DM increases early morbidity following other vascular surgical interventions. [6,7] This study was undertaken to assess the influence of DM on early outcome following CEA.…”