Two-phase amputation among critically ill patients with ischemic gangrene of lower limbs as a way to improve treatment outcome. Cohort study

Abstract

Background The results of lower limb amputation, especially in critically ill patients with severe endogenous intoxication, sepsis, multi-organ failure and severe concomitant diseases are still unsatisfactory. Guillotine amputation is a method routinely used to reduce wound complications associated with wet gangrene and severe cases of diabetic foot, however, it is unclear how well it could help to decrease mortality and improve functional outcome when dealing with critically ill patients. The objective of the study was to estimate the effectiveness of two-phase method of urgent low limb amputation among critically ill patients with high risk of complications. The effectiveness was evaluated in terms of perioperative mortality, frequency of early complications and ultimate level of limb loss. Materials and methods Two cohort groups of patients with acute lower limb gangrene were retrospectively matched. Approximately 25.8% of patients from the comparison (control) group (N = 240) died without surgery due to severity of their condition and ineffective pre-operative treatment. The remaining patients underwent one-phase high-level amputation after 48–72 h of pre-operative intensive care. The experimental group consisted of 153 patients who underwent guillotine amputation at the lower part of tibia (34.6%), knee disarticulation (32.0%), or open thigh amputation (33.3%), depending on the level of irreversible soft tissue necrosis. The reamputation with the stump shaping was performed later when their health status improved. Results The assessment of treatment outcomes showed that the two-phase amputation in critically ill patients (i) decreased the mortality from 48.7 to 37.9%, (ii) reduced the risk of wound complications from 20.9 to 11.1%, and (iii) improved functional results by saving the knee joint in 34.6 versus 4.5% in comparison/control group. Conclusion The method of two-phase amputation is recommended for critically ill patients .

A Novel Utility of Bilobed Flap for Amputation Stump Coverage

“…1,9,10 Alternatively, the amputation can be left open initially with the guillotine procedure. In a cohort study by Tsvetkov et al, 11 the two-phase amputation consisting of guillotine amputation and planned final phase of surgery in critically ill patients had proven to decrease mortality from 48.7% to 37.9%, reduced the risk of wound complications from 20.9% to 11.1%, and improved functional results by saving the joint. We used guillotine amputation in crush injuries because of the need for prompt stabilization of the patient’s general condition.…”

Understanding Gangrene in the Context of Peripheral Vascular Disease: Prevalence, Etiology, and Considerations for Amputation-Level Determination

“…Once the surgeon determines that the infection is under control and the wound is suitable for closure, a definitive surgical closure is performed. Guillotine amputation provides the advantage of immediate infection control and enables a more precise determination of the level of tissue viability before final closure, reducing the risk of complications [ 42 ].…”

Outcomes in drainage ankle disarticulation vs. guillotine transtibial amputation in the staged approach to below knee amputation

“…6 Although the TTA allows for adequate source control, a tibial osteotomy is performed which potentiates tibial bacterial seeding and postoperative bleeding. 8 AD has emerged as an alternative method of drainage amputation to minimize these risks. When disarticulating the ankle joint, osteotomies are avoided as it is a technically simple procedure with minimal instrumentation.…”