Functional Outcome After Redo Below-Knee Amputation

A Novel Strategy to Manage Below-Knee-Amputation (BKA) Stump Complications for Early Wound Healing and BKA Salvage

INTRODUCTION

The optimal management of major stump complications (operative infection or dehiscence) following below-knee-amputation (BKA) is unknown. We evaluated a novel operative strategy to aggressively treat major stump complications hypothesizing it would improve our rate of BKA salvage.

METHODS

Retrospective review of patients requiring operative intervention for BKA stump complications between 2015 and 2021. A novel strategy employing staged operative debridement for source control, negative pressure wound therapy, and reformalization was compared to standard care (less structured operative source control or above knee amputation).

RESULTS

32 patients were studied, 29 of which were male (90.6%) with an average age of 56.1 ± 9.6 y. 30 (93.8%) had diabetes and 11 (34.4%) peripheral arterial disease (PAD). The novel strategy was used in 13 patients and 19 had standard care. Novel strategy patients had higher BKA salvage rates, 100% vs 73.7% (P = .064), and postoperative ambulatory status, 84.6% vs 57.9% (P = .141). Importantly, none of the patients undergoing the novel therapy had PAD, while all progressing to above-knee amputation (AKA) did. To better assess the efficacy of the novel technique, patients progressing to AKA were excluded. Patients undergoing novel therapy who had their BKA level salvaged (n = 13) were compared to usual care (n = 14). The novel therapy's time to prosthetic referral was 72.8 ± 53.7 days vs 247 ± 121.6 days (P < .001), but they did undergo more operations (4.3 ± 2.0 vs 1.9 ± 1.1, P < .001).

CONCLUSION

Utilization of a novel operative strategy for BKA stump complications is effective in salvaging BKAs, particularly for patients without PAD.

Utilizing of Removable Rigid Dressing to Decrease Below the Knee Amputations to Above the Knee Amputations Conversion Rates

INTRODUCTION/OBJECTIVE

Below the knee amputations (BKAs) are preferred to above the knee amputations (AKAs) due to better rehabilitation and functional outcomes. Assessment of literature for best practice identified that utilization of a removable rigid dressing (RRD) improves post-operative BKA care by expediting wound healing and reduces the hospital length of stay compared to a soft dressing. We hypothesized that there would be a decrease of conversions from BKA to AKA following utilizing of RRD device.

METHODS

Retrospective chart review of all BKA performed by the vascular surgery service at a tertiary care hospital between January 2017 and December 2021. Demographic data obtained including age, body mass index (BMI), comorbid conditions, infection at time of BKA, anesthesia type, and operative blood loss. Data analyzed using Wilcoxon rank sum, Fisher's exact, and Student's t-tests. This study was approved by the institutional review board.

RESULTS

From 2017 to 2019, conversion to AKA occurred in 18 out of the 42 patients who underwent BKA (42.86%) within the first 4-week post-operative period. After the standard used of a RRD, 53 patients underwent BKA surgery, with only 4 (7.55%) requiring conversion to AKA within the 4-week post-operative period.

CONCLUSION

Utilizing a RRD after BKA can improve wound healing, protect the residual limb, and help prevent conversions to AKA. In this retrospective review at a single institution there was a decrease of conversion from BKA to AKA in a 2-year period. Ridged removal dressings should be considered first-line therapy in the post-operative care of BKA patients.

A systematic review of functional and quality of life assessment after major lower extremity amputation

BACKGROUND

When judging the success or failure of major lower extremity (MLE) amputation, the assessment of appropriate functional and quality of life (QOL) outcomes is paramount. The heterogeneity of the scales and tests in the current literature is confusing and makes it difficult to compare results. We provide a primer for outcome assessment after amputation and assess the need for the additional development of novel instruments.

METHODS

MEDLINE, EMBASE, and Google Scholar were searched for all studies using functional and QOL instruments after MLE amputation. Assessment instruments were divided into functional and QOL categories. Within each category, they were subdivided into global and amputation-specific instruments. An overall assessment of instrument quality was obtained.

RESULTS

The initial search revealed 746 potential studies. After a review of abstracts, 102 were selected for full review, and 40 studies were then included in this review. From the studies, 21 different assessment instruments were used 63 times. There were 14 (67%) functional measures and 7 (33%) QOL measures identified. Five (36%) of the functional instruments and 3 (43%) of the QOL measures were specific for MLE amputees. Sixteen instruments were used >1 time, but only 5 instruments were used >3 times. An additional 5 instruments were included that were deemed important by expert opinion. The 26 assessment instruments were rated. Fourteen of the best-rated instruments were then described.

CONCLUSIONS

The heterogeneity of instruments used to measure both functional and QOL outcomes make it difficult to compare MLE amputation outcome studies. Future researchers should seek to use high-quality instruments. Clinical and research societies should endorse the best validated instruments for future use in order to strengthen overall research in the field.