Clinical outcomes after closed, staged, and open forefoot amputations

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Unique Challenges in Diabetic Foot Science

In the past 30 years, there has been a rapid influx of information pertaining to the diabetic foot (DF) coming from numerous directions and sources. This article discusses the current state of the DF literature and challenges it presents to clinicians with its associated increase in knowledge on their derivations, complications, and interventions. Further, we attempt to provide tips on how to navigate and criticize the current literature to encourage and maximize positive outcomes in this challenging patient population.

Predictors of Major Adverse Limb Events after Open Forefoot Amputation in Patients with Chronic Limb-Threatening Ischemia

BACKGROUND

Management of patients with chronic limb-threatening ischemia (CLTI) and extensive foot necrosis presents a challenge for limb salvage. Our study evaluates preoperative risk factors that contributed to durability and efficacy of limb salvage after open transmetatarsal amputation (TMA) in patients with critical limb-threatening ischemia.

METHODS

We abstracted data from patients who underwent open TMA at Los Angeles County-University of Southern California Medical Center and Keck Hospital of University of Southern California from 2009 to 2018. Multivariable logistic regression analysis, adjusting for preoperative risk factors, was used to examine predictors of major adverse limb events (MALE). The aim was to evaluate outcomes following open TMA with MALE as the primary outcome. Our hypotheses were that outcomes would be worse for patients with foot infections and renal failure.

RESULTS

Forty-three open TMAs were done in 39 patients during the study period. The cohort had a mean age of 63 ± 11.6 years, 89% had a history of diabetes, 95% hypertension (HTN), 54% had end-stage renal disease (ESRD), and 26% were current smokers. MALE occurred in 39% of the cohort. Sex, race, indication, HTN, smoking status, and history of prior ipsilateral revascularization or minor amputations were not associated with MALE (P > 0.05). Multivariate logistic regression found ESRD to be an independent predictor of MALE (odds ratio 7.43, 95% confidence interval 1.12-49.17, P = 0.038) after adjusting for clinically significant covariates.

CONCLUSIONS

Open TMA provides acceptable rates of limb salvage for complex patients with CLTI. ESRD is an independent risk factor for MALE following open TMA in these patients. Vigilant follow-up is essential for this morbid patient population given poorer outcomes after forefoot amputation.

Quality of time spent without symptoms of disease or toxicity of treatment for transmetatarsal amputation versus digital amputation in diabetic patients with digital gangrene

Aim

We aim to compare the outcome of diabetic patients with gangrenous toes who were managed initially either by digital amputation or by transmetatarsal amputation. The null hypothesis is that transmetatarsal amputation had less theatre trips and better healing.

Materials and Methods

A parallel observational comparative study of all diabetic patients who underwent either digital or transmetatarsal amputation in a tertiary referral center from 2002 through 2015. Comorbid conditions, subsequent amputations, hospital stay, and readmission were noted.

Results

A total of 223 patients underwent minor amputation during the study period, of which 147 patients were diabetic and 76 patients were non-diabetic. Seventy-seven patients had digital amputation and 70 transmetatarsal amputation in diabetic patients. Demographics were similar in both groups. The median time to major amputation was (400 ± IQR 1205 days) in the digital amputation group, compared to 690 ± IQR 891 days in the transmetatarsal amputation group ( P = 0.974). 29.9% of digital amputations and 15.7% of transmetatarsal amputations in diabetic patients, required minor amputations or revision procedures ( P = 0.04). Median length of hospital stay was (20 days, IQR 27) in the digital group and (17 days, IQR17) in the transmetatarsal amputation group ( P = 0.17). Need for re-admission was 48.1% in digital patients compared to 50% in transmetatarsal amputation patients ( P = 0.81). Quality of time spent without symptoms of disease or toxicity of treatment (Q-TWiST) was (315 days, IQR 45) in digital group and (346 days, IQR 48) in the transmetatarsal amputation patients ( P = 0.099).

Conclusion

Despite the lack of statistical significance, transmetatarsal amputation offered better outcome in the diabetic patients, with less re-intervention rate, shorter hospital stays, less theatre trips, and longer time without toxicity (TWiST).

Outcomes after foot surgery in people with a diabetic foot ulcer and a 12-month follow-up

OBJECTIVE

The aim of this study was to retrospectively measure the outcomes of foot-sparing surgery at one year follow-up for patients with diabetic foot ulcers (DFUs). We assessed wound healing and the need for further surgery in relation to the variables that influence healing.

METHOD

Data were retrospectively collected by reviewing the electronic files of patients attending the Wound Expert Clinic (WEC). Outcomes of surgical debridement, toe, ray and transmetatarsal amputations were assessed.

RESULTS

A total of 129 cases in 121 patients were identified for inclusion. The results demonstrated that complete wound healing was reached in 52% (61/117) of the patients within 12 months. The need for additional surgery or for major amputation was 56% (n=72/129) and 30% (n=39/129) respectively. The need for an additional procedure was particularly high after surgical debridement (75%, 33/44) and transmetatarsal amputation (64%, 7/11). Risk factors for non-healing or for a major amputation were: infection (p=0.01), ischaemia (p=0.01), a history of peripheral arterial occlusive disease (p<0.01) and smoking (p=0.01). Additional findings were that not all patients underwent vascular assessment and in half of the patients there was a delay in undergoing revascularisation.

CONCLUSION

The results of the study reveal some areas for improvement including timely revascularisation and performance of multiple debridement procedures if needed in order to save a limb.

Results of One-Stage or Staged Amputations of Lower Limbs Consequent to Critical Limb Ischemia and Infection

BACKGROUND

Amputations of lower limbs can be conducted as one-stage amputation (OSA) or staged amputation (SA) procedures. The objective of this study was to analyze technical success and mortality rates of both techniques, as well as factors that might influence outcomes in patients with critical limb ischemia (CLI).

METHODS

A retrospective study of 185 consecutive patients with CLI who underwent amputations in the period 2004-2011. Primary end points were rates of technical success (healing without dehiscence or reintervention) and mortality. The influence on outcomes of demographic data, clinical status, and comorbidities was also analyzed by logistic regression.

RESULTS

A total of 101 SA (91 patients) and 106 OSA (94 patients) were analyzed. SA had proportionally higher success rate (SA 77.2% vs. OSA 66.0%, P = 0.0253), lower perioperative mortality rate (SA, 10.9% vs. OSA, 20.7%, P = 0.0247), and lower 30-day mortality rate (SA, 12.2% vs. OSA, 23.8%, P = 0.0220) in spite of more cases with Rutherford classes 5 and 6 (SA, 87.1% vs. OSA, 72.6%, P = 0.0047), diabetes (71.2% vs. 55.6%, P = 0.0076), and infection (44.5% vs. 28.3%, P = 0.0061). Logistic regression demonstrated that in SA, success was more frequent in patients with diabetes who did not use insulin (P = 0.0072), in those with transfemoral amputations (P = 0.0392), with no coronary artery disease (P = 0.0053), and in foot infection (P = 0.0446), while for OSA success was more frequent in nondiabetic patients (P = 0.0077), limbs without infection (P = 0.0298), amputations at foot level (P = 0.0155), or transfemoral amputations (P = 0.0030).

CONCLUSIONS

SA had a higher rate of technical success and lower mortality rates than OSA, even with greater number of patients with diabetes and more severe cases of ischemia and infection. However, prospective studies comparing both techniques are needed for further evidence.

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.

In response to reports from the Institute of Medicine1 ,2 and a mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) modified its methodology.3 –5 The relationships among guidelines, data standards, appropriate use criteria, and performance measures are addressed elsewhere.5

Treatment Failure and Leg Amputation Among Patients With Foot Osteomyelitis

We sought to identify factors associated with treatment failure and leg amputations among those patients who presented with foot osteomyelitis. Characteristics, treatments, and outcomes for all patients treated for probable or definite foot osteomyelitis (per consensus definition) between January 2011 and March 2015 were reviewed. Multivariate Cox regression models were used to identify risk factors for treatment failure (unanticipated resection of additional bone or leg amputation) and of leg amputation alone. A total of 184 episodes of foot osteomyelitis met inclusion criteria. Treatment failure occurred in 53 (28.8%) and leg amputation in 21 (11.4%). Risk factors for treatment failure included severe/unaddressed peripheral artery disease, homelessness, Pseudomonas aeruginosa or Escherichia coli bone isolates, serum albumin <2.8 mg/dL, hallux involvement, insulin therapy, 60 or more pack-years smoking, and <7 days of directed antibiotic therapy for a positive bone margin. Delayed primary wound closure (ie, staged operations) had significantly lower treatment failure risk. Unanticipated resection of bone was not associated with leg amputation. Foot osteomyelitis treatment failure is common. Various factors can help identify those at risk for treatment failure and/or leg amputation, and further studies should focused whether initial management or follow-up should change when these factors are present.

Saving the Limb in Diabetic Patients With Ischemic Foot Lesions Complicated by Acute Infection

Ischemia and infection are the most important factors affecting the prognosis of foot ulcerations in diabetic patients. To improve the outcome of these patients, it is necessary to aggressively treat 2 important pathologies—namely, occlusive arterial disease affecting the tibial and femoral arteries and infection of the ischemic diabetic foot. Each of these 2 conditions may lead to major limb amputation, and the presence of both critical limb ischemia (CLI) and acute deep infection is a major risk factor for lower-extremity amputation. Thus, the management of diabetic foot ulcers requires specific therapeutic approaches that vary significantly depending on whether foot lesions are complicated by infection and/or ischemia. A multidisciplinary team approach is the key to successful treatment of a diabetic foot ulcer: ischemic diabetic foot ulcers complicated by acute deep infection pose serious treatment challenges because high levels of skill, organization, accuracy, and timing of intervention are required to maximize the chances of limb salvage: these complex issues are better managed by a multidisciplinary clinical group.

Primary closure of elective toe amputations in the diabetic foot--is it safe?

BACKGROUND

Toe amputation is the most common partial foot amputation. Controversy exists regarding whether to primarily close toe amputations or to leave them open for secondary healing. The purpose of this study was to evaluate the results of closed toe amputations in diabetic patients, with respect to wound healing, complications, and the need for further higher level amputation.

METHODS

We retrospectively reviewed the results of 40 elective or semi-elective toe amputations with primary closure performed in 35 patients treated in a specialized diabetic foot unit. Patients with abscesses or necrotizing fasciitis were treated emergently and were excluded. Patients in whom clean margins could not be achieved due to extensive cellulitis or tenosynovitis and patients requiring vascular intervention were excluded as well. Outcome endpoints included wound healing at 3 weeks, delayed wound healing, or subsequent higher level amputation.

RESULTS

Out of 40 amputations, 38 healed well. Thirty amputations healed by the time of stitch removal at 3 weeks and eight had delayed healing. In two patients the wounds did not heal and subsequent higher level amputation was eventually required.

CONCLUSIONS

In carefully selected diabetic foot patients, primary closure of toe amputations is a safe surgical option. We do not recommend primary closure when infection control is not achieved or in patients requiring vascular reconstruction. Careful patient selection, skillful assessment of debridement margins and meticulous technique are required and may be offered by experienced designated surgeons in a specialized diabetic foot unit.

Inpatient management of diabetic foot disorders: a clinical guide

The implementation of an inpatient diabetic foot service should be the goal of all institutions that care for patients with diabetes. The objectives of this team are to prevent problems in patients while hospitalized, provide curative measures for patients admitted with diabetic foot disorders, and optimize the transition from inpatient to outpatient care. Essential skills that are required for an inpatient team include the ability to stage a foot wound, assess for peripheral vascular disease, neuropathy, wound infection, and the need for debridement; appropriately culture a wound and select antibiotic therapy; provide, directly or indirectly, for optimal metabolic control; and implement effective discharge planning to prevent a recurrence. Diabetic foot ulcers may be present in patients who are admitted for nonfoot problems, and these ulcers should be evaluated by the diabetic foot team during the hospitalization. Pathways should be in place for urgent or emergent treatment of diabetic foot infections and neuropathic fractures/dislocations. Surgeons involved with these patients should have knowledge and interest in limb preservation techniques. Prevention of iatrogenic foot complications, such as pressure sores of the heel, should be a priority in patients with diabetes who are admitted for any reason: all hospitalized diabetic patients require a clinical foot exam on admission to identify risk factors such as loss of sensation or ischemia. Appropriate posthospitalization monitoring to reduce the risk of reulceration and infection should be available, which should include optimal glycemic control and correction of any fluid and electrolyte disturbances.

Prognostic difference between soft tissue abscess and osteomyelitis of the foot in patients with diabetes: data from a consecutive series of 452 hospitalized patients

From January 2008 to December 2010, 452 patients with diabetes were admitted to our diabetic foot unit because of deep soft tissue abscess (group A: n = 210) or chronic osteomyelitis (group B: n = 242). Patients from group A underwent emergency debridement in the operating room. Patients from group B underwent elective surgery. Twenty-six (5.8%) major amputations were performed: of these, 18 (8.57%) were performed in patients from group A and 8 (3.31%) were performed in patients from group B (p = .024). Multivariate analysis showed the independent role on amputation outcome of the abscess (odds ratio, 2.64; p = .029; confidence interval [CI] 1.11 to 6.28), dialysis treatment (odds ratio, 3.17; p = .039, CI 1.06-9.51), and C-reactive protein > 0.5 mg/dL (odds ratio, 3.75; p = .022, CI 1.21-11.64). In group A, 43 (22.6%) patients healed only with drainage, and 147 (70.0%) minor amputations were performed: 53 (36.1%) at the level of the forefoot and 94 (63.9%) at the level of the midfoot. In group B, 234 (96.7%) minor amputations were performed, 208 (88.9%) at the forefoot and 26 (11.1%) at the midfoot level (p < .001). Fourteen postoperative complications occurred in patients from group A and 2 in patients from group B (p < .001). In group A, 3 patients died during hospitalization, 1 from septic shock and 2 from sudden death. None of the group B patients died. This study demonstrates that the severity of a foot soft tissue abscess is not comparable with that of a chronic osteomyelitis not only because of a higher rate of major amputation, but also because of a much more proximal level of minor amputation.

Minor amputation in patients with diabetes mellitus and severe foot ulcers achieves good outcomes

OBJECTIVE

To analyse the outcome of minor amputations (through, or distal to, the ankle joint) in patients with diabetes.

METHOD

All diabetic patients in a defined population undergoing one or more minor amputation between 1982 and 2006 were investigated according to a standardised protocol and were followed until final outcome (healing or death). A total of 410 consecutive amputations in 309 patients with a median age of 73 (32-93) years were identified.

RESULTS

In 94% of amputations, deep infection (39%) and/or gangrene (55%) was present. Severe peripheral vascular disease or critical limb ischaemia was present in 61% of amputations. 261/410 (64%) of the amputations healed at a level below the ankle joint; 69/410 (17%) healed after a re-amputation above the ankle joint; in 76/410 of amputations (19%), the patient died before healing could occur. In surviving patients, 79% of the amputations healed below the ankle. Median healing time for amputations that healed below the ankle was 26 (2-250) weeks; 21% of amputations required a re-amputation above the ankle. None of the analysed parameters excluded the possibility of healing below the ankle.

CONCLUSION

In this population-based survey, the goal of avoiding major amputation was achieved in almost two thirds of minor amputations, but at the price of long healing times. In almost all amputations, the patient had deep infection and/or gangrene. In spite of this, 64% of all amputations, and 79% of amputations in surviving patients, healed at a level below the ankle. This indicates that minor amputations in these patients are worthwhile.

DECLARATION OF INTEREST

None.

Factors associated with late specialized rehabilitation among veterans with lower extremity amputation who underwent immediate postoperative rehabilitation

OBJECTIVE

The aim of this study was to determine what patient- and facility-level characteristics drive late specialized rehabilitation among veterans who already received immediate postoperative services.

DESIGN

Data were obtained from eight administrative databases for 2,453 patients who underwent lower limb amputation in Veterans Affairs Medical Centers in 2002-2004. A Cox proportional hazards model was used to determine the hazard ratios and 95% confidence intervals of the factors associated with days to readmission for late services after discharge from surgical hospitalization.

RESULTS

There were 2304 patients who received only immediate postoperative services, whereas 152 also received late specialized rehabilitation. After adjustment, veterans who were less disabled physically, residing in the South Central compared with the Southeast region, and had their surgeries in facilities accredited by the Commission on Accreditation of Rehabilitation Facilities were all more likely to receive late services. The hazard ratios for type of immediate postoperative rehabilitation were not constant over time. At hospital discharge, there was no difference in receipt; however, after 3 mos, those who received early specialized rehabilitation were significantly less likely to receive late services.

CONCLUSIONS

The factors associated with late specialized rehabilitation were due mainly to facility-level characteristics and care process variables. Knowledge of these factors may help with decision-making policies regarding units accredited by the Commission on Accreditation of Rehabilitation Facilities.

Review: use of electronic medical records for health outcomes research: a literature review

This review assessed the use of electronic medical record (EMR) systems in outcomes research. We systematically searched PubMed to identify articles published from January 2000 to January 2007 involving EMR use for outpatient-based outcomes research in the United States. EMR-based outcomes research studies (n = 126) have increased sixfold since 2000. Although chronic conditions were most common, EMRs were also used to study less common diseases, highlighting the EMRs' flexibility to examine large cohorts as well as identify patients with rare diseases. Traditional multi-variate modeling techniques were the most commonly used technique to address confounding and potential selection bias. Data validation was a component in a quarter of studies, and many evaluated the EMR's ability to achieve similar results previously achieved using other data sources. Investigators using EMR data should aim for consistent terminology, focus on adequately describing their methods, and consider appropriate statistical methods to control for confounding and treatment-selection bias.

Amputation in diabetic patients

In diabetes-related amputations, the risk of nonhealing or infection of a wound and the need for revision are increased. Medical treatment before amputation should optimize general and local conditions including the regression of edema, the control of infection, and the optimization of glucoregulation. A major argument for foot-sparing surgery is the poor functional recovery after major limb amputation. Diabetic patients are frail, with an increased postoperative morbidity and mortality after major amputation. Factors detrimental to functional outcome are advanced age, end-stage renal disease, dementia, and above-knee amputation. A multidisciplinary approach is required to optimize the results of diabetes-related amputations. The authors discuss medical and technical aspects that may reduce the failure of minor or major diabetes-related amputations.