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Örneholm H, Mevik J, Wenger D. Above-ankle Reamputation and Mortality following Transmetatarsal Amputation in Diabetic and Nondiabetic Peripheral Artery Disease. J Foot Ankle Surg 2024:S1067-2516(24)00115-7. [PMID: 38876207 DOI: 10.1053/j.jfas.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 05/30/2024] [Accepted: 05/30/2024] [Indexed: 06/16/2024]
Abstract
The risk of above-ankle reamputation following a transmetatarsal amputation is around 30%. Patient selection may be crucial to achieve good outcomes, and to avoid futile operations and suffering. We are aware of no previous comparison between the two largest patient groups that undergo lower extremity amputations: patients with diabetes, and patients with non-diabetic peripheral artery disease. Patients with diabetes or nondiabetic peripheral artery disease who had undergone a transmetatarsal amputation from 2004 to 2018 at our institution were included. Patient characteristics and perioperative details were analyzed retrospectively. Subjects with diabetes were compared with subjects with nondiabetic peripheral artery disease regarding above-ankle reamputation, reamputation level, and mortality. Five-hundred-and-sixty transmetatarsal amputations in 513 subjects were included. The majority of transmetatarsal amputations (86%) occurred in diabetic subjects. Subjects with non-diabetic PAD had a higher risk of above-ankle reamputation (p = .008), and death (p < .001). At the time of data collection, only multiple-ray amputation (vs. single-ray) was an independent risk factor for above-ankle reamputation. Only age, medical comorbidity in general, and chronic heart failure were independent risk factors of death. To our knowledge, this study is the first to report marked differences in above-ankle reamputation rates and mortality following transmetatarsal amputation, comparing diabetics with non-diabetic patients with peripheral artery disease. However, the differences may be attributed to non-diabetics being older, having more medical comorbidities, and having more advanced foot ulcers at the time of transmetatarsal amputation. In patients exhibiting several of these risk factors, transmetatarsal amputation may be futile.
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Affiliation(s)
- Hedvig Örneholm
- Department of Orthopaedics, Skåne University Hospital, Malmö, Sweden and Department of Clinical Sciences, Lund University, Lund, Sweden.
| | | | - Daniel Wenger
- Department of Orthopaedics, Skåne University Hospital, Malmö, Sweden and Department of Clinical Sciences, Lund University, Lund, Sweden
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Verdin C, Zarick C, Steinberg J. Unique Challenges in Diabetic Foot Science. Clin Podiatr Med Surg 2024; 41:323-331. [PMID: 38388128 DOI: 10.1016/j.cpm.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
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.
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Affiliation(s)
- Craig Verdin
- Department of Plastic Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, Washington DC 20007, USA
| | - Caitlin Zarick
- Department of Plastic Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, Washington DC 20007, USA
| | - John Steinberg
- Department of Plastic Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, Washington DC 20007, USA.
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Hill R, Ajbani K, Jebackumar B, Adebayo T, Meyr AJ. Morbidity and Mortality of the Transmetatarsal Amputation: A Comparative NSQIP Analysis. J Foot Ankle Surg 2024; 63:161-164. [PMID: 37838089 DOI: 10.1053/j.jfas.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/20/2023] [Accepted: 10/07/2023] [Indexed: 10/16/2023]
Abstract
The objective of this investigation was to compare the morbidity and mortality of transmetatarsal amputation to other frequently performed surgical procedures utilizing a large US database. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was interrogated for the purposes of this investigation. We initially extracted data related to the Current Procedural Terminology (CPT) code 28805 (amputation, foot; transmetatarsal) and the variable labels "estimated probability of morbidity" and "estimated probability of mortality." We subsequently performed a CPT code search for those procedures occurring at a frequency greater than 10,000 in the database, and additionally extracted data for estimated probability of morbidity and estimated probability of mortality for these procedures. This resulted in identification of 17 additional procedures. CPT code 28805 was associated with the highest estimated probability of morbidity of the cohort (0.1360 ± 0.0669), and this demonstrated statistical significance higher than all other CPT codes (p < .001). CPT code 28805 was associated with the second-highest estimated probability of mortality of the cohort (0.0327 ± 0.0596). This demonstrated statistical significance less than that of CPT code 27245 (0.0327 ± 0.0596 vs 0.0547 ± 0.0661; p < .0001), but statistical significance higher than all other CPT codes (p<0.001). The results of this investigation indicate that transmetatarsal amputation carries a substantial risk for morbidity and mortality in comparison to other commonly performed surgical procedures.
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Affiliation(s)
- Russell Hill
- Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA
| | - Kavya Ajbani
- Podiatric Medical Student, Temple University School of Podiatric Medicine, Philadelphia, PA
| | - Benita Jebackumar
- Podiatric Medical Student, Temple University School of Podiatric Medicine, Philadelphia, PA
| | - Temitope Adebayo
- Podiatric Medical Student, Temple University School of Podiatric Medicine, Philadelphia, PA
| | - Andrew J Meyr
- Professor, Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
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Coye T, Ansert E, Suludere MA, Chung J, Kang GE, Lavery LA. Healing rates and outcomes following closed transmetatarsal amputations: A systematic review and random effects meta-analysis of proportions. Wound Repair Regen 2024; 32:182-191. [PMID: 38111147 DOI: 10.1111/wrr.13143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/20/2023] [Accepted: 11/27/2023] [Indexed: 12/20/2023]
Abstract
Transmetatarsal amputation (TMA) is a common surgical procedure for addressing severe forefoot pathologies, such as peripheral vascular disease and diabetic foot infections. Variability in research methodologies and findings within the existing literature has hindered a comprehensive understanding of healing rates and complications following TMA. This meta-analysis and systematic review aims to consolidate available evidence, synthesising data from multiple studies to assess healing rates and complications associated with closed TMA procedures. Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic search of Medline, Embase, and Cochrane databases was conducted for articles published from January 1st, 1988, to June 1st, 2023. Inclusion criteria comprised studies reporting healing rates in non-traumatic transmetatarsal amputation patients with more than 10 participants, excluding open TMAs. Two independent reviewers selected relevant studies, with disagreements resolved through discussion. Data extracted from eligible studies included patient demographics, healing rates, complications, and study quality. Among 22 studies encompassing 1569 transmetatarsal amputations, the pooled healing rate was 67.3%. Major amputation rates ranged from 0% to 55.6%, with a random-effects pooled rate of 23.9%. Revision rates varied from 0% to 36.4%, resulting in a pooled rate of 14.8%. 30-day mortality ranged from 0% to 9%, with a fixed-effects pooled rate of 2.6%. Post-operative infection rates ranged from 3.0% to 30.7%, yielding a random-effects pooled rate of 16.7%. Dehiscence rates ranged from 1.7% to 60.0%, resulting in a random-effects pooled rate of 28.8%. Future studies should aim for standardised reporting and assess the physiological and treatment factors influencing healing and complications.
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Affiliation(s)
- Tyler Coye
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Elizabeth Ansert
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mehmet A Suludere
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jayer Chung
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Gu Eon Kang
- Department of Bioengineering, The University of Texas, Dallas, Texas, USA
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern, Dallas, Texas, USA
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Luong B, Brown CM, Humphries MD, Maximus S, Kwong M. Assessing the Utility of Toe Arm Index and Toe Pressure in Predicting Wound Healing in Patients Undergoing Vascular Intervention. Ann Vasc Surg 2023; 97:221-235. [PMID: 37659650 DOI: 10.1016/j.avsg.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/06/2023] [Accepted: 08/15/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Objective measures of perfusion such as an ankle-brachial index (ABI) and toe pressure remain important in prognosticating wound healing. However, the use of ABI is limited in patients with incompressible vessels and toe pressure may not be comparable across patients. While a toe arm index (TAI) may be of value in this setting, its role as clinical indicator of perfusion for healing in patients with lower-extremity wounds has not been well established. METHODS A retrospective review was performed of all vascular patients with lower-extremity wounds that underwent peripheral vascular intervention between 2014-2019. Data regarding patient demographics, comorbidities, TAI, ABI, toe pressures, and the wound, ischemia, and foot infection (WIfI) score were collected. Associations between patient variables and wound healing at various time points were evaluated. RESULTS A total of 173 patients (67.7 ± 10.9 years; 71.1% male) were identified with lower-extremity wounds. Most patients underwent endovascular intervention (77.5%). Patients were followed for a median of 416 (IQR 129-900) days. Mean postoperative TAI was 0.35 ± 0.19 and mean WIfI score was 2.60 ± 1.17. Nine percent (15) of patients healed within 1 month, 44.8% (69) healed within 6 months, and 65.5% (97) healed within 1 year of revascularization without need for major amputation. Those that healed within 1 year without any major amputation did not differ from those that did not heal based on age, gender, race, comorbidities, periprocedural medications, or procedures performed. However, patients that healed without major amputation had a higher postoperative TAI (0.38 vs. 0.30, P = 0.02), higher toe pressure (53 vs. 40 mm Hg, P = 0.004), and lower WIfI score (2.26 vs. 3.12, P < 0.001). Patients that healed with 1 year without requiring any amputation had similar associations with postoperative TAI, toe pressure, and WIfI. Additionally, they were more likely to be White (P = 0.019) and have an open surgical procedure (P < 0.001) and less likely to have chronic kidney disease (P = 0.001) or diabetes (P = 0.008). A Youden index was calculated and identified a TAI value of 0.30 that optimized sensitivity and specificity for wound healing. The area under the curve for TAI as a predictor of wound healing was 0.62. CONCLUSIONS Higher postoperative TAI is associated with higher odds of wound healing without need for major amputation. Toe arm index is therefore a useful tool to identify patients with adequate arterial perfusion to heal lower-extremity wounds. However, the area under the curve is poor for TAI when used as a sole predictor of wound healing potential suggesting that TAI should be one of multiple factors to considered when prognosticating wound healing potential.
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Affiliation(s)
- Brian Luong
- College of Biological Sciences, University of California, Davis, Sacramento, CA
| | - Christina M Brown
- College of Biological Sciences, University of California, Davis, Sacramento, CA
| | - Misty D Humphries
- Division of Vascular Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, CA
| | - Steven Maximus
- Division of Vascular Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, CA
| | - Mimmie Kwong
- Division of Vascular Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, CA.
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Troisi N, Bertagna G, Juszczak M, Canovaro F, Torri L, Adami D, Berchiolli R. Emergent management of diabetic foot problems in the modern era: Improving outcomes. Semin Vasc Surg 2023; 36:224-233. [PMID: 37330236 DOI: 10.1053/j.semvascsurg.2023.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 06/19/2023]
Abstract
Limb amputation is a consequence, and the leading complication, of diabetic foot ulcers. Prevention depends on prompt diagnosis and management. Patients should be managed by multidisciplinary teams and efforts should be focused on limb salvage ("time is tissue"). The diabetic foot service should be organized in a way to meet the patient's clinical needs, with the diabetic foot centers at the highest level of this structure. Surgical management should be multimodal and include not only revascularization, but also surgical and biological debridement, minor amputations, and advanced wound therapy. Medical treatment, including an adequate antimicrobial therapy, has a key role in the eradication of infection and should be guided by microbiologists and infection disease physicians with special interest in bone infection. Input from diabetologists, radiologists, orthopedic teams (foot and ankle), orthotists, podiatrists, physiotherapists, and prosthetics, as well as psychological counseling, is required to make the service comprehensive. After the acute phase, a well-structured, pragmatic follow-up program is necessary to adequately manage the patients with the aim to detect earlier potential failures of the revascularization or antimicrobial therapy. Considering the cost and societal impact of diabetic foot problems, health care providers should provide resources to manage the burden of diabetic foot problems in the modern era.
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Affiliation(s)
- Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy.
| | - Giulia Bertagna
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Maciej Juszczak
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Francesco Canovaro
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Lorenzo Torri
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Daniele Adami
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Raffaella Berchiolli
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
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Correa CAS, Vargas-Hernández JS, García LF, Jaimes J, Caicedo M, Niño ME, Quijano JR. Risk factors for reamputation in patients with diabetic foot: A case-control study. Foot Ankle Surg 2023:S1268-7731(23)00100-5. [PMID: 37301675 DOI: 10.1016/j.fas.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/25/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Reamputation as a complication of diabetic foot ulcers presents a high economic burden and represents a therapeutic failure. It is paramount to identify as early as possible patients in whom a minor amputation may not be the best option. The purpose of this investigation was to do a case-controlled study to determine risk factors associated with re-amputation in patients with DFU (diabetic foot ulcers) at two University Hospitals. METHODS Multicentric, observational, retrospective, case-control study from clinical records of 2 university hospitals. Our study included 420 patients, with 171 cases (re-amputations), and 249 controls. We performed a multivariate logistic regression analysis and time-to-event survival analysis to identify re-amputation risk factors. RESULTS Statistically significant risk factors were artery history of tobacco use (p = 0.001); male sex (p = 0.048); arterial occlusion in Doppler ultrasound (p = 0.001); percentage of stenosis in arterial ultrasound >50 % (p = 0.053); requirement of vascular intervention (p = 0.01); and microvascular involvement in photoplethysmography (p = 0.033). The most parsimonious regression model suggests that history of tobacco use, male sex, arterial occlusion in ultrasound, and percentage of stenosis in arterial ultrasound >50 % remained statistically significant. The survival analysis identified earlier amputations in patients with larger occlusion in arterial ultrasound, high leukocyte count, and elevated ESR. CONCLUSION Direct and surrogate outcomes in patients with diabetic foot ulcers identify vascular involvement as an important risk factor for reamputation. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | | | - Luisa Fernanda García
- Resident in Orthopedics and Traumatology, Pontificia Universidad Javeriana, Colombia
| | | | - Martha Caicedo
- Hospital Universitario de La Samaritana, Universidad de la Sabana, Colombia
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Apel PJ, Cripe BA, Schmitt MW, Orfield NJ, Lozano AJ, Hanlon AL, Capito AE. Predictors of Mortality and Revision Following Digital Amputation for Infection and Necrosis. J Hand Surg Am 2023; 48:460-467. [PMID: 36932011 PMCID: PMC11160110 DOI: 10.1016/j.jhsa.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 12/18/2022] [Accepted: 01/13/2023] [Indexed: 03/19/2023]
Abstract
PURPOSE Digital amputation is a commonly performed procedure for infection and necrosis in patients with diabetes, peripheral vascular disease (PVD), and on dialysis. There is a lack of data regarding prognosis for revision amputation and mortality following digital amputation in these patients. METHODS All digital amputations over 10-year period (2008-2018) at a single center were reviewed. There were 484 amputations in 360 patients, among which 358 were performed for trauma (reference sample) and 126 for infection or necrosis (sample of interest). Patient death and revision were determined from National Vital Statistics System and medical records. Propensity score matching was performed to compare groups. Data were then compared to the Social Security Administration Actuarial Life Table for 2015 to determine age-matched expected mortality. RESULTS The 2-year revision rate was 34% for amputations performed for infection or necrosis, compared to 15% for amputations due to trauma. For amputations performed for infection or necrosis, the revision rate was 47.7% when diabetes, PVD, and dialysis were present. Among all patients with infection or necrosis (n = 104) undergoing a digital amputation, overall survival at 2, 5, and 10 years was 79.4%, 57.3%, and 17.5%, respectively, which represented a 3.2-fold increased risk of death compared to controls. (hazard ratio, 3.19; 95% confidence interval, 1.47-6.93). For amputations due to trauma, mortality was no different from that in the age-matched general population. CONCLUSIONS Mortality and revision risk are high for patients requiring a digital amputation for infection or necrosis and are further increased with medical comorbidities. Hand surgeons should consider the prognostic implications of these data when counseling patients. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Peter J Apel
- Musculoskeletal Education and Research Center, Department of Orthopaedic Surgery, Institute for Orthopaedics and Neurosciences, Carilion Clinic, VA
| | - Brian A Cripe
- Virginia Tech Carilion, Department of Surgery, Plastic Surgery Section, VA
| | - Mark W Schmitt
- Musculoskeletal Education and Research Center, Department of Orthopaedic Surgery, Institute for Orthopaedics and Neurosciences, Carilion Clinic, VA
| | - Noah J Orfield
- Virginia Tech Carilion, Department of Surgery, Plastic Surgery Section, VA
| | - Alicia J Lozano
- Center for Biostatistics and Health Data Science, Department of Statistics, College of Science, Virginia Polytechnic Institute and State University, VA
| | - Alexandra L Hanlon
- Center for Biostatistics and Health Data Science, Department of Statistics, College of Science, Virginia Polytechnic Institute and State University, VA
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Ron I, Kyin C, Peskin B, Ghrayeb N, Norman D, Ben-Kiki T, Shapira J. Risk Factors for a Failed Transmetatarsal Amputation in Patients with Diabetes. J Bone Joint Surg Am 2023; 105:651-658. [PMID: 36943915 DOI: 10.2106/jbjs.22.00718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND Transmetatarsal amputation (TMA) is a well-recognized limb-salvage procedure, often indicated for the treatment of diabetic foot infections. Currently, there is no widespread agreement in the literature with regard to the factors associated with failure of TMA. This study aimed to define risk factors for the failure of TMA, defined as below-the-knee or above-the-knee amputation, in patients with diabetes. METHODS This retrospective cohort study included 341 patients who underwent primary TMA. Patients who had a revision to a higher level (the failed TMA group) were compared with those who did not have failure of the initial amputation (the successful TMA group). RESULTS This study showed a higher frequency of renal impairment, defined as a high creatinine level and/or a previous kidney transplant or need for dialysis, in the failed TMA group (p = 0.002 for both). Furthermore, a Charlson Comorbidity Index (CCI) threshold value of 7.5 was identified as the optimal predictive value for failure of TMA (p = 0.002), and patients with a CCI of >7.5 had a median time of 1.13 months until the initial amputation failed. CONCLUSIONS TMA is associated with a high risk of revision. CCI may be used as a preoperative selection criterion, as 71.8% of patients with a CCI of >7.5 had failure of the TMA. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Itay Ron
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Cynthia Kyin
- University of Central Florida College of Medicine, Orlando, Florida
| | - Bezalel Peskin
- Orthopedic Department, Rambam Medical Center, Haifa, Israel
| | - Nabil Ghrayeb
- Orthopedic Department, Rambam Medical Center, Haifa, Israel
| | - Doron Norman
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
- Orthopedic Department, Rambam Medical Center, Haifa, Israel
| | - Tal Ben-Kiki
- Orthopedic Department, Rambam Medical Center, Haifa, Israel
| | - Jacob Shapira
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
- Orthopedic Department, Rambam Medical Center, Haifa, Israel
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van der Wal GE, Dijkstra PU, Geertzen JH. Lisfranc and Chopart amputation: A systematic review. Medicine (Baltimore) 2023; 102:e33188. [PMID: 36897730 PMCID: PMC9997832 DOI: 10.1097/md.0000000000033188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/14/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Lisfranc and Chopart amputations are historically controversial procedures. To obtain evidence for the pros and cons we performed a systematic review to analyze wound healing, the need for re-amputation at a higher level, and ambulation after a Lisfranc or Chopart amputation. METHODS A literature search was performed in 4 databases (Cochrane, Embase, Medline, and PsycInfo), using database-specific search strategies. Reference lists were studied to include relevant studies that were missed in the search. Of the 2881 publications found, 16 studies could be included in this review. Excluded publications concerned editorials, reviews, letters to the editor, no full text available, case reports, not meeting the topic, and written in a language other than English, German, or Dutch. RESULTS Failed wound healing occurred in 20% after Lisfranc amputation, in 28% after modified Chopart amputation, and 46% after conventional Chopart amputation. After Lisfranc amputation, 85% of patients were able to ambulate without prosthesis for short distances, and after modified Chopart 74%. After a conventional Chopart amputation, 26% (10/38) had unlimited household ambulation. CONCLUSIONS The need for re-amputation because wound healing problems occurred most frequently after conventional Chopart amputation. All 3 types of amputation levels do, however, provide a functional residual limb, with the remaining ability to ambulate without prosthesis for short distances. Lisfranc and modified Chopart amputations should be considered before proceeding to a more proximal level of amputation. Further studies are needed to identify patient characteristics to predict favorable outcomes of Lisfranc and Chopart amputations.
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Affiliation(s)
- Gesiena E. van der Wal
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Center of Rehabilitation, The Netherlands
| | - Pieter U. Dijkstra
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Center of Rehabilitation, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of Oral and Maxillofacial Surgery, The Netherlands
| | - Jan H.B. Geertzen
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Center of Rehabilitation, The Netherlands
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Berli MC, Rancic Z, Schöni M, Götschi T, Schenk P, Kabelitz M, Böni T, Waibel FWA. Salami-Tactics: when is it time for a major cut after multiple minor amputations? Arch Orthop Trauma Surg 2023; 143:645-656. [PMID: 34370043 PMCID: PMC9925494 DOI: 10.1007/s00402-021-04106-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/26/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Repetitive minor amputations carry the concomitant risks of multiple surgical procedures, major amputations have physical and economical major drawbacks. The aim of this study was to evaluate whether there is a distinct number of minor amputations predicting a major amputation in the same leg and to determine risk factors for major amputation in multiple minor amputations. MATERIALS AND METHODS A retrospective chart review including 429 patients with 534 index minor amputations between 07/1984 and 06/2019 was conducted. Patient demographics and clinical data including number and level of re-amputations were extracted from medical records and statistically analyzed. RESULTS 290 legs (54.3%) had one or multiple re-amputations after index minor amputation. 89 (16.7%) legs needed major amputation during follow up. Major amputation was performed at a mean of 32.5 (range 0 - 275.2) months after index minor amputation. No particular re-amputation demonstrated statistically significant elevated odds ratio (a.) to be a major amputation compared to the preceding amputation and (b.) to lead to a major amputation at any point during follow up. Stepwise multivariate Cox regression analysis revealed minor re-amputation within 90 days (HR 3.8, 95% CI 2.0-7.3, p <0.001) as the only risk factor for major amputation if at least one re-amputation had to be performed. CONCLUSIONS There is no distinct number of prior minor amputations in one leg that would justify a major amputation on its own. If a re-amputation has to be done, the timepoint needs to be considered as re-amputations within 90 days carry a fourfold risk for major amputation. LEVEL OF EVIDENCE Retrospective comparative study (Level III).
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Affiliation(s)
- Martin C Berli
- Division of "Prosthetics and Orthotics", Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Zoran Rancic
- Clinic for Vascular Surgery, University Hospital Zurich, and Medical Faculty, University of Zurich, Zurich, Switzerland
| | - Madlaina Schöni
- Division of "Prosthetics and Orthotics", Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Tobias Götschi
- Department of Orthopaedic Surgery, University of Zurich, Institute for Biomechanics, ETH Zurich, Balgrist Campus, Zurich, Switzerland
| | - Pascal Schenk
- Division of "Prosthetics and Orthotics", Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Method Kabelitz
- Division of "Prosthetics and Orthotics", Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Thomas Böni
- Division of "Prosthetics and Orthotics", Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Felix W A Waibel
- Division of "Prosthetics and Orthotics", Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zürich, Switzerland.
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12
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Lepow BD, Zulbaran-Rojas A, Park C, Chowdhary S, Najafi B, Chung J, Ross JA, Mills JL, Montero-Baker M. Guillotine Transmetatarsal Amputations With Staged Closure Promote Early Ambulation and Limb Salvage in Patients With Advanced Chronic Limb-Threatening Ischemia. J Endovasc Ther 2022:15266028221144587. [PMID: 36565249 DOI: 10.1177/15266028221144587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE Transmetatarsal amputation (TMA) with primary closure has long been an option for limb salvage in patients with advanced chronic limb-threatening ischemia (CLTI) with extensive tissue loss of the forefoot. However, TMA healing and closure techniques are challenging, specifically in high-risk patients. Guillotine transmetatarsal amputations (gTMA) with staged closure may provide an alternative treatment in this population. We report long-term outcomes of such technique. MATERIALS AND METHODS A single-center retrospective cohort study of CLTI patients undergoing gTMA between 2017 and 2020 was performed. Limb salvage, wound healing, and survival rates were quantified using Kaplan-Meier (KM) analysis. Multivariate regression was used to identify the effect of patient characteristics on the outcomes. RESULTS Forty-four gTMA procedures were reviewed. Median follow-up was 381 (interquartile range [IQR], 212-539.75) days. After gTMA, 87.8% (n=36) of the patients were able to ambulate after a median interval of 2 (IQR, 1-3) days. Eventual coverage was achieved in a personalized and staged approach by using a combination of skin substitutes (88.6%, n=39) ± split thickness skin grafts (STSG, 61.4%, n=27). KM estimates for limb salvage, wound healing, and survival were 84.1%, 54.5%, and 88.6% at 1 year and 81.8%, 63.8%, and 84.1% at 2 years. Wound healing was significantly associated with STSG application (p=0.002, OR=16.5, 95% CI 2.87-94.81). CONCLUSION gTMA resulted in high limb salvage rates during long-term follow-up in CLTI patients. Adjunctive STSG placement may enhance wound healing at the gTMA site, thus leading to expedited wound closure. Surgeons may consider gTMA as an alternative to reduce limb loss in CLTI patients at high risk of major amputation. CLINICAL IMPACT Currently, the clinical presentation of CLTI is becoming more complex to deal with due to the increasing comorbidities as the society becomes older. The data shown in this article means for clinicians that when facing diffused forefoot gangrene and extensive tissue loss, limb preservation could still be considered instead of major amputation. Guillotine transmetatarsal amputations in the setting of an aggressive multidisciplinary group, can be healed by the responsibly utilization of dermal substitutes and skin grafts leading to the preservation of the extremity, allowing mobility, avoiding of sarcopenia, and decreasing frailty. This will equate to maintenance of independent living and preservation of lifespan.
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Affiliation(s)
- Brian D Lepow
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Alejandro Zulbaran-Rojas
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Catherine Park
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Michael E. DeBakey VA Medical Center, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, VA Health Services Research & Development, Houston, TX, USA
- The Big Data Scientist Training Enhancement Program, VA Office of Research & Development, Washington, DC, USA
| | - Saakshi Chowdhary
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Bijan Najafi
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jayer Chung
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jeffrey A Ross
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Miguel Montero-Baker
- Vascular Surgery, Houston Methodist Cardiovascular Surgery Associates, Houston, TX, USA
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13
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Pedras S, Meira-Machado L, Couto de Carvalho A, Carvalho R, Pereira MG. Anxiety and/or depression: which symptoms contribute to adverse clinical outcomes after amputation? J Ment Health 2022; 31:792-800. [PMID: 33100065 DOI: 10.1080/09638237.2020.1836554] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND One of the most serious complications of diabetes mellitus (DM) is a diabetic foot ulcer (DFU), with lower extremity amputation (LEA). AIMS This study aims to explore the role of anxiety and depression on mortality, reamputation and healing, after a LEA due to DFU. METHODS A sample of 149 patients with DFU who underwent LEA answered the Hospital Anxiety and Depression Scale and a sociodemographic and clinical questionnaire. This is a longitudinal and multicenter study with four assessment moments that used Cox proportional hazards models adjusted for demographic and clinical variables. RESULTS Rate of mortality, reamputation and healing, 10 months after LEA were 9.4%, 27.5% and 61.7%, respectively. Anxiety, at baseline, was negatively associated with healing. However, depression was not an independent predictor of mortality. None of the psychological factors was associated with reamputation. CONCLUSION Results highlight the significant contribution of anxiety symptoms at pre-surgery, to healing after a LEA. Suggestions for psychological interventions are made.
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Affiliation(s)
- Susana Pedras
- School of Psychology, University of Minho, Braga, Portugal
| | - Luís Meira-Machado
- Department of Mathematics and Applications, Faculty of Sciences, University of Minho, Guimarães, Portugal
| | - André Couto de Carvalho
- Division of Endocrinology, Diabetes and Metabolism, Centro Hospitalar do Porto, Porto, Portugal
| | - Rui Carvalho
- Division of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Porto, Porto, Portugal
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14
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Jones MA, George TS, Bullock GS, Sikora RR, Vesely BD, Sinacore DR. Biomarkers of chronic kidney disease-mineral bone disorder (CKD-MBD) in the diabetic foot: A medical record review. Diabetes Res Clin Pract 2022; 194:110160. [PMID: 36410557 PMCID: PMC11214147 DOI: 10.1016/j.diabres.2022.110160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/30/2022] [Accepted: 11/13/2022] [Indexed: 11/19/2022]
Abstract
AIMS Determine the prevalence and relative risk of having single and combinations of biomarkers of chronic kidney disease-mineral bone disorder (CKD-MBD) syndrome in the diabetic foot from an electronic medical record (EMR) review. METHODS Review of 152 patients with one foot radiograph and diagnoses of both diabetes mellitus (DM) and chronic kidney disease (CKD) stages 1-5. Presence/absence of peripheral neuropathy (PN), targeted serum markers, and both pedal vessel calcification (PVC) and buckling ratio (BR) of 2nd and 5th metatarsals from radiographs were recorded. Prevalence of single and combinations of foot biomarkers are reported as count and percentage. Risk ratios (RR) with 95% confidence intervals (95% CI) were calculated to assess risk of foot biomarkers in each stage of CKD-MBD. RESULTS Prevalence and RR of PVC, PN, and BR ≥ 3.5 biomarkers, both single and in combination, all increase with progression of CKD. The RR increases to 9.6 (95 % CI: 3, 26; p < 0.001) when all 3 biomarkers present in stage 5. CONCLUSIONS PVC, PN, and BR ≥ 3.5 are prognostic biomarkers of CKD-MBD syndrome in the diabetic foot. Recognition of these foot biomarkers may allow earlier interventions to help reduce nontraumatic lower extremity amputation in individuals with diabetic CKD-MBD.
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Affiliation(s)
- Michael A Jones
- Atrium Health Wake Forest Baptist Department of Orthopaedic Surgery & Rehabilitation, Winston-Salem, NC 27157, United States.
| | - Tyler S George
- Atrium Health Wake Forest Baptist Department of Orthopaedic Surgery & Rehabilitation, Winston-Salem, NC 27157, United States.
| | - Garrett S Bullock
- Atrium Health Wake Forest Baptist Department of Orthopaedic Surgery & Rehabilitation, Winston-Salem, NC 27157, United States.
| | - Rebecca R Sikora
- Atrium Health Wake Forest Baptist Department of Orthopaedic Surgery & Rehabilitation, Winston-Salem, NC 27157, United States.
| | - Bryanna D Vesely
- Atrium Health Wake Forest Baptist Department of Orthopaedic Surgery & Rehabilitation, Winston-Salem, NC 27157, United States.
| | - David R Sinacore
- Department of Physical Therapy, Congdon School of Health Sciences, High Point University, High Point, NC 27268, United States.
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15
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LeSavage LK, Hoffler HL, Evans JK, Blazek CD. Reulceration and Reoperation Rates After Central Ray Amputations: A Retrospective Study. J Foot Ankle Surg 2022; 62:482-486. [PMID: 36543723 DOI: 10.1053/j.jfas.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/25/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
Reulceration is a common complication following ray amputations of the foot. The primary aim of this study was to evaluate the incidence of re-ulceration following isolated and combined central ray amputations. This was a retrospective review of 55 consecutive limbs that underwent central ray amputations at Wake Forest Baptist Medical Centers. Procedures were performed at the 3 central rays or a combination of central rays. Incidence of postoperative ulceration was evaluated on the ipsilateral foot. We hypothesized there would not be an association between which ray was resected and development of reulceration. 24 patients (43%) experienced repeat ulceration following a central ray amputation. Median follow up time was 17.4 months (range 4 days to 99 months). The estimated ulcer recurrence rate at 1 year was 41.8%. There was no statistical difference based on location of amputation (second, third, 4 rays) with regards to reulceration, further amputation, transmetatarsal amputation, or below knee amputations. However, reulceration seemed to be much quicker in those patients undergoing a third ray amputation. Like the medial and lateral rays, central ray amputations can be a good initial salvage procedure to clear devitalized tissue and prevent the spreading of infection. The results of the present study suggest that there is no detectable difference between location of central ray amputations and development of re-ulceration, more proximal amputations, or death among this cohort.
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Affiliation(s)
- Lindsay K LeSavage
- Resident, Podiatric Medicine and Surgery Residency Program, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Hayden L Hoffler
- Fellow, Southeast Permanente Foot & Ankle Trauma & Reconstructive Fellowship, Atlanta, GA.
| | - Joni K Evans
- Biostatistician, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Cody D Blazek
- Assistant Professor, Podiatric Medicine and Surgery Residency, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC
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16
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Transmetatarsal amputations in patients with diabetes mellitus: A contemporary analysis from an academic tertiary referral centre in a developing community. PLoS One 2022; 17:e0277117. [PMID: 36327256 PMCID: PMC9632785 DOI: 10.1371/journal.pone.0277117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/20/2022] [Indexed: 11/06/2022] Open
Abstract
Transmetatarsal amputation (TMA) involves the surgical removal of the distal portion of metatarsals in the foot. It aims to maintain weight-bearing and independent ambulation while eliminating the risk of spreading soft tissue infection or gangrene. This study aimed to explore the risk factors and surgical outcomes of TMA in patients with diabetes at an academic tertiary referral center in Jordan. Medical records of all patients with diabetes mellitus who underwent TMA at King Abdullah University Hospital, Jordan, between January 2017 and January 2019 were retrieved. Patient characteristics along with clinical and laboratory findings were analyzed retrospectively. Pearson’s chi-square test of association, Student’s t-test, and multivariate regression analysis were used to identify and assess the relationships between patient findings and TMA outcome. The study cohort comprised 81 patients with diabetes who underwent TMA. Of these, 41 (50.6%) patients achieved complete healing. Most of the patients were insulin-dependent (85.2%). Approximately half of the patients (45.7%) had severe ankle-brachial index (ABI). Thirty patients (37.1%) had previous revascularization attempts. The presence of peripheral arterial disease (P<0.05) exclusively predicted poor outcomes among the associated comorbidities. Indications for TMA included infection, ischemia, or both. The presence of severe ABI (≤0.4, P<0.01) and a previous revascularization attempt (P<0.05) were associated with unfavorable outcomes of TMA. Multivariate analysis that included all demographic, clinical, and laboratory variables in the model revealed that insulin-dependent diabetes, low albumin level (< 33 g/L), high C-reactive protein level (> 150 mg/L), and low score of Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC, <6) were the main factors associated with poor TMA outcomes. TMA is an effective technique for the management of diabetic foot infection or ischemic necrosis. However, attention should be paid to certain important factors such as insulin dependence, serum albumin level, and LRINEC score, which may influence the patient’s outcome.
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17
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Bik PM, Heineman K, Levi J, Sansosti LE, Meyr AJ. The Effect of Remnant Metatarsal Parabola Structure on Transmetatarsal Amputation Primary Healing and Durability. J Foot Ankle Surg 2022; 61:1187-1190. [PMID: 34852948 DOI: 10.1053/j.jfas.2021.10.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/22/2021] [Accepted: 10/29/2021] [Indexed: 02/03/2023]
Abstract
Although generally considered to be both a durable and functional procedure for limb preservation, the transmetatarsal amputation (TMA) has high rates of complication, failure, revisional operation, and progression to more proximal amputation. The objective of this investigation was to determine the effect of remnant metatarsal parabola structure on healing outcomes following TMA. A retrospective chart review was performed of subjects undergoing a complete TMA with primary closure. We considered 4 patterns of remnant metatarsal parabola structure. TMA pattern type 1 was a normal parabola with the remnant second metatarsal extending furthest distally and slightly longer than the remnant first and third metatarsals with a gradual lateral taper. TMA pattern type 2 was the first metatarsal remnant extending furthest distally with a gradual lateral taper. TMA pattern type 3 was a relatively long fifth metatarsal remnant without the presence of a gradual lateral taper. And TMA pattern type 4 was a relatively short first metatarsal remnant with a relatively long second metatarsal with a gradual lateral taper. Seventy-three transmetatarsal amputations in 73 subjects met selection criteria. Thirty-nine (53.4%) amputations healed primarily at 90 days. No statistically significant differences were observed between groups with respect to the 90-day primary healing rate (p = .571) or 1-year ambulation rate without wound recurrence or reoperation (p = .811). These results might indicate that the remnant metatarsal structure does not have an effect on transmetatarsal amputation outcome. It is our hope that these results add to the body of knowledge and lead to further investigations into outcomes of limb preservation surgical interventions.
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Affiliation(s)
- Patrick M Bik
- Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA
| | - Kate Heineman
- Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA
| | - Jennifer Levi
- Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA
| | - Laura E Sansosti
- Clinical Assistant Professor, Departments of Surgery and Biomechanics, Temple University School of Podiatric Medicine, Philadelphia, PA
| | - Andrew J Meyr
- Clinical Professor, Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
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18
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Blanchette V, Houde L, Armstrong DG, Schmidt BM. Outcomes of Hallux Amputation Versus Partial First Ray Resection in People with Non-Healing Diabetic Foot Ulcers: A Pragmatic Observational Cohort Study. INT J LOW EXTR WOUND 2022:15347346221122859. [PMID: 36069031 PMCID: PMC10018408 DOI: 10.1177/15347346221122859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There are few data comparing outcomes after hallux amputation or partial first ray resection after diabetic foot ulcer (DFU). In a similar context, the choice to perform one of these two surgeries is attributable to clinician preference based on experience and characteristics of the patient and the DFU. Therefore, the purpose of this study was to determine the more definitive surgery between hallux amputation and partial first ray resection. We abstracted data from a cohort of 70 patients followed for a 1-year postoperative period to support clinical practice. We also attempted to identify patient characteristics leading to these outcomes. Our results suggested no statistical difference between the type of surgery and outcomes such as recurrence of DFU and amputation at 3, 6, and 12 months or death. However, there was a statistically significantly increased likelihood of re-ulceration for patients with CAD who underwent hallux amputation (p = 0.02). There was also a significantly increased likelihood of re-ulceration for people with depression or a history when the partial ray resection was performed (p = 0.02). Patients with prior amputation showed a higher probability of undergoing another re-amputation with partial ray resection (p = 0.01). Although the trends that emerge from this project are limited to what is observed in this statistical context, where the number of patients included and the number of total observations per outcome were limited, it highlights interesting data for future research to inform clinical decisions to support best practices for the benefit of patients.
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Affiliation(s)
- Virginie Blanchette
- Department of Human Kinetics and Podiatric Medicine, Université du Québec à Trois-Rivières, 3351, boul. des Forges, C.P. 500, Trois-Rivières, Canada, G9A 5H7
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, 1520 San Pablo, St. Los Angeles, CA, 90031, USA
| | - Louis Houde
- Department of Mathematic and Informatic, Université du Québec à Trois-Rivières, 3351, boul. des Forges, C.P. 500, Trois-Rivières, Canada, G9A 5H7
| | - David G. Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, 1520 San Pablo, St. Los Angeles, CA, 90031, USA
| | - Brian M. Schmidt
- University of Michigan Medical School, Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, Domino’s Farms (Lobby C, Suite 1300) 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48106, USA
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19
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Berli MC. Mid- and Hindfoot Amputations in Diabetic Patients. Foot Ankle Clin 2022; 27:687-700. [PMID: 36096559 DOI: 10.1016/j.fcl.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Several surgical options exist to avoid or at least to delay a below-the-knee amputation (BKA). These are the so-called mid- or hindfoot amputations. They are a valuable treatment option in order to maintain the ability to ambulate without major auxiliary means (eg, a prosthesis). Hence, these amputations allow the patients to maintain certain autonomy. The acceptance of these amputations is significantly higher than a BKA, as the body image is less disturbed. The complication rate in hindfoot amputations in diabetic patients is high due to the comorbidities, in particular peripheral arterial disease and polyneuropathy.
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Affiliation(s)
- Martin C Berli
- Division of Technical Orthopaedics, Department of Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland; Universitätsklinik Balgrist, Forchstrasse 340, 8008 Zurich, Switzerland.
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20
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Mortality and Conversion Rates to Below-Knee or Above-Knee Amputation After Transmetatarsal Amputation. J Am Acad Orthop Surg 2022; 30:767-779. [PMID: 35442927 DOI: 10.5435/jaaos-d-21-00872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 03/08/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The purpose of this study was to identify associated risk factors for complications, need for a higher level of amputation such as below-knee amputation (BKA) or above-knee amputation (AKA), and mortality after transmetatarsal amputation (TMA). METHODS We identified 265 patients who underwent 286 TMA procedures between June 2002 and July 2016. Medical records were reviewed for revision surgery and amputation. Mortality was verified using the National Death Index. We identified and documented potential risk factors including diabetes, hemoglobin A1c level, end-stage renal disease, cardiovascular disease, peripheral vascular disease, history of revascularization, contralateral amputation, and neuropathy. Sixty-eight percent were male, the mean age was 56.9 years (SD 12.8; range 24.1 to 92.1), and the median body mass index was 28.6 (interquartile range, 24.5 to 33.1). RESULTS Twenty-seven percent of the patients required a subsequent BKA or AKA after the index TMA surgery. The results of a multivariable model indicated that women (odds ratio [OR], 3.63; 95% confidence interval [CI], 1.716 to 7.672), patients aged 57 to 64 years (OR, 0.17; 95% CI, 0.06 to 0.51), and patients with a history of revascularization (OR, 7.06, 95% CI, 2.86 to 17.44) had markedly higher odds than the relevant comparison groups. Forty percent of the patients died after the index TMA at a median of 27 months. After adjusting for all patient factors, history of end-stage renal disease (OR, 2.2; 95% CI, 1.206 to 4.014) and cardiovascular disease (OR, 2.879; 95% CI, 1.615 to 5.131) remained markedly associated with mortality after TMA. DISCUSSION There are high rates of additional amputation after nontraumatic TMA and a high mortality rate. Surgeons should set realistic expectations with patients considered for TMA and identify risk factors, which may guide treatment. Treatment is multidisciplinary, requiring attention to surgical details, correction of vascular deficiency or contracture when present, and perioperative medical optimization. LEVEL OF EVIDENCE IV.
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21
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The Outcome of Surgical Treatment for the Neuropathic Diabetic Foot Lesions-A Single-Center Study. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081156. [PMID: 36013336 PMCID: PMC9409874 DOI: 10.3390/life12081156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 07/23/2022] [Accepted: 07/28/2022] [Indexed: 11/16/2022]
Abstract
The prevalence of diabetic foot complications is continuously increasing as diabetes has become one of the most important "epidemics" of our time. The main objective of this study was to describe the appropriate surgical intervention for the complicated neuropathic diabetic foot; the secondary goal was to find the risk factors associated with minor/major amputation and good or adverse surgical outcomes. This is an observational, retrospective study conducted between 1 January 2018 and 31 December 2019, which included 251 patients from the General Surgery Department at the Dr I. Cantacuzino Clinical Hospital in Bucharest with type II diabetes mellitus and neuropathic diabetic foot complications. The surgical conditions identified at admission were the following: osteitis (38.6%), infected foot ulcer (27.5%), gangrene (20.7%), infected Charcot foot (3.6%), non-healing wound (3.6%), necrosis (3.2%), and granulated wound (2.8%). We found that a minor surgical procedure (transmetatarsal amputation of the toe and debridement) was performed in 85.8% of cases, and only 14.2% needed major amputations. Osteitis was mainly associated with minor surgery (p = 0.001), while the gangrene and the infected Charcot foot were predictable for major amputation, with OR = 2.230, 95% CI (1.024-4.857) and OR = 5.316, 95% CI (1.354-20.877), respectively. Admission anemia and diabetic nephropathy were predictive of a major therapeutical approach, with p = 0.011, OR = 2.975, 95% CI (1.244-8.116) and p = 0.001, OR = 3.565, 95% CI (1.623-7.832), respectively. All the major amputations had a good outcome, while only several minor surgeries were interpreted as the adverse outcome (n = 24). Osteitis (45.8%) and admission anemia (79.2%) were more frequently associated with adverse outcomes, with p = 0.447 and p = 0.054, respectively. The complicated neuropathic diabetic foot requires a surgical procedure mainly associated with a good outcome.
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22
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Tokarski AR, Barton EC, Wagner JT, Elliott AD, Simonson DC, Hordyk PJ, Rademaker M. Are Transmetatarsal Amputations a Durable Limb Salvage Option? A Single-Institution Descriptive Analysis. J Foot Ankle Surg 2022; 61:537-541. [PMID: 34794876 DOI: 10.1053/j.jfas.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 06/01/2021] [Accepted: 10/03/2021] [Indexed: 02/03/2023]
Abstract
In limb and life-threatening diabetic foot infections, transmetatarsal amputations are often indicated as a limb salvage procedure. The aim of this study is to analyze the long-term durability of initially successful transmetatarsal amputations in the diabetic population. We defined a successful transmetatarsal amputation as one which had clinical healing 1 year after surgery. A retrospective review of transmetatarsal amputations completed at our institution over an 11-year period was performed. We identified 83 amputations that met inclusion criteria. The mean follow-up was 4 years. The mean time to surgical healing was 109.8 days. After successfully healing the transmetatarsal amputation the long-term outcomes were analyzed. Re-ulcerations occurred in 44% of the transmetatarsal amputations a mean of 15 months after surgical healing. Patients who re-ulcerated were noted to be significantly younger (p value 0.02) with a significantly higher preprocedure hemoglobin A1c (p value < .001). Additional procedures after successful healing included 13 (15.66%) revision surgeries and 12 (14.46%) more proximal amputations. While transmetatarsal amputations remain a viable and durable limb preserving surgery, all patients who have undergone a transmetatarsal amputation should be monitored lifelong as they remain at risk for re-ulceration and more proximal amputation.
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Affiliation(s)
- Alexander R Tokarski
- Podiatric Medicine and Surgery Resident, Gundersen Health Systems, La Crosse, WI.
| | - Ellen C Barton
- Podiatric Medicine and Surgery Resident, Gundersen Health Systems, La Crosse, WI
| | - Jacob T Wagner
- Podiatric Medicine and Surgery Resident, Gundersen Health Systems, La Crosse, WI
| | | | | | | | - Marc Rademaker
- Undergraduate Student, University of Wisconsin-La Crosse, La Crosse, WI
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Deldar R, Cach G, Sayyed AA, Truong BN, Kim E, Atves JN, Steinberg JS, Evans KK, Attinger CE. Functional and Patient-reported Outcomes following Transmetatarsal Amputation in High-risk Limb Salvage Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4350. [PMID: 35646494 PMCID: PMC9132523 DOI: 10.1097/gox.0000000000004350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/12/2022] [Indexed: 11/26/2022]
Abstract
Background Transmetatarsal amputation (TMA) is performed in patients with nonhealing wounds of the forefoot. Compared with below-knee amputations, healing after TMA is less reliable, and often leads to subsequent higher-level amputation. The aim of this study was to evaluate the functional and patient-reported outcomes of TMA. Methods A retrospective review of patients who underwent TMA from 2013 to 2021 at our limb-salvage center was conducted. Primary outcomes included postoperative complications, secondary proximal lower extremity amputation, ambulatory status, and mortality. Univariate and multivariate analyses were performed to evaluate independent risk factors for higher-level amputation after TMA. Patient-reported outcome measures for functionality and pain were also obtained. Results A total of 146 patients were identified. TMA success was achieved in 105 patients (72%), and 41 patients (28%) required higher-level amputation (Lisfranc: 31.7%, Chopart: 22.0%, below-knee amputations: 43.9%). There was a higher incidence of postoperative infection in patients who subsequently required proximal amputation (39.0 versus 9.5%, P < 0.001). At mean follow-up duration of 23.2 months (range, 0.7-97.6 months), limb salvage was achieved in 128 patients (87.7%) and 83% of patients (n = 121) were ambulatory. Patient-reported outcomes for functionality corresponded to a mean maximal function of 58.9%. Pain survey revealed that TMA failure patients had a significantly higher pain rating compared with TMA success patients (P = 0.016). Conclusions TMA healing remains variable, and many patients will eventually require a secondary proximal amputation. Multi-institutional studies are warranted to identify perioperative risk factors for higher-level amputation and to further evaluate patient-reported outcomes.
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Affiliation(s)
- Romina Deldar
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - Gina Cach
- Georgetown University School of Medicine, Washington, D.C
| | - Adaah A. Sayyed
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
- Georgetown University School of Medicine, Washington, D.C
| | | | - Emily Kim
- Georgetown University School of Medicine, Washington, D.C
| | - Jayson N. Atves
- Department of Podiatric Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - John S. Steinberg
- Department of Podiatric Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - Karen K. Evans
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - Christopher E. Attinger
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
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Whelan JH, Kiser CR, Lazoritz JP, Vardaxis V. Avoiding the Deep Plantar Arterial Arch in Transmetatarsal Amputations: A Cadaver Study. J Am Podiatr Med Assoc 2022; 112:20-298. [PMID: 36115032 DOI: 10.7547/20-298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The deep plantar arterial arch (DPAA) is formed by an anastomosis between the deep plantar artery and the lateral plantar artery. The potential risk of injury to the DPAA is concerning when performing transmetatarsal amputations, and care must be taken to preserve the anatomy. We sought to determine the positional anatomy of the DPAA based on anatomical landmarks that could be easily identified and palpated during transmetatarsal amputation. METHODS In an effort to improve our understanding of the positional relationship of the DPAA to the distal metatarsal parabola, dissections were performed on 45 cadaveric feet to measure the location of the DPAA with respect to the distal metatarsal epiphyses. Images of the dissected specimens were digitally acquired and saved for measurement using in-house-written software. The mean, SD, SEM, and 95% confidence interval were calculated for all of the measurement parameters and are reported on pooled data and by sex. An independent-samples t test was used to assess for sex differences. Interrater reliability of the measurements was estimated using the intraclass correlation coefficient. RESULTS The origin of the DPAA was located a mean ± SD of 35.6 ± 3.9 mm (95% confidence interval, 34.5-36.8 mm) proximal to the perpendicular line connecting the first and fifth metatarsal heads. The average interrater reliability across all of the measurements was 0.921. CONCLUSIONS This study provides the positional relationship of the DPAA with respect to the distal metatarsal parabola. This method is easily reproducible and may assist the foot and ankle surgeon with surgical planning and approach when performing partial pedal amputation.
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Meyr AJ, Skolnik J, Mateen S, Sansosti LE. A Comparison of Adverse Short-Term Outcomes Following Forefoot Amputation Performed on an Inpatient Versus Outpatient Basis. J Foot Ankle Surg 2022; 61:67-71. [PMID: 34266720 DOI: 10.1053/j.jfas.2020.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 02/03/2023]
Abstract
The objective of this investigation was to evaluate short-term adverse outcomes following forefoot amputation with a specific comparison between those procedures performed on an inpatient versus outpatient basis. The 2018 American College of Surgeons National Surgical Quality Improvement Program database was interrogated to select those subjects with a 28805 current procedural terminology code (amputation, foot; transmetatarsal) that underwent the procedure with "all layers of incision (deep and superficial) fully closed." This resulted in 326 subjects who underwent the procedure on an inpatient basis and 72 subjects who underwent the procedure on an outpatient basis. Results of the primary outcome measures found no significant differences between groups with respect to the development of a superficial surgical site infection (5.8% vs 5.6%; p = .950), deep incisional infection (3.4% vs 5.6%; p = .380), or wound disruption (3.4% vs 6.9%; p = .163). Additionally, no significant differences were observed between groups with respect to unplanned reoperations (15.6% vs 12.5%; p = .500) or unplanned hospital readmissions (21.8% vs 23.6%; p = .957). The results of this investigation demonstrate no difference in short-term adverse outcomes following the performance of forefoot amputation with primary closure when the procedure is performed on an inpatient or outpatient basis. We hope that this information is utilized in future investigations specifically examining this clinical scenario as it relates to hospital admission criteria related to lower extremity tissue loss, length of hospital stay considerations, the timing of partial foot amputation following revascularization, and the economics of limb preservation.
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Affiliation(s)
- Andrew J Meyr
- Clinical Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
| | - Jennifer Skolnik
- Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA
| | - Sara Mateen
- Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA
| | - Laura E Sansosti
- Clinical Assistant Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA
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Gennai S, Leone N, Covic T, Migliari M, Lonardi R, Silingardi R. Health-related quality of life outcomes and Hospitalization length of stay after micro-fragmented autologous adipose tissue injection in minor amputations for diabetic foot ulceration (MiFrAADiF trial): results from a randomized controlled single-center clinical trial. INT ANGIOL 2021; 40:512-519. [PMID: 34515448 DOI: 10.23736/s0392-9590.21.04570-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The diabetic foot ulcer (DFU) is a high prevalence complication that significantly impairs the health-related quality of life (HRQoL) and is characterized by prolonged hospital length of stay (LOS). The impact of the micro-fragmented autologous adipose tissue injection at the minor amputation wound in the case of DFU (MiFrAADiF) on HRQoL and LOS compared to the standard care has not been determined yet. METHODS This was a two-arm, 6-month, individually randomized controlled single-center clinical trial. A 1:1 randomization to local injection of autologous micro-fragmented adipose tissue (treatment group; n=57) or standard clinical care (control group; n=57) was performed. The primary objective was the HRQoL. The secondary endpoint was the LOS. HRQoL was assessed with the Medical Outcomes Study 36-item Short-Form Health Survey which provides 2 scores focused on physical (PCS) and mental functioning (MCS). The trial was registered in ClinicalTrials.gov (NCT03276312). RESULTS The type of treatment (p=0.009) and the time elapsed since surgery (p= 0.0000) demonstrated a significant improvement on PCS. The MCS improvements resulted in a non-significant association with treatment (p= 0.21). The time elapsed since surgery showed a significant influence on the MCS (p= 0.0000). The mean LOS was 16.2 days and 24.4 days for the treatment and the control group respectively (p= 0.025). CONCLUSIONS The MiFrAADiF trial demonstrated a significant improvement in terms of physical HRQoL and a significant reduction of the hospital length of stay after injection of micro-fragmented autologous adipose tissue in diabetic patients' minor amputations wound.
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Affiliation(s)
- Stefano Gennai
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy -
| | - Tea Covic
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Mattia Migliari
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Lonardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
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Speer CG, Rendos NK, Davis CE, Au B, Manway JM, Burns PR. Reoperation, reamputation, and new ulceration following complete or partial toe amputation among diabetic and non-diabetic patients. Diabetes Res Clin Pract 2021; 179:109008. [PMID: 34411621 DOI: 10.1016/j.diabres.2021.109008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 07/19/2021] [Accepted: 08/11/2021] [Indexed: 01/22/2023]
Abstract
AIMS To compare the number of reoperations, reamputations, and new ulcers following toe amputation in diabetic and non-diabetic patients with sub-group analysis on index amputation level. METHODS One-hundred sixteen patients with a complete (CTA) or partial (PTA) toe amputation and minimum of 12-month (12 M) follow-up were identified in electronic medical records. The number of reoperations and reamputations, number and location of new ulcers, and final amputation level of the ipsilateral extremity were compared between diabetic and non-diabetic patients and between those with CTA and PTA at 12 M and final follow-up (FFU). RESULTS Diabetic patients had significantly more reoperations, reamputations, and new ulcers than non-diabetic patients at 12 M and FFU. There were no differences in reoperations, reamputations, or new ulcer location between CTA and PTA; however, patients with PTA developed more new ulcers at 12 M and FFU and were more likely to have a distal final amputation level compared to those with CTA. CONCLUSIONS Diabetic patients required significantly more reoperations and reamputations following a toe amputation and developed more new ulcers than non-diabetic patients regardless of index amputation level. These high rates among diabetic patients highlight the complications encountered following toe amputation and emphasize the need for close, multi-disciplinary care.
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Affiliation(s)
- Carl G Speer
- Emerald Coast Foot and Ankle Center, 8333 N Davis Highway, Suite 6E, Pensacola, FL, 32514, United States; Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center, 1400 Locust Street, Pittsburgh, PA 15219, United States.
| | - Nicole K Rendos
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, 1441 Clifton Road NE, Atlanta, GA 30322, United States.
| | - Calvin E Davis
- Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center, 1400 Locust Street, Pittsburgh, PA 15219, United States.
| | - Brian Au
- Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center, 1400 Locust Street, Pittsburgh, PA 15219, United States.
| | - Jeffrey M Manway
- Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center, 1400 Locust Street, Pittsburgh, PA 15219, United States.
| | - Patrick R Burns
- Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center, 1400 Locust Street, Pittsburgh, PA 15219, United States.
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Bandeira MA, Dos Santos ALG, Woo K, Gamba MA, de Gouveia Santos VLC. Incidence and Predictive Factors for Amputations Derived From Charcot's Neuroarthropathy in Persons With Diabetes. INT J LOW EXTR WOUND 2021:15347346211025893. [PMID: 34142879 DOI: 10.1177/15347346211025893] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Charcot's neuroarthropathy (CN) is the progressive destruction of the bones and joints of the feet, as a consequence of severe peripheral neuropathy, which predisposes patients to amputations. The purpose of this study was to measure the cumulative incidence of amputations resulting from CN and risk factors among amputated people with diabetes mellitus (DM). This was an epidemiological, observational, and retrospective study of 114 patients with DM who had an amputation involving the lower limbs. Data were collected from 2 specialized outpatient clinics between 2015 and 2019, including socio-demographic and clinical variables (cause of amputation: CN, peripheral arterial disease [PAD], infected ulcers, fracture, osteomyelitis, and others; body mass index [BMI]; 1 or 2 DM, time since DM diagnosis, insulin treatment, glycated hemoglobin; creatinine; smoking and drinking; systemic arterial hypertension, diabetic retinopathy, diabetic kidney disease, diabetic peripheral neuropathy, acute myocardial infarction, PAD, and stroke; characteristics of amputation [level and laterality], in addition to the specific variables related to CN [time of amputation in relation to the diagnosis of CN, diagnosis of CN in the acute phase, and treatment implemented in the acute phase]). We compared socio-demographic and clinical characteristics, including types of amputation, between patients with and without CN. Statistical analyses were performed using the 2 sample t-test or Wilcoxon-Mann-Whitney test, for quantitative variables, and the Pearson's χ2 test or Fisher's exact test for categorical variables. The investigation of the possible association of predictive factors for a CN amputation was carried out through logistic regression. The amputation caused by CN was present in 27 patients with a cumulative incidence of 23.7% in 5 years. There was a statistically significant association between BMI and the occurrence of CN (odds ratio: 1.083; 95% confidence interval: 1.001-1.173; P = .048); higher values of BMI were associated with a higher occurrence of amputations secondary from CN.
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Affiliation(s)
| | | | - Kevin Woo
- 4257Queen's University, Kingston, Ontario, Canada
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Liu R, Petersen BJ, Rothenberg GM, Armstrong DG. Lower extremity reamputation in people with diabetes: a systematic review and meta-analysis. BMJ Open Diabetes Res Care 2021; 9:9/1/e002325. [PMID: 34112651 PMCID: PMC8194332 DOI: 10.1136/bmjdrc-2021-002325] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 05/09/2021] [Indexed: 12/03/2022] Open
Abstract
In this study, we determined the reamputation-free survival to both limbs and to the contralateral limb only following an index amputation of any-level and assessed whether reamputation rates have changed over time. We completed a systematic search using PubMed and screened a total of 205 articles for data on reamputation rates. We reported qualitative characteristics of 56 studies that included data on reamputation rates and completed a meta-analysis on 22 of the studies which enrolled exclusively participants with diabetes. The random-effects meta-analysis fit a parametric survival distribution to the data for reamputations to both limbs and to the contralateral limb only. We assessed whether there was a temporal trend in the reamputation rate using the Mann-Kendall test. Incidence rates were high for reamputation to both limbs and to the contralateral limb only. At 1 year, the reamputation rate for all contralateral and ipsilateral reamputations was found to be 19% (IQR=5.1%-31.6%), and at 5 years, it was found to be 37.1% (IQR=27.0%-47.2%). The contralateral reamputation rate at 5 years was found to be 20.5% (IQR=13.3%-27.2%). We found no evidence of a trend in the reamputation rates over more than two decades of literature analyzed. The incidence of lower extremity reamputation is high among patients with diabetes who have undergone initial amputations secondary to diabetes, and rates of reamputation have not changed over at least two decades.
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Affiliation(s)
- Rongqi Liu
- Podimetrics Inc, Somerville, Massachusetts, USA
- Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Gary M Rothenberg
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - David G Armstrong
- Department of Surgery, USC Keck School of Medicine, Los Angeles, California, USA
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Ratliff HT, Shibuya N, Jupiter DC. Minor vs. major leg amputation in adults with diabetes: Six-month readmissions, reamputations, and complications. J Diabetes Complications 2021; 35:107886. [PMID: 33653663 DOI: 10.1016/j.jdiacomp.2021.107886] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 10/22/2022]
Abstract
AIMS The objective of this study was comparing medium-term outcomes between comparable minor and major amputations in adults with diabetes. METHODS We used data from the 2016-2017 National Readmissions Database to construct a representative cohort of 15,581 adults with diabetes with lower extremity amputations. Patients were categorized by level of index amputation (major/minor), and propensity score matched to compare outcomes in candidates for either level of amputation. Readmission and reamputations were assessed at 1, 3, and 6 months following index amputation. RESULTS In the 6 months following index amputation, large proportions of patients were readmitted (n = 7597, 48.8%) or had reamputations (n = 1990, 12.8%). Patients with minor amputations had greater odds of readmission (OR = 1.25; 95% CI 1.18-1.31), reamputation (OR = 3.71; 95% CI 3.34-4.12), and more proximal reamputation (OR = 2.61; 95% 2.33-2.93) (all P < 0.001). Further, minor amputation patients had higher and lower odds of readmission for postoperative infection (OR = 4.45; 95% CI 3.27-6.05), or sepsis (OR = 0.79; 95% CI 0.68-0.93), respectively. CONCLUSION Patients desire to save as much limb as possible and should be counseled on higher risk for reamputation, readmission, and infection with minor amputations.
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Affiliation(s)
- Hunter T Ratliff
- School of Medicine, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555, United States
| | - Naohiro Shibuya
- Texas A&M University, College of Medicine, Temple, TX, United States; Section of Podiatry, Department of Surgery, Central Texas Veterans Affairs Health Care System, Temple, TX, United States.
| | - Daniel C Jupiter
- Department of Preventive Medicine and Population Health, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1148, United States; Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0165, United States.
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Jupiter DC, LaFontaine J, Barshes N, Wukich DK, Shibuya N. Transmetatarsal and Minor Amputation Versus Major Leg Amputation: 30-Day Readmissions, Reamputations, and Complications. J Foot Ankle Surg 2021; 59:484-490. [PMID: 32354505 DOI: 10.1053/j.jfas.2019.09.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 02/03/2023]
Abstract
AIMS The optimal level of lower-extremity amputation, particularly in diabetic patients with ulceration, is debated. Proximal amputations more greatly decrease function versus distal amputations, but healing and complication rates may differ between the 2 types. This study compares early postoperative outcomes after transmetatarsal and other partial foot amputations and major leg amputations. METHODS Data were derived from National Surgical Quality Improvement Program datasets covering 2012 to 2014. Outcomes studied include 30-day rates of readmission to hospital for wound complications. We matched the 2 types of amputation patients by propensity score to fairly compare between levels of amputation when either type of amputation might be indicated. The same analysis was then performed with emphasis on diabetic patients. RESULTS Major amputation patients were more likely to have dependent functional status, although their surgeries tended to be more complicated. Minor amputation patients had 2.5 times the odds of irrigation and debridement compared with major amputation patients, but only 0.49 and 0.47 times the odds of urinary tract infection or transfusion, respectively. CONCLUSIONS Although short-term complications, readmissions, and reoperations were more common in distal amputation, UTI and the need for transfusion were higher in major amputation.
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Affiliation(s)
- Daniel C Jupiter
- Associate Professor, Department of Preventive Medicine and Population Health, The University of Texas Medical Branch, Galveston, TX; Research Associate, Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, TX.
| | - Javier LaFontaine
- Professor, Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Neal Barshes
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Dane K Wukich
- Professor and Chairman, Department of Orthopaedic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Naohiro Shibuya
- Professor, Texas A&M University, College of Medicine, Temple, TX; Section of Podiatry, Department of Surgery, Central Texas Veterans Affairs Health Care System, Temple, TX; Department of Surgery, Baylor Scott & White Health, Temple, TX
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Lipsky BA, Uçkay İ. Treating Diabetic Foot Osteomyelitis: A Practical State-of-the-Art Update. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:339. [PMID: 33916055 PMCID: PMC8066570 DOI: 10.3390/medicina57040339] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/17/2022]
Abstract
Background and Objectives: Diabetic foot osteomyelitis (DFO) can be difficult to treat and securing optimal clinical outcomes requires a multidisciplinary approach involving a wide variety of medical, surgical and other health care professionals, as well as the patient. Results of studies conducted in the past few years have allowed experts to formulate guidelines that can improve clinical outcomes. Material and Methods: We conducted a narrative review of the literature on treat- ment of DFO, with an emphasis on studies published in the last two years, especially regarding antimicrobial therapies and surgical approached to treatment of DFO, supplemented by our own extensive clinical and research experience in this field. Results: Major amputations were once com- mon for DFO but, with improved diagnostic and surgical techniques, "conservative" surgery (foot- sparing, resecting only the infected and necrotic bone) is becoming commonplace, especially for forefoot infections. Traditional antibiotic therapy, which has been administered predominantly in- travenously and frequently for several months, can often be replaced by appropriately selected oral antibiotic regimens following only a brief (or even no) parenteral therapy, and given for no more than 6 weeks. Based on ongoing studies, the recommended duration of treatment may soon be even shorter, especially for cases in which a substantial portion of the infected bone has been resected. Using the results of cultures (preferably of bone specimens) and antimicrobial stewardship princi- ples allows clinicians to select evidence-based antibiotic regimens, often of a limited pathogen spec- trum. Intra-osseous antimicrobial and surgical approaches to treatment are also evolving in light of ongoing research. Conclusions: In this narrative, evidenced-based review, taking consideration of principles of antimicrobial stewardship and good surgical practice, we have highlighted the recent literature and offered practical, state-of-the-art advice on the antibiotic and surgical management of DFO.
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Affiliation(s)
- Benjamin A. Lipsky
- Department of Medicine, University of Washington, Seattle, WA 98116, USA
| | - İlker Uçkay
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland;
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Lear W. Response to letter from Verdura et al. JAAD Case Rep 2021; 9:69-70. [PMID: 33665280 PMCID: PMC7902486 DOI: 10.1016/j.jdcr.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Struggling for normality: experiences of patients with diabetic lower extremity amputations and post-amputation wounds in primary care. Prim Health Care Res Dev 2020; 21:e63. [PMID: 33323161 PMCID: PMC7801928 DOI: 10.1017/s146342362000064x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Aim: To explore the experiences of patients living with diabetic lower extremity amputation (DLEA) and its post-amputation wound in primary care. Background: DLEA, including both minor and major amputation, is a life-altering condition that brings numerous challenges to an individual’s life. Post-amputation physical wound healing is complicated and challenging because of wound dehiscence and prolonged healing times. Understanding patients’ experiences after DLEA with a post-amputation wound will enable healthcare professionals to develop interventions to assist patients in physical healing and psychosocial recovery. Methods: This study employs a qualitative design using interpretative phenomenological analysis (IPA). A purposive maximum variation sample of nine patients who had had lower extremity amputations and post-amputation wound attributed to diabetes in the previous 12 months was recruited from a primary care setting in Singapore. Semi-structured audio recorded one-to-one interviews with a duration of 45–60 min each were conducted between September 2018 and January 2019. The interviews were transcribed verbatim and analysed using IPA. Findings: The essential meaning of the phenomenon ‘the lived experiences for patients with DLEA and post-amputated wound’ can be interpreted as ‘struggling for “normality”’ which encompasses four domains of sense making: physical loss disrupted normality, emotional impact aggravated the disrupted normality, social challenges further provoked the disrupted normality, and attempt to regain normality. The study highlights the complex physical and psychosocial transition facing patients after DLEA before post-amputation wound closure. In primary care, an amputation, whether minor or major, is a life-altering experience that requires physical healing, emotional recovery, and social adaptation to regain normality. Patients living with DLEA and a post-amputation wound may benefit from an interdisciplinary team care model to assist them with physical and psychosocial adjustment and resume normality.
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Sareh S, Ugarte R, Dobaria V, Hadaya J, Sirody J, McCallum JC, de Virgilio C, Benharash P. Impact of Frailty on Clinical and Financial Outcomes Following Minor Lower Extremity Amputation: A Nationwide Analysis. Am Surg 2020; 86:1312-1317. [PMID: 33103459 DOI: 10.1177/0003134820964230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Frailty has been shown to portend worse outcomes in surgical patients. Our goal was to identify the impact of frailty on outcomes and resource utilization among patients undergoing minor lower extremity amputation in the United States. Using the Nationwide Readmission Database, we identified all adults undergoing a minor amputation between 2010 and 2015, and assessed 90-day outcomes, including readmission, reamputation, mortality, and cumulative hospitalization costs. Frailty was defined by International Classification of Diseases codes consistent with the ten frailty clusters as defined by the Johns Hopkins Adjusted Clinical Group System. Multivariable regression models were developed for risk adjustment. An estimated 302 798 patients (mean age = 61.8 years) were identified, of which 15.2% were categorized as Frail. Before adjustment, frailty was associated with increased rates of readmission (44% vs. 36%, P < .001) and in-hospital mortality (4% vs. 2%, P < .001). Frailty was also associated with increased cumulative costs of care ($39 417 vs. $27 244, P < .001). After risk adjustment, frailty remained an independent predictor of readmission (Adjusted odds ratio [AOR] 1.18, CI 1.14-1.23), in-hospital mortality (AOR 1.48, CI 1.34-1.65), and incremental costs (+$7 646, CI $6927-$8365). Frailty is an independent marker of worse outcomes following minor foot amputation, and may be utilized to direct quality improvement efforts.
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Affiliation(s)
- Sohail Sareh
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Los Angeles County Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Ramsey Ugarte
- Los Angeles County Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Vishal Dobaria
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Joseph Sirody
- Los Angeles County Harbor-UCLA Medical Center, Torrance, CA, USA
| | - John C McCallum
- Los Angeles County Harbor-UCLA Medical Center, Torrance, CA, USA
| | | | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Zhang GQ, Canner JK, Haut E, Sherman RL, Abularrage CJ, Hicks CW. Impact of Geographic Socioeconomic Disadvantage on Minor Amputation Outcomes in Patients With Diabetes. J Surg Res 2020; 258:38-46. [PMID: 32980774 DOI: 10.1016/j.jss.2020.08.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/13/2020] [Accepted: 08/30/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Socioeconomic disadvantage is a known contributor to adverse events and higher admission rates in the diabetic population. However, its impact on outcomes after lower extremity amputation is unclear. We aimed to assess the association of geographic socioeconomic disadvantage with short- and long-term outcomes after minor amputation in patients with diabetes. MATERIALS AND METHODS Geographic socioeconomic disadvantage was determined using the area deprivation index (ADI). All patients from the Maryland Health Services Cost Review Commission database (2012-2019) who underwent minor amputation with a concurrent diagnosis of diabetes were included and stratified by the ADI quartile. Associations of the ADI quartile with 30-day readmission and 1-year reamputation were evaluated using Kaplan-Meier survival analyses and multivariable logistic regression models adjusting for baseline differences. RESULTS A total of 7415 patients with diabetes underwent minor amputation (70.1% male, 38.7% black race), including 28.1% ADI1 (least deprived), 42.8% ADI2, 22.9% ADI3, and 6.2% ADI4 (most deprived). After adjusting for demographic and clinical factors, the odds of 30-day readmission were greater in the intermediate ADI groups than those in the ADI1 group, but not among the most deprived. Adjusted odds of 1-year reamputation were greater among ADI4 than those among ADI1. Kaplan-Meier analysis confirmed a greater likelihood of reamputation with an increasing ADI quartile over a 1-year period (P < 0.001). CONCLUSIONS Geographic socioeconomic disadvantage is independently associated with both short- and long-term outcomes after minor diabetic amputations in Maryland. A targeted approach addressing the health care needs of deprived regions may be beneficial in optimizing postoperative care in this vulnerable population.
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Affiliation(s)
- George Q Zhang
- The Johns Hopkins University School of Medicine, Baltimore, Maryland; Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Joseph K Canner
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Elliott Haut
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland; Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Ronald L Sherman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Caitlin W Hicks
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland; Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland.
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Rathnayake A, Saboo A, Malabu UH, Falhammar H. Lower extremity amputations and long-term outcomes in diabetic foot ulcers: A systematic review. World J Diabetes 2020; 11:391-399. [PMID: 32994867 PMCID: PMC7503503 DOI: 10.4239/wjd.v11.i9.391] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/06/2020] [Accepted: 08/15/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Diabetes mellitus causes a large majority of non-traumatic major and minor amputations globally. Patients with diabetes are clinically complex with a multifactorial association between diabetic foot ulcers (DFU) and subsequent lower extremity amputations (LEA). Few studies show the long-term outcomes within the cohort of DFU-associated LEA.
AIM To highlight the long-term outcomes of LEA as a result of DFU.
METHODS PubMed/MEDLINE and Google Scholar were searched for key terms, “diabetes”, “foot ulcers”, “amputations” and “outcomes”. Outcomes such as mortality, re-amputation, re-ulceration and functional impact were recorded. Peer-reviewed studies with adult patients who had DFU, subsequent amputation and follow up of at least 1 year were included. Non-English language articles or studies involving children were excluded.
RESULTS A total of 22 publications with a total of 2334 patients were selected against the inclusion criteria for review. The weighted mean of re-amputation was 20.14%, 29.63% and 45.72% at 1, 3 and 5 years respectively. The weighted mean of mortality at 1, 3 and 5 years were 13.62%, 30.25% and 50.55% respectively with significantly higher rates associated with major amputation, re-amputation and ischemic cardiomyopathy.
CONCLUSION Previous LEA, level of the LEA and patient comorbidities were significant risk factors contributing to re-ulceration, re-amputation, mortality and depreciated functional status.
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Affiliation(s)
- Ayeshmanthe Rathnayake
- Department of Medicine, Townsville University Hospital, Townsville 4814, Queensland, Australia
| | - Apoorva Saboo
- Department of Medicine, Townsville University Hospital, Townsville 4814, Queensland, Australia
| | - Usman H Malabu
- Department of Medicine, Townsville University Hospital, Townsville 4814, Queensland, Australia
- Department of Medicine, Townsville University Hospital, Townsville 4814, Queensland, Australia
- School of Medicine and Dentistry, James Cook University, Townsville 4811, Queensland, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm 17176, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm 17176, Sweden
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Häller TV, Kaiser P, Kaiser D, Berli MC, Uçkay I, Waibel FWA. Outcome of Ray Resection as Definitive Treatment in Forefoot Infection or Ischemia: A Cohort Study. J Foot Ankle Surg 2020; 59:27-30. [PMID: 31882144 DOI: 10.1053/j.jfas.2019.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/08/2019] [Accepted: 06/13/2019] [Indexed: 02/08/2023]
Abstract
Ray resection is frequently performed in cases of infection or ischemia, but the literature is scarce concerning its outcome as a definitive treatment. In this retrospective cohort study, we reviewed our cohort with transmetatarsal ray resection with a mean follow-up of 36.3 months. Reulcerations, transfer ulcers, and reamputations were determined. Risk factor analysis for revision surgery was conducted. Among 185 patients, 71 (38.4%) had revision surgery within a mean of 1.4 ± 2.6 years (range 2 days to 12.9 years), 22 (11.9%) had major amputations, 49 (26.5%) had minor amputations, 11 (5.9%) had same-ray reulceration, 40 (21.6%) had transfer ulceration, and 2 (1.1%) had both reulceration and transfer ulceration. Occurrence of a postoperative ulcer was statistically significantly associated with revision surgery (p < .01). In conclusion, metatarsal ray resection is a reasonable treatment option in cases of forefoot ischemia or infection to prevent major amputation but fails in 11.9%, and reulceration is associated with further revisions, making ulcer prevention paramount.
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Affiliation(s)
- Thomas V Häller
- Resident Orthopaedic Surgeon, Orthopedic Department, Balgrist University Hospital, Zurich, Switzerland.
| | - Peter Kaiser
- Resident Orthopaedic Surgeon, Orthopedic Department, Balgrist University Hospital, Zurich, Switzerland
| | - Dominik Kaiser
- Consultant Orthopaedic Surgeon, Orthopedic Department, Balgrist University Hospital, Zurich, Switzerland
| | - Martin C Berli
- Senior Consultant Orthopaedic Surgeon, Orthopedic Department, Balgrist University Hospital, Zurich, Switzerland
| | - Ilker Uçkay
- Senior Consultant Infectiologist, Unit for Clinical and Applied Research, Balgrist University Hospital, Zurich, Switzerland; Senior Consultant Infectiologist, Infectiology, Balgrist University Hospital, Zurich, Switzerland
| | - Felix W A Waibel
- Consultant Orthopaedic Surgeon, Orthopedic Department, Balgrist University Hospital, Zurich, Switzerland
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Wang A, Lv G, Cheng X, Ma X, Wang W, Gui J, Hu J, Lu M, Chu G, Chen J, Zhang H, Jiang Y, Chen Y, Yang W, Jiang L, Geng H, Zheng R, Li Y, Feng W, Johnson B, Wang W, Zhu D, Hu Y. Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition). BURNS & TRAUMA 2020; 8:tkaa017. [PMID: 32685563 PMCID: PMC7336185 DOI: 10.1093/burnst/tkaa017] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 03/21/2020] [Indexed: 02/07/2023]
Abstract
In recent years, as living standards have continued to improve, the number of diabetes patients in China, along with the incidence of complications associated with the disease, has been increasing. Among these complications, diabetic foot disease is one of the main causes of disability and death in diabetic patients. Due to the differences in economy, culture, religion and level of medical care available across different regions, preventive and treatment methods and curative results for diabetic foot vary greatly. In multidisciplinary models built around diabetic foot, the timely assessment and diagnosis of wounds and appropriate methods of prevention and treatment with internal and external surgery are key to clinical practice for this pathology. In 2019, under the leadership of the Jiangsu Medical Association and Chinese Diabetes Society, the writing group for the Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition) was established with the participation of scholars from the specialist areas of endocrinology, burn injury, vascular surgery, orthopedics, foot and ankle surgery and cardiology. Drawing lessons from diabetic foot guidelines from other countries, this guide analyses clinical practices for diabetic foot, queries the theoretical basis and grades and gives recommendations based on the characteristics of the pathology in China. This paper begins with assessments and diagnoses of diabetic foot, then describes treatments for diabetic foot in detail, and ends with protections for high-risk feet and the prevention of ulcers. This manuscript covers the disciplines of internal medicine, surgical, nursing and rehabilitation and describes a total of 50 recommendations that we hope will provide procedures and protocols for clinicians dealing with diabetic foot. Registry number: IPGRP-2020cn124
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Affiliation(s)
- Aiping Wang
- Diabetic Foot Centre, The Air Force Hospital From Eastern Theater of PLA, Nanjing, 210002, China
| | - Guozhong Lv
- Department of Burn and Plastic Surgery, Affiliated Hospital of Jiangnan University, Wuxi, 214062, China
| | - Xingbo Cheng
- Department of endocrinology, the First Affiliated Hospital of Suzhou University, Suzhou, 215006, China
| | - Xianghua Ma
- Department of endocrinology, Jiangsu Province Hospital, Nanjing, 210029, China.,Department of endocrinology, Xuzhou Central Hospital, Xuzhou, 221009,China
| | - Wei Wang
- Vascular Surgery, Gulou Hospital, Nanjing, 210008, China
| | - Jianchao Gui
- Department of orthopedics, Nanjing First Hospital, Nanjing, 210006, China
| | - Ji Hu
- Department of endocrinology, The Second Affiliated Hospital of Suzhou University, Suzhou, 215004, China
| | - Meng Lu
- Diabetic Foot Centre, The Air Force Hospital From Eastern Theater of PLA, Nanjing, 210002, China
| | - Guoping Chu
- Department of Burn and Plastic Surgery, Affiliated Hospital of Jiangnan University, Wuxi, 214062, China
| | - Jin'an Chen
- Diabetic Foot Centre, The Air Force Hospital From Eastern Theater of PLA, Nanjing, 210002, China
| | - Hao Zhang
- Department of endocrinology, Jiangsu Province Hospital, Nanjing, 210029, China
| | - Yiqiu Jiang
- Department of orthopedics, Nanjing First Hospital, Nanjing, 210006, China
| | - Yuedong Chen
- Diabetic Foot Centre, The Air Force Hospital From Eastern Theater of PLA, Nanjing, 210002, China
| | - Wengbo Yang
- Department of orthopedics, Nanjing First Hospital, Nanjing, 210006, China
| | - Lin Jiang
- Department of endocrinology, Jiangsu Province Hospital, Nanjing, 210029, China
| | - Houfa Geng
- Department of endocrinology, Xuzhou Central Hospital, Xuzhou, 221009,China
| | - Rendong Zheng
- Department of endocrinology, Jiangsu Province Hospital on Traditional of Chinese and Western Medicine, 210028, China
| | - Yihui Li
- Diabetic Foot Centre, The Air Force Hospital From Eastern Theater of PLA, Nanjing, 210002, China
| | - Wei Feng
- Operating department, Jiangsu Medical Association, Nanjing, 210008, China
| | - Boey Johnson
- Diabetic Foot Centre, The National University Hospital, 119077, Singapore
| | - Wenjuan Wang
- Department of Chronic Non-Communicable Diseases, Chinese Center for Disease Control and Prevention, Beijing, 102206, China
| | - Dalong Zhu
- Vascular Surgery, Gulou Hospital, Nanjing, 210008, China
| | - Yin Hu
- Operating department, Jiangsu Medical Association, Nanjing, 210008, China
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Joyce A, Yates B, Cichero M. Transmetatarsal amputation: A 12 year retrospective case review of outcomes. Foot (Edinb) 2020; 42:101637. [PMID: 32032924 DOI: 10.1016/j.foot.2019.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Diabetic foot pathology has rapidly increased, presenting a vast economic burden with severe implications for patients. Establishing effective limb salvage techniques such as transmetatarsal amputation is essential to offer viable alternatives to major limb amputation in severe foot infection, where outcomes are variable and mortality rates high. METHODS A retrospective review of outcomes was performed on patients who underwent TMA at a single United Kingdom hospital between 2005-2017. Healing rate and time to healing, mortality, duration of hospital admission and incidence of revision surgery was evaluated. Forty-seven patients had 54 TMA's by the Podiatric Surgery team. Data was assessed for Mean (SD) and Median. The impact of co-morbidities was considered and the perioperative and surgical management reviewed to identify techniques which may improve outcomes. RESULTS A 78% healing rate was achieved. Six patients (11%) died before healing. The aremaining 11% did not heal and resulted in major limb amputation. No further surgery to the same foot was required after the TMA healed. A Median healing time of 83 days was identified and the Median duration of hospital admission was 24 days. Adjunctive wound care products may to have a positive impact on these factors. Five-year mortality was 43%, and demonstrated an association with renal and/or vascular pathology. All patients had diabetes, with many also having Peripheral Vascular Disease (PVD). Almost all TMA's failing to heal had PVD. The presence and severity of renal disease also seemed to have a negative impact on wound healing. CONCLUSION Positive healing and mortality rates with low need for revision surgery support TMA to be an effective alternative to major limb amputation. Adjunctive agents may have a positive impact on wound healing and length of hospital admission. Skilled surgical technique and Multidisciplinary work is essential for positive long-term outcomes and cost-effective care.
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Affiliation(s)
- Anthony Joyce
- Great Western Hospital, Marlborough Road, Swindon, SN3 6BB, United Kingdom.
| | - Ben Yates
- Great Western Hospital, Marlborough Road, Swindon, SN3 6BB, United Kingdom
| | - Matthew Cichero
- Great Western Hospital, Marlborough Road, Swindon, SN3 6BB, United Kingdom
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Lin JH, Jeon SY, Romano PS, Humphries MD. Rates and timing of subsequent amputation after initial minor amputation. J Vasc Surg 2020; 72:268-275. [PMID: 31980248 DOI: 10.1016/j.jvs.2019.10.063] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/13/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Studies evaluating major amputation after initial minor amputation are few with rates of subsequent major amputation ranging from 14% to 35% with limited understanding of associated comorbidities and time to limb loss. The aim of this study is to determine the major amputation rates for patients who had already undergone an initial minor amputation and determine which factors are associated with the need for subsequent major amputation. METHODS Using statewide data between 2005 and 2013, patients with peripheral artery disease (PAD), diabetes mellitus (DM), and combined PAD/DM who had a lower extremity ulcer and who had also undergone a minor amputation were identified. These patients were evaluated for the rate of subsequent major amputation and competing risk Cox proportional hazards modeling was used to study which factors were associated with the risk of subsequent limb loss. RESULTS The cohort consisted of 11,597 patients (DM, n = 4254; PAD, n = 2142; PAD/DM, n = 5201) with lower extremity ulcers who underwent an initial minor amputation. The rate of any subsequent amputation was highest in patients with PAD/DM (23% vs DM = 17%, PAD = 17%; P = not statistically significant). The rate of subsequent minor amputation was 16% in the PAD/DM versus 15.2% in PAD and 12.2% in patients with DM (P < .001). Patients with PAD/DM had the highest rate of subsequent major amputation (6.3% vs DM = 5.2%, PAD = 2.1%; P < .001). There was no statistically significant difference in the median time to major amputation among the three groups (PAD/DM, 13 months; DM, 14 months; PAD, 8.6 months; P = NS). Patients who were revascularized before a repeat minor amputation had a decreased risk of a major amputation compared with those who were intervened on after a repeat minor amputation (hazard ratio, 0.002; 95% confidence interval, 0-0.22). Patients treated completely in the outpatient setting were also less likely to undergo subsequent major amputation (hazard ratio, 0.7; 95% confidence interval, 0.5-0.98) compared with those who required hospitalization or presented to the emergency room. CONCLUSIONS Patients with ulcers and combined PAD and DM have a higher risk for secondary major and minor amputation than patients with either disease alone with half of the limb loss occurring at approximately 1 year after the initial minor amputation. Additionally, early diagnosis and appropriate referral may result in decreased limb loss for these patients.
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Affiliation(s)
- Jonathan H Lin
- Division of Vascular Surgery, University of California, Davis Medical Center, Sacramento, Calif.
| | - Sun Young Jeon
- Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, Calif
| | - Patrick S Romano
- Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, Calif
| | - Misty D Humphries
- Division of Vascular Surgery, University of California, Davis Medical Center, Sacramento, Calif
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Kaiser P, Häller TV, Uçkay I, Kaiser D, Berli M, Böni T, Waibel F. Revision After Total Transmetatarsal Amputation. J Foot Ankle Surg 2019; 58:1171-1176. [PMID: 31679669 DOI: 10.1053/j.jfas.2019.03.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/19/2019] [Accepted: 03/28/2019] [Indexed: 02/03/2023]
Abstract
Total transmetatarsal amputation (TMA) can be an option for foot salvage in gangrene, sepsis, or infected necrosis. However, the literature concerning predictive outcome factors and bacterial sampling is scarce. To identify potential associations between revision surgery and underlying bacteria or other preoperative selection criteria, we reviewed all patients with TMA who were treated at our institution. We compared the patients with remissions with surgical revisions. Among 96 adult patients with TMA (105 amputations), 42 required a revision surgery (40%), 18 had a further minor proximal surgical reamputation (17%) and 18 had a major proximal surgical reamputation (14%). In group comparisons, a previous infection with Staphylococcus aureus was protective with a lower revision risk (4/26 with revision surgery vs 22/26 without revisions; p = .03). This was the opposite for postoperative persistent soft tissue or bone infections (p < .01) and delayed wound healing (p < .01), which were positively associated with a revision risk. The American Society of Anesthesiologists Score, sex, age, body mass index, diabetes, polyneuropathy, chronic renal failure, dialysis, peripheral arterial disease, smoking status, and antibiotic regimen did not influence this revision risk. These results must be interpreted cautiously because no multiple variable calculations could be conducted as a result of the paucity of cases and confounding could not be evaluated sufficiently. TMA is an option to prevent major amputations, but it may be associated with a subsequent revision risk of 40% in adult patients. In our cohort study, persistent postamputation infection and delayed wound healing were associated with revision. However, no preoperative selection criteria were found that lead to revision surgery except for an infection with Staphylococcus aureus, which protected against revision surgery.
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Affiliation(s)
- Peter Kaiser
- Resident, Orthopedic Department, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
| | - Thomas Vincent Häller
- Resident, Orthopedic Department, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Ilker Uçkay
- Head of Infectiology, Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Dominik Kaiser
- Surgeon, Orthopedic Department, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Martin Berli
- Surgeon, Orthopedic Department, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Thomas Böni
- Surgeon and Head of Technical Orthopedics, Orthopedic Department, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Felix Waibel
- Surgeon, Orthopedic Department, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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de Souza YP, Dos Santos ACO, de Albuquerque LC. Characterization of amputees at a large hospital in Recife, PE, Brazil. J Vasc Bras 2019; 18:e20190064. [PMID: 31692948 PMCID: PMC6822958 DOI: 10.1590/1677-5449.190064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND Limb amputation can be defined as a procedure that consists of separating a limb or a segment of a limb from the body. OBJECTIVES To describe the profile of limb amputation procedures performed at a large hospital run by the state of Pernambuco (Brazil). METHODS Cross-sectional descriptive and retrospective study conducted at a large hospital in the city of Recife, PE. Data were collected from the records of patients who underwent amputations during 2017. Records from patients who had had a limb amputation during 2017 were included, unless data were illegible or missing. RESULTS A total of 328 procedures were performed on 274 patients, the majority of whom were male (57.7%). There was a predominance of lower limb amputations (64.2%), of non-traumatic causes (86.5%), and urgent treatment (96.4%). The majority of patients who underwent amputations remained in hospital for 11 to 25 days (32.1%). The study found that the majority of amputees were discharged (69.7%), although a proportion died. Deaths of lower limb amputees were primarily among elderly women in the age range of 60 to 90 years (76%), females (55%), and patients subjected to a single amputation (91%). CONCLUSIONS The data observed in this study are alarming, particularly considering that many of these amputations could have been avoided, since they were caused by complications of diseases that can be prevented and controlled at healthcare services of a lower level of complexity and at a relatively low cost.
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Affiliation(s)
- Ylkiany Pereira de Souza
- Universidade Federal de Pernambuco - UFPE, Programa de Pós-graduação em Gerontologia, Recife, PE, Brasil
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Fard B, Dijkstra PU, Voesten HGJM, Geertzen JHB. Mortality, Reamputation, and Preoperative Comorbidities in Patients Undergoing Dysvascular Lower Limb Amputation. Ann Vasc Surg 2019; 64:228-238. [PMID: 31629839 DOI: 10.1016/j.avsg.2019.09.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/29/2019] [Accepted: 09/12/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Historically, mortality rates after major lower limb amputations (LLAs) have been very high. However, there are inconsistencies regarding the risk factors. The reamputation rate after major LLAs is largely unknown. The aim of this study is to report the 30-day and 1-year mortality and 1-year reamputation rates after major LLA and to identify potential risk factors. METHODS An observational cohort study in which all patients undergoing dysvascular major LLA in 2012-2013 in 12 hospitals in the northern region of the Netherlands is included. RESULTS Of total 382 patients, who underwent major LLA, 65% were male and the mean age (standard deviation [SD]) was 71.9 ± 12.5 years. Peripheral arterial disease was observed in 88% and diabetes mellitus (DM), in 56% of patients. No revascularization or prior LLA on the amputated side was observed among 26%, whereas 56% had no minor or major LLA on either limb before the study period. The 30-day and 1-year mortality rates were 14% and 34%, respectively. Patients aged 75-84 and >85 years had 3-4 times higher odds of dying within 1 year. Transfemoral amputations (odds ratio [OR], 2.2), history of heart failure (OR, 2.3), myocardial infarction (OR, 1.7), hemodialysis (OR, 5.7), immunosuppressive medication (OR, 2.8), and guillotine amputations (OR, 5.1) were independently associated with 1-year mortality. Twenty-six percent underwent ipsilateral reamputation within 1 year, for which no risk factors were identified. CONCLUSIONS The mortality rate in the first year after major LLA is high, particularly among those undergoing transfemoral amputations, which is likely to be indicative of more severe vascular disease. Higher mortality among the most elderly patients, those with more severe cardiac disease and who underwent hemodialysis reflects the frailty of this population. Interestingly, DM, revascularization history, and prior minor or major LLA were not associated with mortality rates.
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Affiliation(s)
- Behrouz Fard
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Roessingh Center for Rehabilitation, Enschede, the Netherlands.
| | - Pieter U Dijkstra
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Henricus G J M Voesten
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Vascular Surgery, Nij Smellinghe Hospital, Drachten, the Netherlands
| | - Jan H B Geertzen
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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López-de-Andrés A, Jiménez-García R, Esteban-Vasallo MD, Hernández-Barrera V, Aragon-Sánchez J, Jiménez-Trujillo I, de Miguel-Diez J, Palomar-Gallego MA, Romero-Maroto M, Perez-Farinos N. Time Trends in the Incidence of Long-Term Mortality in T2DM Patients Who Have Undergone a Lower Extremity Amputation. Results of a Descriptive and Retrospective Cohort Study. J Clin Med 2019; 8:jcm8101597. [PMID: 31581755 PMCID: PMC6832955 DOI: 10.3390/jcm8101597] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 09/20/2019] [Accepted: 09/30/2019] [Indexed: 01/22/2023] Open
Abstract
(1) Background: The aims of this study were to examine the incidence of lower extremity amputations (LEAs) among patients with type 2 diabetes mellitus (T2DM) and to compare the mortality risk of diabetic individuals who underwent LEA with age and sex-matched diabetic individuals without LEA. (2) Methods: We performed a descriptive observational study to assess the trend in the incidence of LEA and a retrospective cohort study to evaluate whether undergoing LEA is a risk factor for long-term mortality among T2DM patients. Data were obtained from the Hospital Discharge Database for the Autonomous Community of Madrid, Spain (2006–2015). (3) Results: The incidence rates of major below-knee and above-knee amputations decreased significantly from 24.9 to 17.1 and from 63.9 to 48.2 per 100000 T2DM individuals from 2006 to 2015, respectively. However, the incidence of minor LEAs increased over time. Mortality was significantly higher among T2DM patients who underwent LEA compared with those who did not undergo this procedure (HR 1.75; 95% CI 1.65–1.87). Male sex, older age, and comorbidity were independently associated with higher mortality after LEA. (4) Conclusions: Undergoing a LEA is a significant risk factor for long term mortality among T2DM patients, and those who underwent a major above-knee LEAs have the highest risk.
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Affiliation(s)
- Ana López-de-Andrés
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Rodrigo Jiménez-García
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain.
| | | | - Valentin Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Javier Aragon-Sánchez
- Department of Surgery, Diabetic Foot Unit, La Paloma Hospital, 35005 Las Palmas de Gran Canaria, Spain.
| | - Isabel Jiménez-Trujillo
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Javier de Miguel-Diez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28009 Madrid, Spain.
| | - Maria A Palomar-Gallego
- Basic Science Department, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Martin Romero-Maroto
- Medical Department, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Napoleón Perez-Farinos
- Department of Public Health and Psychiatry, Faculty of Medicine, Universidad de Malaga, 29071 Malaga, Spain.
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Humphrey JA, Kanthasamy S, Coughlin P, Coll AP, Robinson AAH. Outcome of trans-metatarsal amputations in patients with diabetes mellitus. Foot (Edinb) 2019; 40:22-26. [PMID: 31054475 DOI: 10.1016/j.foot.2019.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 04/05/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND This retrospective case series reports the reoperation rate, survival rate and mobility status in patients with diabetes mellitus who had undergone a trans-metatarsal amputation (TMA) managed within a diabetic foot care service. METHODS Forty-one consecutive patients (37 men, 4 women) underwent a TMA with primary wound closure between January 2008 and December 2017. Eighty-eight per cent (36/41) of the patients were followed-up for a mean of 2.3 years. The outcomes were retrospectively reviewed. RESULTS Four (11%) of the 36 patients required reoperation, including three (8%) major amputations. All of the patients requiring a reoperation had peripheral vascular disease. Eleven patients died giving a four-year survival rate of 69% (25/36). Of the surviving patients who had not required revision to a major amputation 96% (21/22) were fully mobile in bespoke orthoses. A third used a walking cane. CONCLUSION This study shows that a TMA with primary wound closure in patients with diabetes mellitus, is effective for limb salvage with low reoperation and major amputation rates. A well healed TMA stump provides independent mobility in the majority of patients. The failures occurred in patients with peripheral vascular disease who, even after percutaneous trans-luminal angioplasty, had a 19% major amputation rate. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Joel A Humphrey
- Department of Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - Senthooran Kanthasamy
- Department of Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Patrick Coughlin
- Department of Vascular Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Anthony P Coll
- Wolfson Diabetes and Endocrine Clinic, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew A H Robinson
- Department of Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Lonardi R, Leone N, Gennai S, Trevisi Borsari G, Covic T, Silingardi R. Autologous micro-fragmented adipose tissue for the treatment of diabetic foot minor amputations: a randomized controlled single-center clinical trial (MiFrAADiF). Stem Cell Res Ther 2019; 10:223. [PMID: 31358046 PMCID: PMC6664586 DOI: 10.1186/s13287-019-1328-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/09/2019] [Accepted: 07/04/2019] [Indexed: 12/16/2022] Open
Abstract
Background The diabetic foot ulcer (DFU) is one of the most prevalent complications of diabetes mellitus and often develops severe effects that can lead to amputation. A non-healing “minor” amputation often precedes a major amputation resulting in a negative impact on the function and quality of life of the patients. Stem cell-based therapies have emerged as a promising option to improve healing, and the adipose tissue is an abundant and easy to access source. The injection of autologous micro-fragmented adipose tissue at the amputation stump of a diabetic population undergoing a lower limb minor amputation was evaluated and compared with the standard care. Methods In this randomized controlled trial with two arms (parallel assignment) and no masking, 114 patients undergoing a lower limb minor amputation were randomized to standard of care or to micro-fragmented adipose tissue injection prepared using a minimal manipulation technique (Lipogems®) in a closed system. Clinical outcomes were determined monthly up to 6 months. Primary endpoint of the study was the evaluation of the healing rate and time after the minor amputation. Secondary endpoints included the assessment of safety, feasibility, technical success, relapse rate, skin tropism, and intensity of pain. Results At 6 months, 80% of the micro-fragmented adipose tissue-treated feet healed and 20% failed as compared with the control group where 46% healed and 54% failed (p = 0.0064). No treatment-related adverse events nor relapses were documented, and technical success was achieved in all cases. The skin tropism was improved in the treatment group, and the pain scale did not differ between the two groups. Conclusion The results of this randomized controlled trial suggest that the local injection of autologous micro-fragmented adipose tissue is a safe and valid therapeutic option able to improve healing rate following minor amputations of irreversible DFU. The technique overcomes several stem cell therapy-related criticisms and its potential in wound care should be better evaluated and the therapeutic indications could be expanded. Trial registration ClinicalTrials.gov number: NCT03276312. Date of registration: September 8, 2017 (retrospectively registered).
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Affiliation(s)
- Roberto Lonardi
- Department of Vascular Surgery, Ospedale Civile S. Agostino-Estense, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Via Giardini, 1355, 41126, Baggiovara, MO, Italy
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile S. Agostino-Estense, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Via Giardini, 1355, 41126, Baggiovara, MO, Italy.
| | - Stefano Gennai
- Department of Vascular Surgery, Ospedale Civile S. Agostino-Estense, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Via Giardini, 1355, 41126, Baggiovara, MO, Italy
| | - Giulia Trevisi Borsari
- Department of Vascular Surgery, Ospedale Civile S. Agostino-Estense, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Via Giardini, 1355, 41126, Baggiovara, MO, Italy
| | - Tea Covic
- Department of Vascular Surgery, Ospedale Civile S. Agostino-Estense, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Via Giardini, 1355, 41126, Baggiovara, MO, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, Ospedale Civile S. Agostino-Estense, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Via Giardini, 1355, 41126, Baggiovara, MO, Italy
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48
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019; 58:S1-S109.e33. [PMID: 31182334 PMCID: PMC8369495 DOI: 10.1016/j.ejvs.2019.05.006] [Citation(s) in RCA: 701] [Impact Index Per Article: 140.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GUIDELINE SUMMARY Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of, Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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49
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69:3S-125S.e40. [PMID: 31159978 PMCID: PMC8365864 DOI: 10.1016/j.jvs.2019.02.016] [Citation(s) in RCA: 686] [Impact Index Per Article: 137.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, Ill
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minn
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50
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Okello TR, Magada SM, Atim P, Ezati D, Campion A, Moro EB, Huck J, Byrne G, Redmond A, Nirmalan M. Major limb loss (MLL): an overview of etiology, outcomes, experiences and challenges faced by amputees and service providers in the post-conflict period in Northern Uganda. JOURNAL OF GLOBAL HEALTH REPORTS 2019. [DOI: 10.29392/joghr.3.e2019028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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