Open Or Closed? Searching For Evidence-Based Guidance On Amputations
There is a moment in the operating room when every surgeon must make a decision about an amputation. Should we perform the amputation as a two-stage procedure or is it wise to close the surgical site right then and there? There was a time when surgeons always left these surgical sites open due to the concern of possibly closing over some bacterial contamination that would flourish in the sutured environment. Of course, there was also a time when patients were admitted to the hospital for elective bunion surgery. Obviously, times have changed. Now the surgeon who sends a tissue sample to the lab for bacterial analysis prior to closure (a “quant count”) is met with disdain in some areas of the country. Yet in other areas, people believe it is legally risky not to take this action. What evidence is there to take either action when performing an amputation? Surprisingly, there is little reported evidence to guide us in that decision making process. The surgeon is on his or her own. Many feel that there is a greater risk in leaving the surgical site open. After all, there is the chance of further contamination, desiccation of fragile tissues, the need to submit the patient to a second anesthesia exposure, the need for wound care services and the resulting increased use of limited medical resources. However, it you close the surgical site at the time of the amputation, there is the concern for infection. Surgical Treatment For Wet Gangrene: What One Study Revealed Closing the site is a gamble that most wound specialists choose to take. Unfortunately, we have to look at other medical scenarios reported in the literature in order to gain insight into the evidence behind this choice. The most definitive effort to report on this issue involved a 1988 randomized study that was done at the University of Texas Southwestern Medical Center in Dallas.1 The authors advocated primary wound closure for patients who were taken to surgery for wet gangrene. The randomized study involved 47 patients who underwent a one-stage amputation or a two-stage procedure.1 All other factors were relatively equal. Researchers noted that antibiotic coverage was standardized with clindamycin and gentamicin. The authors of the study obtained deep muscle samples from along the saphenous vein. They found that 21 percent of the one-stage group had positive cultures from tissue at that level while 43 percent of the two-stage group had positive cultures.1 Did leaving it open cause the spread of infection? Researchers saw the same bacterial trend in cultures of the lymphatic system at the saphenous level. Eight percent of these cultures were positive for patients who underwent the one-stage surgery whereas 30 percent of the patients who underwent the two-stage surgery had positive cultures.1 A Closer Look At One Study That Showed No Difference In Outcomes Pinzur and his group at the Hines Veterans Administration Hospital in Illinois produced a study in 1995 that seemed to refute the UT Southwestern study.2 In a prospective randomized study comparing one-stage and two-stage Syme’s ankle disarticulations in infected diabetic feet, the researchers found no difference between the two groups.2 The researchers ended the randomization after 21 patients had similar results regardless of the type of surgery. The remaining participants had a primary closure at the time of amputation. This limited the patients’ exposure to additional medical procedures, anesthesia and potential morbidity from those events.2 However, for the podiatric surgeon, the amputation level is more immediately adjacent to the previously infected site. Does this increase the risk of infection? Study Advocates Open Amputations In The Presence Of Sepsis General surgeons at the Wright State University School of Medicine in Ohio studied 65 lower-extremity amputations that were performed due to sepsis in diabetic patients.3 The etiologies of the infections were wide-ranging, including gangrene, chronic plantar ulcers and web space fissures. The vascular status of the patients also was wide-ranging, with ABIs below 0.5 in one-third of the patient population. In the patient group who underwent partial foot amputation, 71 percent went on to healing but required revision.