Open Or Closed? Searching For Evidence-Based Guidance On Amputations

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Here is an example of a two-stage amputation that is now ready for debulking and delayed primary closure.
The vascular demands needed to heal a hallux amputation in this patient were underestimated. Gangrene in the forefoot led to a proximal amputation.
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Author(s): 
By Kathleen Satterfield, DPM

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. The authors advised that in the presence of sepsis, one should leave the amputation open for revisional wound care.3

Other Pertinent Points
German researchers have coined the word “grenzzonenamputation” to describe the combination of minor amputation in the zone between affected and vital tissues.4 These surgeons believed that by operating at this junction, they could conserve vital and functional tissues, and reduce the duration of treatment. They gave the most guidelines for treating these amputations. They emphasized that only experienced surgeons should perform this procedure and only if there is sufficient arterial perfusion.

The researchers also raise the controversies behind the use of tourniquets, resection/conservation of cartilage and sesamoids, and the resection of tendons but do not attempt to answer the controversies through evidence in their article.4
Until there is adequate, evidence-based research to tell us the definitive answer, there are a few questions that will help you make the correct decision when considering an amputation procedure.
• Is there any question about whether or not there is remaining infected tissue? If you are unsure, leave it open.
• Does the patient have vascular compromise to the extent that the remaining tissue is potentially devitalized? If so, leave it open as it will require further wound care before closure.

A Few Thoughts About The Medical/Surgical Team
John Donne’s comment, “No man is an island,” was never truer than in the healthcare system. A provider cannot do it all by him- or herself and should not even try. Medical specialists enhance the performances of one another, ensuring better outcomes.
In an interesting study of orthopaedists treating osteomyelitis at the University of Pittsburgh Medical Center, researchers found that the better outcomes came from the surgical team that worked in concert with a dedicated musculoskeletal infectious disease specialist.5 In addition, “adequate and aggressive” surgical debridement along with soft tissue coverage made for more positive outcomes.5

Final Notes
Clearly, the patient’s best interests come first but it is difficult to work in today’s environment and not pay due attention to the demand for medical resources that are expensive and limited.
Since there hasn’t been a great deal of research into the open versus closed amputation, especially at the level of the forefoot, much of the knowledge that we operate under comes from research at other anatomic levels by other specialists.
This issue then represents a challenge to not only the podiatric surgeon standing at that OR table but also to the researchers who will hopefully provide an evidence-based answer for us one day.

Dr. Satterfield is an Associate Professor within the Department of Orthopaedics/Podiatry Service at the University of Texas Health Science Center in San Antonio, Texas.

Dr. Steinberg (shown at the right) is an Assistant Professor in the Department of Orthopaedics/Podiatry Service at the University of Texas Health Science Center.




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