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. 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.
References 1. Fisher DF Jr, Clagett GP, Fry RE, Humble TH, Fry WJ.One-stage versus two-stage amputation for wet gangrene of the lower extremity: a randomized study. J Vasc Surg. 1988 Oct;8(4):428-33. 2. Pinzur MS, Smith D, Osterman H. .Syme ankle disarticulation in peripheral vascular disease and diabetic foot infection: the one-stage versus two-stage procedure. Foot Ankle Int. 1995 Mar;16(3):124-7. 3. Scher KS, Steele FJ. The septic foot in patients with diabetes. Surgery. 1988 Oct;104(4):661-6. 4. Rumenapf G. Borderline amputations in diabetics--open questions and critical evaluation. Zentralbl Chir. 2003 Sep;128(9):726-33. 5. Ziran BH, Rao N, Hall RA. A Dedicated Team Approach Enhances Outcomes of Osteomyelitis Treatment Clinical Orthopaedics and Related Research, Number 414, pg. 31-36. Lippincott Williams and Wilkins, Inc. Additional Reference 6. Kumagi SG, Mahoney CR, Fitzgibbons TC, McMullen ST, Connolly TL, Henkel L. Treatment of diabetic (neuropathic) foot ulcers with two-stage debridement and closure. Foot Ankle Int. 1998 Sep;19(9):649.