Dehiscence and poor healing, among other complications, can be issues with post-amputation wounds in the lower extremity. Accordingly, these panelists address common complications, which amputation types are more at risk for problems and what support systems are in place to help amputees.
What are the most common wound complications you find following post-op amputation?
Dehiscence is the most common wound complication for David G. Armstrong, DPM, MD, PhD, and Desmond Bell, DPM, CWS. Kazu Suzuki, DPM, CWS, agrees, noting that dehiscence is usually due to inadequate offloading with the example of a patient walking on the stump when instructed not to, something more common in patients with diabetic neuropathy.
Dr. Suzuki and his colleagues perform transmetatarsal amputations (TMAs) on a weekly basis. He says they usually like to keep patients protected from full ambulation for three weeks post-op when the sutures and staples are scheduled for removal. He may allow TMA patients to use the heel within a day or two postoperatively so they can transfer from bed to chair and back to bed safely. Dr. Suzuki always works with physical therapists in the hospital to make sure patients get adequate training and take-home instructions prior to discharge home or to a skilled nursing facility. He notes inadequate skin perfusion or inadequate control of infection may lead to surgical incision dehiscence as well. However, Dr. Suzuki says that is rare as long as podiatrists diligently test and monitor patients’ perfusion and infection status preoperatively.
Barry Rosenblum, DPM, notes poor healing, due to either ischemia or infection, is the most common wound complication he sees.
“The attempt to salvage a limb with critical limb ischemia (CLI) is devastating in cases when the blood flow cannot be improved,” says Dr. Rosenblum.
As Dr. Bell points out, post-op infection is less of an issue as most of the amputations he performs are on hospitalized patients who are already on IV antibiotics. After performing the amputation and properly addressing infection, he notes a post-op complication is less likely than an inadequate perfusion issue.
Which amputation types are more susceptible to wound complications?
Dr. Suzuki believes unstable ray amputations, as opposed to an inherently stable TMA, may be more susceptible to wound complications. Due to the extent of gangrene or bone infection, he notes physicians are often forced to make a choice of doing an “unstable” ray amputation as most patients want to keep the maximum amount of foot as possible.
“At that point, the responsibility is on us to educate and convince the patient that the remaining unstable toe or ray in a partial foot amputation is more trouble than it is worth as those unstable toes and rays will inevitably result in skin ulceration in the future, and most likely be in need of repeated surgical correction (i.e. more amputation),” says Dr. Suzuki.
Dr. Suzuki emphasizes that the TMA is the “workhorse” procedure, which is durable and reliable. As long as one has performed a TMA correctly and ensured adequate blood flow, he has found patients with a well-performed TMA can remain ambulatory without any wound complication for a decade or more. Therefore, he will recommend a TMA over most ray amputations if the amputation involves more than a single ray in each foot.
Dr. Bell notes TMAs and below-knee amputations are probably the most susceptible to complications. The primary reasons are inadequate tissue perfusion, often combined with pressure resulting from the underlying osseous structure. When performing a TMA, it is advisable to preserve as much soft tissue as possible while taking bone back a bit further than might seem necessary, according to Dr. Bell.
“The transmetatarsal amputation is the procedure that tries to salvage a walking foot. When these (procedures) are performed in an ischemic limb, the risk of wound complications goes up dramatically,” says Dr. Rosenblum.
Dr. Armstrong says the most common amputations associated with complications like dehiscence are in patients on renal replacement therapy.
“Now that some 40 percent of our clinic volume in our highest risk clinics includes patients on dialysis, these complications are, to put it mildly, commonplace,” notes Dr. Armstrong.
Does your institution have a support system in place to support patients after amputation?
Dr. Rosenblum’s institution has a support group that counsels patients both before and after major limb loss. He notes one of the patients in the group is an amputee “who has an incredibly positive outlook after his own below-knee amputation.”
Dr. Armstrong’s facility also has an amputee support group. He and his colleagues “have been much more rapid” to convert closed TMAs to open TMAs. Often, he will then apply negative pressure wound therapy (NPWT), biologics like the Integra allograft (Integra LifeSciences) and then split-thickness skin grafting to preserve as much length and function as possible.
While Dr. Suzuki’s facility does not have a support group, he is aware of a few institutions that provide counseling and monthly support meeting for amputees, which enable patients to meet and receive peer support and counseling. He notes that even a single-sided fifth toe amputation may be as psychologically damaging for some people as losing a family member or a close relative.
“I do believe that we must be diligent and support our patients, not only as surgeons, but as health care providers to consider their mental health and well-being as a whole,” says Dr. Suzuki.
A few years ago, Dr. Bell and colleagues attempted to create such a support program through the Save A Leg, Save A Life Foundation. He notes there were patients undergoing amputations and receiving very little support, even if they were fortunate enough to be transferred to a rehab unit after discharge from the hospital. While Dr. Bell created a support group outside the hospital through his foundation to address this issue, he says no formal program exists in his hospital currently.
“New administration is supportive of our wound center and efforts so hopefully things will change for the better in this regard,” says Dr. Bell.
Do you have any pearls of wisdom in preventing post-op amputation complications?
Dr. Suzuki supports optimizing nutrition and blood glucose, saying adequate hydration and nutrition (protein and calorie) are helpful in post-surgical recovery as well as maintaining lean body mass and preventing sarcopenia.
Dr. Suzuki will counsel patients at each visit that everyone should strive to eliminate processed meats and processed food from their diet. At the same time, he says patients should incorporate whole food (rather than processed) and a plant-based diet (which is low in saturated fats and cholesterol), rich in vegetables and fruits. Dr. Suzuki notes this is scientifically proven to be the healthiest diet in terms of preventing heart disease, diabetes and many chronic diseases, based on the work by Dean Ornish, MD, and others.1
Dr. Armstrong is a Professor of Surgery at Keck School of Medicine at the University of Southern California. He is the Director of the Southwestern Academic Limb Salvage Alliance (SALSA).
Dr. Bell is a board-certified wound specialist of the American Academy of Wound Management and a Fellow of the American College of Clinical Wound Specialists. He is the founder of the “Save a Leg, Save a Life” Foundation, a multidisciplinary, non-profit organization dedicated to the reduction of lower extremity amputations and improving wound healing outcomes through evidence-based methodology and community outreach.
Dr. Rosenblum is an Assistant Clinical Professor of Surgery at Harvard Medical School and the Associate Chief of the Division of Podiatric Medicine and Surgery at the Beth Israel Deaconess Medical Center in Boston. He is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Suzuki is the Medical Director of the ICM Wound Care Clinic in Beverly Hills, CA. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles CA. He can be reached at Kazu.Suzuki@cshs.org.
1. Tuso PJ, Ismail MH, Ha BP, Bartolotto C. Nutritional update for physicians: plant-based diets. Perm J. 2013; 17(2):61-66