Outcomes of staged versus primary amputations for diabetic foot disease
Tracy Cheun, Mark Davies
UT HEALTH SAN ANTONIO, SAN ANTONIO, TX
Background: Lower extremity amputations (LEAs) are among the most common procedures performed by vascular surgeons in patients with diabetes and peripheral vascular disease. This population commonly suffers from re-admission, wound complication, and conversion to more proximal amputation. These events impact quality in terms of cost, resources, and subjective quality of life. The aim of this study is to compare outcomes between primary LEA (pLEA) and staged guillotine amputation followed by interval formalization (sLEA) for diabetic foot disease.
Methods: A retrospective chart review of LEAs performed by vascular surgeons at a single institution between January 2014 and March 2017 was performed. Inclusion criteria were diabetic patients with foot gangrene who underwent a major LEA. Amputations for trauma, acute limb ischemia, or malignancy were excluded. Per institutional practice, sLEA had been performed for uncontrolled infection, and pLEA had been performed in the absence of active infection. The primary outcome measure was 30-day freedom from conversion to a higher-level amputation. Secondary outcome measures were stump complications, re-admissions, major adverse cardiovascular events (MACE), and mortality.
Results: 116 patients met inclusion criteria. Mean age was 58 years; 68% were male; 18% were active smokers; 30% had end-stage renal disease; and 22% had congestive heart failure. 62 limbs underwent sLEA, and 67 limbs underwent pLEA. The two cohorts were well-matched by demographics and comorbidities. Consistent with the above-mentioned institutional practice, 57% of sLEA patients met 2 or more SIRS criteria at presentation compared to 24% of pLEA patients (p<0.01). There were no 30-day mortalities. There was no significant difference in MACE between the groups. sLEA patients had a lower rate of 30-day re-admission (6% versus 20%, p=0.05) and 30-day unplanned conversion to higher level amputation (2% versus 13%, p=0.026) compared to pLEA. Average length of stay did not significantly differ between sLEA and pLEA (14 days +/-SEM1.04 versus 11 days +/- SEM1.44; p=0.1).
Conclusions: In the setting of infected diabetic foot disease, a staged amputation achieves quality outcomes superior to a one-stage amputation, despite the former cohortís greater acuity level. Staged amputation should be considered in all diabetic patients presenting with unsalvageable foot wounds.
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