Guillotine Amputation Prior to Major Amputation Decreases Infectious Complications and Long-term Amputation Failure in Lower Extremity Chronic Wound Patients

Abstract

PURPOSE: Chronic wounds of the lower extremity (LE) are often complicated by infection. Definitive treatment of wounds resistant to conservative management often entails major amputation and/or reconstruction. For severely infected chronic wounds, a guillotine amputation performed before definitive amputation can help control infection and maximize success of subsequent major amputation. A recent study demonstrated that this two-stage approach may decrease short-term complications; however long-term outcomes are yet to be evaluated.1 This study aims to assess the effect of guillotine amputation on rates of long-term success of major amputation. METHODS: A retrospective review of all major LE amputations performed between January 2017 and July 2020 at our tertiary wound center was conducted. Major amputation was performed in the setting of chronic and/or infected LE wounds that were not amenable to limb salvage. Patients who were lost to follow up or who expired during the study period, as well as patients undergoing amputation for trauma, chronic pain, a non-infected limb deformity, or cancer, were excluded. Patient characteristics, preoperative labs, and amputation data were collected. Postoperative complications assessed included rates of hematoma, dehiscence, infection, and infection requiring takeback to the operating room. Other outcomes of interest included stump revision, time to complete healing, and amputation failure, which was defined as failure to heal or need for more proximal amputation. Patients were separated into guillotine and no guillotine amputation groups. Statistical analysis was performed to compare patient characteristics and amputation outcomes between groups. Student t-test and Mann-Whitney U-test were used to analyze continuous variable while Chi-square test and Fisher exact test were used to analyze binary variables, as appropriate. RESULTS: An estimated 193 patients meeting inclusion criteria were identified: 54 did not undergo guillotine amputation; 139 underwent guillotine amputation before definitive major amputation. Demographics, comorbidities, relevant preoperative laboratories, and amputation location were not statistically different between the two groups. Rates of hematoma and dehiscence were similar between groups; however, the guillotine group had significantly decreased rates of infection (7.19% versus 22.22%, P = 0.003), infection requiring takeback to operating room (4.32% versus 20.37%, P < 0.001), stump revision (2.88% versus 10.91%, P = 0.032), and amputation failure (4.32% versus 12.73%, P = 0.035) compared with the no guillotine group. Time to healing for successful amputations (2.76 versus 2.32 months, P = 0.925) and follow-up (15.07 versus 14.33 months, P = 0.445) were similar between groups. CONCLUSIONS: The results of this study suggest that guillotine amputation prior to definitive major amputation play a significant role in limiting the spread of infection, resulting in decreased infectious complications and improved success rates following major amputation, compared with single-stage major amputations. A two-stage approach is also advantageous in decreasing the need to return to the operating room for infection or stump revision. Guillotine amputations should be considered in the setting of infected chronic lower extremity wounds to improve long-term patient outcomes. REFERENCE: 1. Cheun TJ, Jayakumar L, Sideman MJ, et al. Short-term contemporary outcomes for staged versus primary lower limb amputation in diabetic foot disease. J Vascular Surgery. 2020;72:658–666.e2. doi:10.1016/j.jvs.2019.10.083