Short-term contemporary outcomes for staged versus primary lower limb amputation in diabetic foot disease

Abstract

BackgroundMajor lower extremity amputations remain among the most common procedures performed by vascular surgeons in patients with diabetes and its associated peripheral vascular disease. After major amputation, this population commonly suffers from high readmission rates, increased wound complications, and conversion to more proximal major amputations. 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 lower extremity above-ankle amputations (primary amputation [PA]) and staged ankle guillotine amputations followed by interval formalization to an above-ankle amputation (staged amputation [SA]) for nonsalvageable infected diabetic foot disease. MethodsA retrospective review of all de novo major lower extremity amputations performed by the vascular surgery service at a single institution between January 2014 and March 2017 was performed. Inclusion criteria were diabetic patients with foot gangrene who underwent a major de novo above- or below-knee amputation. Amputations for trauma, acute limb ischemia, or malignancy were excluded. Per institutional practice, SA was performed for uncontrolled infection and/or infection with uncontrolled diabetes, and PA was performed in the absence of active infection and in stable diabetes. The primary outcome measure was 30-day freedom from conversion to a higher level amputation. Secondary outcome measures were 30-day stump complications, 30-day readmissions, 30-day major adverse cardiovascular events, and 30-day mortality. ResultsOne hundred sixteen patients met the inclusion criteria. Sixty-eight percent were male, 18% were active smokers, 30% had end-stage renal disease, and 22% had congestive heart failure. Sixty-one patients underwent SA, and 55 patients underwent PA. The two cohorts were well-matched by demographics and comorbidities. Consistent with the institutional practice, 57% of SA patients met two or more systemic inflammatory response syndrome criteria at presentation compared with 24% of PA patients (P = .0003). There were no 30-day mortalities. There was no significant difference in major adverse cardiovascular events between the groups (2% vs 4%; SA vs PA, respectively; P = .6). The average length of stay did not significantly differ between SA and PA (mean of 14 ± 8 days vs 11 ± 11 days; P = .1). SA patients had a lower rate of 30-day readmission (7% vs 27%; P = .005) and 30-day unplanned conversion to higher level amputation (2% vs 13%; P = .026) compared with PA patients. ConclusionsIn the setting of infected diabetic foot disease, a staged lower extremity amputation achieves quality outcomes superior to a one-stage amputation, despite the former cohort's greater illness acuity level. SA should be considered in all diabetic patients presenting with active foot infection.