Attempted Limb Salvage Research Articles

THE PLIGHT OF THE TRAUMATIC AMPUTEE

This retrospective review of the long-term problems of patients with lower extremity amputation from trauma fails to support the opinion that most traumatic amputees do well. Overall, anatomic problems involved 51% of the amputees, and social problems involved 56%. Attempting limb salvage with subsequent secondary amputation did not seem to compromise the long-term outcome for these problems. The surgeon performing the amputation should try to obtain the best possible stump and insure that the patient gets the careful follow up and multidisciplinary team support needed to manage the anticipated problems.

Axillodistal bypass on critical limb ischaemia

The axillodistal extra anatomic bypass is not an operation commonly performed and the only reason for performing it is to attempt limb salvage for a reasonable period of time or until death in patients with critical ischaemia. During the period 1983-1991 we performed 67 such bypasses where no other form of reconstructive arterial surgery was feasible. There were 27 axillopopliteal (15 below and 12 above the knee), five crossover, seven bilateral, 11 axillotibial and 17 jump (sequential bypasses). The first 34 procedures (1983-1987, early period) had a 5-year cumulative secondary graft patency of 20%, which increased to 33% for the 33 bypasses performed during the second period (1987-1991). The primary graft patency of the 67 bypasses was 13%. Our clinical results show that even in these patients with diffuse occlusive arterial lesions, limb salvage is possible in a reasonable number even when axillodistal bypass is used. Improvements in the technique, better selection of patients, the performance of jump grafts and the aggressive treatment of early and late graft occlusions have led to much better results being achieved.

Salvaging the ischemic transmetatarsal amputation through distal arterial reconstruction

From 1982 to 1991, 17 patients underwent a lower extremity arterial bypass to salvage an ischemic transmetatarsal amputation at the New England Deaconess Hospital. Eleven patients were male, and 16 had diabetes for an average of 29 years. The mean age was 71 years. Twelve patients presented with an ischemic ulcer, one had rest pain, and four underwent bypass for failure to heal a transmetatarsal amputation. Twelve patients presented with findings of secondary infection. All 17 patients underwent successful lower extremity bypass procedures to a variety of outflow vessels. Thirteen bypasses were to infrapopliteal arteries, including four to the dorsalis pedis artery. There were no perioperative deaths and all patients were discharged with patent grafts and healing limbs. Actuarial graft patency of the 14 vein grafts was 90% at 2 years. Actuarial limb salvage for the entire group was 93% at 2 years. Thirteen of the 14 patients who maintained patent grafts and healed their transmetatarsal amputations were ambulatory at their last known follow-up examination. Ischemic complications of previously created transmetatarsal amputations are uncommon. However, limb salvage attempts by lower extremity arterial bypass have a high likelihood of success. Major amputation in these patients should not be done without having first undergone a comprehensive vascular evaluation.

THE FUTILITY OF PREDICTIVE SCORING OF MANGLED LOWER EXTREMITIES

Fifty-eight lower limb salvage attempts over a 10-year period were retrospectively scored using the Mangled Extremity Syndrome Index (MESI), Mangled Extremity Severity Score (MESS), Predictive Salvage Index (PSI), and the Limb Salvage Index (LSI). Primary amputations were excluded. Limb salvage failure was defined at four levels, including functional failure 2 years postinjury. Cross-validational sensitivity and specificity analyses revealed no predictive utility in any of the four indices. Although most failed limb salvage attempts could be identified early in the course of management, a significant percentage of our patients suffered prolonged reconstructive efforts. We conclude that efforts must be directed at more precisely determining the factors that aid in the decisions to terminate futile salvage efforts.

Effect of a failed distal reconstruction on the level of amputation

Controversy exists as to whether the level of amputation is adversely affected by an unsuccessful limb salvage attempt. Two hundred ten amputations following failed reconstruction attempts in 191 patients were studied and compared with 551 amputations in limbs with no prior revascularization. Initially, 147 of those with failed reconstruction attempts underwent below-knee (BK) amputation and 63 underwent above-knee (AK) amputation. One hundred ten of 143 (77%) surviving BK amputations eventually healed. This is in contrast to the eventual healing in 266 of 298 (89%) of the BK amputations performed with no prior attempts at reconstruction. A statistically significant (p less than 0.05) difference in eventual healing favoring those with no prior reconstruction was demonstrated. Successful reconstruction of the ischemic extremity is the goal of vascular surgery and should be attempted when indicated. However, it should be realized that unsuccessful revascularization attempts may adversely affect healing in those limbs initially considered for a BK amputation.

A bacteriological survey of amputation wound sepsis

A retrospective survey of 100 lower limb amputations performed for ischaemia were analysed to assess the influence of preoperative bacterial isolates and the use of prophylactic antibiotics on wound sepsis. Forty-eight per cent had previously undergone a vascular procedure to attempt limb salvage and 17% were diabetics. Benzylpenicillin was given preoperatively and continued for 5 days; diabetics received metronidazole in addition. A total of 51 isolates were obtained from 30 patients preoperatively; Staphylococcus aureus and Enterobacteriaceae each accounted for over 25%. Postoperatively, 74 isolates (20 multiple) were obtained with an overall sepsis rate of 40%. Those patients with a positive preoperative culture were significantly more likely to develop wound sepsis. There was no significant difference in wound sepsis rates for diabetics. In view of the range of organisms causing postoperative infection, we recommend prophylaxis with a broad spectrum antibiotic for amputations.

Infrapopliteal bypasses to heavily calcified rock-like arteries: Management and results

Of the 355 consecutive infrapopliteal bypasses for limb salvage performed over a 5 year period at our institution, 116 (Group I) were to noncalcified vessels, 203 (Group II) were to vessels of varying degrees of calcification (mild to moderate), and 36 (Group III) were to heavily and circumferentially calcified arteries. A new intraoperative fracture technique was used to overcome the rigidity of the arterial wall in the latter group. Three year cumulative patency rates for Groups I, II, and III were 45 percent, 58 percent, and 47 percent, respectively. Comparable limb salvage rates for Groups I, II, and III were 66 percent, 73 percent, and 75 percent. No significant difference in patency or limb salvage results could be elicited between the three groups by the log-rank test. These findings suggest that arterial calcification is an invalid predictor of failure in small vessel bypasses. Even circumferentially calcified arteries, which are generally thought to be surgically unapproachable, should not be a deterrent to limb salvage attempts.

Management of aortic bypass graft thrombosis: Utility of thrombectomy

The condition of many patients with early or late thrombosis after an aortic bypass operation can be improved by appropriate secondary operations. Late thromboses generally occur in patients with impaired arterial outflow. Restoration or establishment of good outflow is the most critical part of most secondary operations. Thrombectomy is an expedient procedure and, if properly monitored by arteriography, can in many instances permit retention of the graft limb as a satisfactory conduit, particularly in emergency limb salvage attempts.