Two-phase amputation among critically ill patients with ischemic gangrene of lower limbs as a way to improve treatment outcome. Cohort study

Vitaly O Tsvetkov; Elena M Gorshunova; Olga V Kolovanova; Jury A Kozlov; Vakhtang V Gobegishvili

doi:10.1016/j.amsu.2020.11.045

Two-phase amputation among critically ill patients with ischemic gangrene of lower limbs as a way to improve treatment outcome. Cohort study

Ann Med Surg (Lond). 2020 Nov 24:60:587-591. doi: 10.1016/j.amsu.2020.11.045. eCollection 2020 Dec.

Authors

Vitaly O Tsvetkov^{1

2}, Elena M Gorshunova², Olga V Kolovanova^{1

2}, Jury A Kozlov², Vakhtang V Gobegishvili¹

Affiliations

¹ I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
² V.V. Vinogradov Moscow Municipal Hospital, Moscow Healthcare Department, Moscow, Russia.

Abstract

Background: The results of lower limb amputation, especially in critically ill patients with severe endogenous intoxication, sepsis, multi-organ failure and severe concomitant diseases are still unsatisfactory. Guillotine amputation is a method routinely used to reduce wound complications associated with wet gangrene and severe cases of diabetic foot, however, it is unclear how well it could help to decrease mortality and improve functional outcome when dealing with critically ill patients.

The objective: of the study was to estimate the effectiveness of two-phase method of urgent low limb amputation among critically ill patients with high risk of complications. The effectiveness was evaluated in terms of perioperative mortality, frequency of early complications and ultimate level of limb loss.

Materials and methods: Two cohort groups of patients with acute lower limb gangrene were retrospectively matched. Approximately 25.8% of patients from the comparison (control) group (N = 240) died without surgery due to severity of their condition and ineffective pre-operative treatment. The remaining patients underwent one-phase high-level amputation after 48-72 h of pre-operative intensive care. The experimental group consisted of 153 patients who underwent guillotine amputation at the lower part of tibia (34.6%), knee disarticulation (32.0%), or open thigh amputation (33.3%), depending on the level of irreversible soft tissue necrosis. The reamputation with the stump shaping was performed later when their health status improved.

Results: The assessment of treatment outcomes showed that the two-phase amputation in critically ill patients (i) decreased the mortality from 48.7 to 37.9%, (ii) reduced the risk of wound complications from 20.9 to 11.1%, and (iii) improved functional results by saving the knee joint in 34.6 versus 4.5% in comparison/control group.

Conclusion: The method of two-phase amputation is recommended for critically ill patients.

Keywords: Amputation; Complications; Disarticulation; Gangrene; Mortality; Preoperative comorbidities; Reamputation.