RESUMEN
The aim of the study was to compare preoperative factors and postoperative outcomes in patients with heel ulcerations that primarily had a transtibial (below the knee) amputation (N = 38) versus vertical contour calcanectomy (n = 62). The groups had no statistical difference between their Charlson Comorbidity Index Score, a prognostic score of 10-year survival in patients with multiple comorbidities. The odds of primary closure were 21.1 times higher in patients that underwent below knee amputation compared to patients that underwent vertical contour calcanectomy (OR 21.1 [95% CI 3.89-114.21]). The odds of positive soft tissue culture at time of closure were 17.1 times higher for patients that underwent vertical contour calcanectomy (OR 17.1 [95% CI 5.40-54.16]). The odds of a patent posterior tibial artery were 3.3 times higher for patients that underwent vertical contour calcanectomy (OR 3.3 [95% 1.09-10.09]). The secondary aim of the study was to evaluate preoperative factors and postoperative outcomes in patients with failed vertical contour calcanectomy, defined as needing a below knee amputation. The odds of vertical contour calcanectomy failure was 13.7 times higher in male patients (OR 13.7 [95% CI 1.80-107.60]). Vertical contour calcanectomy failure was 5.7 times higher in patients with renal disease (OR 5.7 [95% CI 1.10-30.30]), and vertical contour calcanectomy failure was 16.1 times higher for patients who needed additional surgery post closure (OR 16.1 [95% CI 1.40-183.20]).
RESUMEN
A transtibial amputation is the traditional primary staged amputation for source control in the setting of non-salvageable lower extremity infection, trauma, or avascularity prior to progression to proximal amputation. The primary aim of the study is to compare preoperative risk factors and postoperative outcomes between patients who underwent transtibial amputation versus ankle disarticulation in staged amputations. A retrospective review of 152 patients that underwent staged below the knee amputation were compared between those that primarily underwent transtibial amputation (N = 70) versus ankle disarticulation (N = 82). The mean follow-up for all 152 patients was 2.1 years (range = 0.04-7.9 years). The odds of incisional healing were 3.2 times higher for patients with guillotine amputation compared to patients with ankle disarticulation (odds ratio [OR] = 3.2, 95% confidence interval [CI] = 1.437-7.057). The odds of postoperative infection is 7.4 times higher with ankle disarticulation compared to patients with guillotine amputation (OR = 7.345, 95% CI = 1.505-35.834). There were improved outcomes in patients that underwent staged below the knee amputation with primarily guillotine transtibial amputation compared to primarily ankle disarticulation. Ankle disarticulation should be reserved for more distal infections, to allow for adequate infectious control, in the aims of decreasing postoperative infection and improving incisional healing rates.Levels of Evidence: 3, Retrospective study.
RESUMEN
Background: Patients with nonhealing lower extremity (LE) wounds often require a split-thickness skin graft (STSG) for closure. Nonviable tissue must be debrided before STSG inset. Our study aimed to compare differences in debridement depth on STSG outcomes. Methods: Chronic, atraumatic LE wounds receiving STSG from December 2014 to December 2022 at a single institution were reviewed. Demographics, wound characteristics, operative details, and outcomes were collected. Superficially debrided wounds were compared with wounds receiving deep debridement (DD), defined by debriding to the level of white tissue underlying the granulation tissue. Subanalysis was performed on wounds that had a negative and positive postdebridement culture. Primary outcome was graft failure. Results: Overall, 244 wounds in 168 patients were identified. In total, 158 (64.8%) wounds were superficially debrided and 86 (35.3%) received DD. The cohort had a median Charlson Comorbidity Index of 4 [interquartile range (IQR): 3]. Diabetes (56.6%) and peripheral artery disease (36.9%) were prevalent. The only statically significant demographic difference between groups was congestive heart failure (SD: 14.9% versus DD: 3.0%, P = 0.017). Wound size, depth, and all microbiology results were similar between groups. Postoperatively, the DD group demonstrated significantly less graft failure (10.5% versus 22.2%, P = 0.023). In a multivariate regression, DD was independently associated with lower odds of graft failure (OR: 0.0; CI, 0.0-0.8; P = 0.034). Sub-analysis of graft failure supported this finding in culture-positive wounds (DD: 7.6% versus DD: 22.1%, P = 0.018) but not in culture-negative wounds (13.6% versus 22.2%, P = 0.507). Conclusions: The DD technique demonstrates improved outcomes in chronic, culture-positive LE wounds receiving STSG.