Amputations in peripheral vascular disease

Amputations WILFRED I. CARNEY,

in Peripheral M.D.

AND SEEBERT J. GOLDOWSKY,

From the Surgical Seroice and the Peripheral Vascular Clinic of tbe Rhode Island Hospital, Providence, Rhode Island.

E have

been troubled by the great Ioss associated with the management of amputations for peripheral vascular disease. Recently the Massachusetts MedicaI Society [I] conducted a study of a group of 502 cIiabetic patients with foot complications. The cost of hospitahzation in this cohected series reached the considerable figure of $300,000. The committee emphasized, appropriately, the need for early recognition and good prophyIaxis in these cases. Our anaIysis will be focused on the proIonged hospitaIization of patients, both diabetic and non-diabetic, who have come to amputation. We are fuIIy aware that in a sense amputation represents faiIure in treatment. We are convinced, however, despite recent advances in therapy and in vascular that amputations wiI1 be with us surgery, prominently for a Iong time. In our series, which covers a ten-year span, there has been no decIine in the incidence of major amputations in the second as compared to the first five-year period. It has been our purpose to coIIcct and anaIyze a11 major amputations of the Iower extremities performed in the Rhode Island Hospital over a ten-year period from 1945 to 1954. Since we have examined the daily operative schedules, we heIieve that the series is virtuaIIy complete. The number of cases is sufficiently Iarge, in our opinion, to yield results which are statistically valid. We have studied, in all, 344 records. These include major amputations (transmetatnrsal, beIow-knee and thigh) for a11 causes. From this number we have excIuded as not being pertinent to the subject thirty cases in which amputation was done for tumor, trauma or thromboangiitis obIiterans. Of the remaining 314 patients, there were 169 with diabetes and

W of time

Vascular M.D.,

Providence,

Disease Rhode

Island

145 without diabetes. Among the diabetic patients there was a preponderance of femaIes (60 per cent), whereas among the arteriosclerotic patients without diabetes there was a preponderance of males (65 per cent). The average age of a11 femaIes was seventy years, and of maIes sixty-seven; the average age for the whoIe group was sixty-eight years. The tota number of thigh amputations during the ten-year period was 322. This incIudes biIatera1 procedures. There were, in all, thirty-six deaths. This amounted to a patient mortality of 12 per cent for the whoIe series, or an operative mortaIity of I I per cent for the thigh operations (in which a11 of the deaths occurred). This is a significantIy high mortaIity rate, giving fuI1 consideration to the physical status and the age (average age at death, seventy-four years) of these patients. Ten postmortem examinations were performed, a rate of 26 per cent. In genera1 the verified causes of death were consistent with advanced age and degenerative disease. Two deaths were due to puImonary emboIism. One of these was estabIished by autopsy but in the other case postmortem examination was not performed, the diagnosis having been made on cIinica1 grounds. This is a Iower incidence (0.6 per cent) than had been anticipated. FemoraI vein Iigation had not been performed on either of these patients. EarIy in the analysis of this materia1 we were impressed by the high average length of hospitalization. We shaI1 now turn our attention to the causative factors. In determining the length of hospitaIization we have arbitrariIy utilized a period beginning six months before definitive surgery and ending .on the date of the patient’s discharge from the hospitaI. The average hospital stay for patients h aving thigh amputations was forty-three days. There appeared to be a sIight reduction in the Iength of hospitalization in the second

Carney

and GoIdowsky for a11 patients, which in itseIf seems an unreasonably high incidence. We are unable to expIain the increased incidence of impaired healing in the smaller group, but the influence of repeated surgery and prolonged hospitalization cannot readily be dismissed. It wouId seem further that the presence of diabetes and the factor of Iower age must not weigh too heaviIy in favor of selection for limited procedures. To eIucidate the probIem further, beIow-knee and transmetatarsa1 operations were considerecI separateIy. There were thirty-eight below-knee amputations, of which twenty-seven or 71 per cent were successful. This represents a fair degree of success. Of ten cIosed transmetahowever, onIy two or 20 tarsa operations, per cent yieIded a good result. There were, in addition, two open transmetatarsal operations with subsequent skin grafting which were successful, increasing somewhat the gooc1 resuIts at this site of amputation. FaiIures of 29 and 80 per cent wouId not be readiIy accepted, however, in other fields of surgery. One additiona point is worthy of note: Sixty-five or 19 per cent of a11 patients undergoing thigh amputation had undergone previous sympathectomy. Our experience with biIatera1 amputation may be of some genera1 interest. Forty-four or 14 per cent of the patients in the series were subjected to bilateral major amputation (thigh and beIow-knee). In thirty-eight instances both procedures were performed during the period of investigation. Six occurred during a single The average interva1 behospita1 admission. tween amputations was I.5 years.

five years (average forty-one days) as compared to the first five years (average forty-six days). A separate determination of this factor for private cases revealed no significant variation from the whoIe group (average forty and forty-five days, respectiveIy). The average postoperative convaIescence for the whoIe group was twenty days. We have been unabIe to establish any specific criteria with respect to the technical operative procedure that might Iower sign&cantIy the postoperative stay. We believe, nevertheIess, that the postoperative period is somewhat proIonged. It is reasonabIe to assume that it might be shortened by more attention to deIicate operative manipuIation and earIy rehabiIitation. AnaIysis of the factors invoIved in the proIonged preoperative stay is more reveaIing. For that purpose a group of patients was seIected whose thigh operation was preceded by one or more of the foIIowing procedures: sympathectomy, toe amputations, transmetatarsa1 and beIow-knee amputations. Many patients in this group underwent severa operations. There were eighty-seven of these patients, or 27 per cent of a11 those having thigh amputations. The tota hospitaIization in this group was fifty-five days. Since the postoperative convaIescence of these patients averaged twenty days (not significantIy different from the whole group), it is evident that the increase is attributabIe to proIonged preoperative stay. Since a11 of these patients were uItimateIy subjected to thigh amputation, it may seriousIy be questioned whether they were wiseIy seIected for a conservative approach. Contrariwise those 235 patients having no surgery preceding thigh amputation had an average hospita1 stay of thirty-nine days, a difference of sixteen days. Our data couId not be used to support an argument for radica1 approach in a11 cases. It appears, however, that there is room for improvement in the seIection of cases for conservative treatment and in earIier recognition of faiIure. A perusa1 of individua1 protocoIs seems to support this view. The group of eighty-seven patients undergoing muItipIe operations is interesting in severa other respects. There were 73 per cent diabetic patients as compared to 52 per cent for a11 patients. The average age was sixty-five as compared to 68.5 for the whoIe group. Twenty-eight per cent Ieft the hospita1 with unheaIed stumps, as compared to 22 per cent

COMMENT

In undertaking this study we had hoped to discover some technica criteria upon which better resuIts might be based. Factors anaIyzed incIuded Iength of flaps, level of amputation, especiaIIy in the thigh group, and use of femora1 vein Iigation, uniIatera1 or bilateral. Neither the average period of convaIescence (twenty-one days) nor the incidence of unheaIed stumps at time of the patient’s discharge from the hospita1 (22 per cent) was inff uenced by these factors. Fifty-nine patients had either uniIatera1 (thirty-one) or biIatera1 (twenty-eight) femora1 vein Iigation. This constituted 16 per cent of a11 thigh and beIow-knee amputations. None of these patients succumbed to thromboemboIic disease, but the

796

Amputations

in Peripheral

Vascular

Disease

This involves a fair evaluation of the patient with respect to his uItimate potentialities and an accurate estimate of his coIIatera1 circulation. There should be a minimum of deIa3 in the recognition or acceptance of the inevitabiIity of amputation. Prompt admission of faiIure in Iimited operations is equaIIy important. An astute estimate of coIIatera1 circuIation remains, however, the fundamental basis on which improvement can be achieved.

group is too small to be of statistica significance with respect to a complication of low incidence. Our mortality rate (II per cent) compares favorably with the best recorded in the Iiterature. It appears, further, that our average hospitalization is not out of line with experience in other clinics. If this be true, the resuIts reported herein would seem to warrant a new look at the whoIe subject. The adverse effect of proIonged hospitalization and procrastination on heaIing and rehabilitation must be recognized. Despite the high incidence of concomitant degenerative disease and the diffrc&y of the over-all probIem, means must be sought to Iessen mortality and morbidity and to reduce the period of hospitalization. This stucly has discIosed no reasons to consider these goals unreaIistic or unattainabIe. Even though it has not been possibIe to base recommendations on measurabIe surgica1 criteria, adherence to sound surgical principles shouId, nevertheIess, accomplish much. I n pursuit of this objective, maximum respect for tissue and gentle handling cannot be overemphasized. EarIy and sustained attention to rehabilitation wiI1 also aid in the reduction of morbidity. More essentia1, however, is the appIication of sound surgical judgment.

CONCLUSIONS

The average Iength of hospitalization in patients having amputation for periphera1 vascular disease is unduIy long. 2. Improvement in resuIts must depend on cIoser adherence to sound surgical principles. CoIIateraI circuIation is the singIe most important factor to be evaIuated. 3. Conservative treatment or limited surgery should be undertaken onIy after a reaIistic appraisa1 of the probabiIity of a successful EarIy recognition of failure is outcome. essentia1. I.

REFERENCE I. Surgical

lesions of diabetic feet. Committee on Diabetes. Massachusetts Medical Society. New

England J. Med., 253: 685, 1956.

ll’e recommend:

Textbook of British Surgery. The Abdomen. Edited by Sir Henry Souttar, Volume I, 547 pages, with 238 figures, references. Fair Lawn, N.J., 1956.

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