SLR - October 2013 - Matthew German
Reference: Shaikh N, Vaughan P, Varty K, Coll AP, Robinson AHN. Outcome of Limited Forefoot Amputation with Primary Closure in Patients with Diabetes. Bone and Joint Journal. 2013; 19-B: 1083- 1087.
Scientific Literature Review
Reviewed by: Matthew German, DPM
Residency Program: University Hospital, Newark NJ
Podiatric Relevance: As physicians of the foot and ankle, we evaluate and treat many different types of infection, many stemming from the diabetic foot. While dealing with diabetic foot infections, the treating physician should be aware of the risks and complications arising from limited forefoot amputations and debridement with primary closure. This article, among others, presents short-to-immediate term results of those forefoot amputations closed primarily.
Methods: A retrospective review was performed of all limited forefoot amputations closed with initial primary closure from between January 2006 and July 2012. In all cases, indication for surgery was stable Wagner Grade 3 ulceration with toe pressure of >45 mmHg. Anatomical site, and patient demographics (including age, comorbidity, duration of hospital stay, and duration of antibiotic coverage) were obtained. Patients were followed for a mean of 380 days. Primary outcome was “healed, re-ulceration, re-amputation, or death.” Odds-ratio analyses were used to compare rates of re-ulceration and re-amputation between comorbidities.
Results: Of the 74 patients included in the study, 13 received hallux amputations, 13 received partial first ray resections, five received middle metatarsal resections, seven received fifth metatarsal resections, 25 received lesser digit amputations, and 11 received primary transmetatarsal amputations. Six patients died and 23 patients re-ulcerated during follow-up, 12 of which required further amputation. It should be noted that seven re-ulcerated at initial site. It was not stated where the initial anatomic amputation was performed for those patients requiring further amputation. According to this study, the only comorbidity that increased the chance for re-ulceration was for those patients with venous disease (Odds ratio of 4.15, p=0.04)
Conclusion: This paper suggests that with proper surgical technique and antibiotic coverage, primary closure for stable Wagner Grade 3 ulcerations requiring surgical amputation can be performed safely with minimal risk. This paper has significantly prolonged hospital stays (mean = 24 days) and antibiotic coverage (mean = 34 days) following surgery. The authors believe that initial primary closure is equivalent to closure by secondary intention and negative pressure wound therapy. They conclude that primary closure “is a good method of treating foot ulcers with osteomyelitis and reduces the time to healing and resurfaces the foot with good-quality normal skin.”