Predictors of Outcome for Closed, Open and Staged Forefoot Amputations

Back to Annual Meeting
Back to Program

Scott Berceli, MD PhD, Janis Brown, RN, Philip Irwin, C Keith Ozaki, MD.
University of Florida, Gainesville, FL, USA.

BACKGROUND: While varying treatment algorithms for osteomyelitis involving the phalanges and metatarsals have been proposed, local resection of the infected bone stands as an expedient and cost-effective strategy for this problem. Surgical approaches include amputation with primary wound closure, or resection followed by either staged re-resection and wound closure or local care of the open wound for secondary healing. In this longitudinal analysis, we delineate clinical predictors of forefoot amputation healing rates, and the effectiveness of OPEN, CLOSED, and STAGED forefoot amputations in preventing major leg amputation.
Methods: Baseline demographics, need for further operative interventions, time to complete healing, and progression to major amputation were recorded prospectively via a realtime database on all patients undergoing partial foot amputation for osteomyelitis at a single institution between July 2002 and June 2004. Initial management focused on control of local infection with early operative exploration, and limbs with a non-palpable pedal pulse/toe pressure less than 50 mm Hg underwent further evaluation and revascularization. The following treatment algorithm was employed:
1) osteomyelitis with minimal evidence of proximal cellulitis, lymphangitis or undrained tenosynovitis underwent amputation and primary wound closure (CLOSED);
2) osteomyelitis associated with proximal cellulitis or marginally viable soft tissue underwent open amputation, followed by re-resection and wound closure at 2-7 days (STAGED);
3) osteomyelitis associated with tenosynovitis or extensive soft tissue necrosis underwent debridement with no attempt at wound closure (OPEN).
RESULTS: 208 patients underwent amputations during the 2-year enrollment. With 4 subjects lost to follow-up, 204 patients (98%) were followed to complete healing or major amputation (CLOSED n=94, STAGED n=56, and OPEN n=54; Figure 1). OPEN amputations had a significantly reduced primary healing rate (37%, p=0.001) and a frequent need for repeat operative intervention (43%, p=0.001) though, healing is achieved in the majority of these patients (78%). Despite modest primary healing rates in the OPEN group, significant limb salvage was achieved with secondary procedures (78%). The median time to healing for CLOSED, STAGED, and OPEN amputations was 1.2, 1.6 and 4.6 months, respectively (Kaplan-Meier curves, Figure 2). Non-diabetics undergoing OPEN amputation demonstrated reduced healing rates, compared to diabetic patients (Table 1). STAGED simple and Ray toe amputations were equivalent to CLOSED healing rates, and twice that of OPEN amputations.
CONCLUSIONS: While open amputation of extensive forefoot infections frequently requires repeat operative interventions and a prolonged time to complete healing, this approach offers limb salvage rates approaching those observed for less invasive infections amenable to primary closure. Staged closure offers an improved time to healing without negatively impacting the risk of major limb amputation.