Berceli Scott A, Brown Janis E, Irwin Philip B, Ozaki C Keith
Malcom Randall Veterans Affairs Medical Center, Gainesville, FL 32610, USA.
J Vasc Surg. 2006 Aug;44(2):347-351; discussion 352. doi: 10.1016/j.jvs.2006.04.043.
Surgical approaches for forefoot osteomyelitis include amputation with immediate wound closure or resection followed by either staged re-resection and wound closure or local care of the open wound for secondary healing. This study evaluated the effectiveness of closed, staged, and open forefoot amputations in preventing major leg amputation and identified those variables that are associated with successful limb preservation.
From July 2002 to June 2004, 208 patients with forefoot osteomyelitis or gangrene underwent minor amputation according to a standard treatment algorithm. Wounds with limited cellulitis underwent immediate wound closure (CLOSED), wounds with marginally viable soft tissue underwent open amputation followed by wound closure at 2 to 7 days (STAGED), and wounds with tenosynovitis or extensive necrosis underwent débridement with no attempt at wound closure (OPEN). Patient demographics, need for further operative interventions, time to complete healing, and progression to major amputation were recorded.
With four subjects lost to follow-up, 204 patients (98%) (94 CLOSED, 56 STAGED, and 54 OPEN) were monitored to complete healing, major amputation, or death. OPEN amputations had a significantly reduced initial healing rate (37%, P < .001) and a frequent need for repeat operative intervention (43%), although successful limb salvage was ultimately achieved in 70% of the cases. Initial healing in the CLOSED and STAGED amputation groups was similar (71% and 78%, respectively), leading to excellent early limb salvage (86% and 91%). The median time to healing for closed, staged, and open amputations was 1.2, 1.6, and 4.6 months, respectively (P < .001). Follow-up evaluation demonstrated the initial improvements in limb salvage with the CLOSED and STAGED groups were lost, resulting in similar amputation rates among the three groups of 30% to 35% over 36 months.
Although open amputation of extensive forefoot infections frequently requires repeat operative interventions and a prolonged time to complete healing, this approach provides limb salvage rates approaching those observed for less invasive infections amenable to immediate closure. Staged closure offers an improved time to healing without negatively impacting the risk of major limb amputation. Independent of their initial operative approach, these patients frequently progress to early leg amputation.
前足骨髓炎的手术方法包括截肢并立即缝合伤口，或切除后分阶段再次切除并缝合伤口，或对开放伤口进行局部护理以实现二期愈合。本研究评估了闭合性、分阶段和开放性前足截肢在预防大腿截肢方面的有效性，并确定了与成功保肢相关的变量。
2002年7月至2004年6月，208例前足骨髓炎或坏疽患者根据标准治疗方案接受了小截肢手术。蜂窝织炎局限的伤口立即缝合（闭合性），软组织边缘存活的伤口进行开放性截肢，然后在2至7天内缝合伤口（分阶段），腱鞘炎或广泛坏死的伤口进行清创，不尝试缝合伤口（开放性）。记录患者的人口统计学资料、进一步手术干预的需求、完全愈合的时间以及进展为大腿截肢的情况。
4例患者失访，对204例患者（98%）（94例闭合性、56例分阶段和54例开放性）进行了监测，直至其完全愈合、进行大腿截肢或死亡。开放性截肢的初始愈合率显著降低（37%，P <.001），且经常需要重复手术干预（43%），尽管最终70%的病例成功保肢。闭合性和分阶段截肢组的初始愈合情况相似（分别为71%和78%），早期保肢效果良好（分别为86%和91%）。闭合性、分阶段和开放性截肢的中位愈合时间分别为1.2、1.6和4.6个月（P <.001）。随访评估显示，闭合性和分阶段组最初保肢方面的改善情况消失，导致三组在36个月内的截肢率相似，均为30%至35%。
尽管广泛的前足感染进行开放性截肢通常需要重复手术干预且愈合时间延长，但这种方法提供的保肢率接近那些适合立即缝合的侵入性较小感染的保肢率。分阶段缝合可缩短愈合时间，且不会对大腿截肢风险产生负面影响。无论其初始手术方法如何，这些患者经常进展为早期大腿截肢。
