Physiologic amputation for acute pedal sepsis.

There are three options for management of pedal sepsis requiring lower extremity amputation: one-stage emergency, two-stage guillotine, or physiologic amputation. The excessive mortality usually ascribed to amputation surgery is basically derived from the selection of one of these options in emergency situations, with published mortalities of 10 per cent to 40 per cent being the norm. We have performed 465 lower-extremity amputations for vascular insufficiency for seven years, with overall 30-day operative mortalities of 0.5 per cent for below-knee amputations and 2.7 per cent for above-knee amputations. One hundred sixteen of these patients presented with acute pedal sepsis superimposed on significant medical disability, and were managed initially with physiologic amputation and intensive hemodynamic monitoring; the overall mortality for this select group was 5.1 per cent. An algorithm of management of patients presenting with acute pedal sepsis has thereby been derived, and is herein presented.