Vartanian Shant M, Robinson Kristin D, Ofili Kene, Eichler Charles M, Hiramoto Jade S, Reyzelman Alex M, Conte Michael S
Center for Limb Preservation, University of California, San Francisco, San Francisco, CA.
Center for Limb Preservation, University of California, San Francisco, San Francisco, CA.
Ann Vasc Surg. 2015 Apr;29(3):534-42. doi: 10.1016/j.avsg.2014.10.030. Epub 2015 Jan 14.
Multidisciplinary amputation prevention teams decrease the frequency of major amputations by increasing the use of revascularization procedures and minor amputations. The outcomes of wound healing, wound recurrence, and ambulatory status are assumed to be improved but are not routinely reported. This study investigates the midterm outcomes of neuroischemic wounds treated by our multidisciplinary team.
A retrospective review of patients with neuroischemic wounds treated at a single institution amputation prevention clinic from March 2012 to July 2013. Patient demographics, wound characteristics, procedural details, and clinical and functional outcomes were reviewed. Clinical end points under study included time to wound healing, reulceration rate, and ambulatory status.
Over 16 months, there were 202 new patients and 1,355 clinic visits. Ninety-one limbs from 89 patients were treated for complex neuroischemic wounds. In 67% (61 of 91) of limbs, wounds were present for >6 weeks before referral. A history of previous revascularization was present in 39% (31 of 91), and 28% (22 of 91) had a previous minor amputation. Forty-one percent of wounds (38 of 91) were limited to the toes or the forefoot whereas 24% (22 of 91) involved the hindfoot or ankle. A total of 151 podiatric and 86 vascular interventions were performed, with an equal distribution of endovascular and open revascularizations. Complete healing was observed for 59% of wounds (54 of 91) over the observation period (median follow up, 207 days; range 56-561 days), and the average time to full healing was 12 weeks. Hindfoot wounds were predictive of failure to heal (odds ratio, 0.21; P < 0.01; 95% confidence interval, 0.06-0.68). Nineteen percent of patients (17 of 91) developed a new wound in the ipsilateral leg during follow-up. Three major amputations were performed (2 below-knee amputation and 1 above-knee amputation) for a major/minor amputation ratio of 0.06. Ambulatory status was preserved or improved in 74% (67 of 91) of patients. The 30-day readmission rate was 11%, which was lower than that observed (21%) in a contemporaneous but all-inclusive population of lower extremity revascularization procedures performed at our institution.
Multidisciplinary limb salvage teams effectively heal wounds and maintain ambulatory status in patients with limb-threatening neuroischemic wounds. Patient specific factors, such as hindfoot or ankle wounds, can adversely influence the outcome. Even with aggressive care, healing can be prolonged and a substantial proportion of patients can be expected to have a recurrence, making subsequent surveillance mandatory. Our data also suggest that a coordinated amputation prevention program may help to minimize hospital readmissions in this high-risk population.
多学科截肢预防团队通过增加血管重建手术和小截肢手术的使用频率，降低了大截肢的发生率。人们认为伤口愈合、伤口复发和行走状态的结果会得到改善，但这些结果并未常规报告。本研究调查了我们多学科团队治疗的神经缺血性伤口的中期结果。
对2012年3月至2013年7月在一家机构截肢预防诊所接受治疗的神经缺血性伤口患者进行回顾性研究。回顾了患者的人口统计学资料、伤口特征、手术细节以及临床和功能结果。研究的临床终点包括伤口愈合时间、再溃疡率和行走状态。
在16个月的时间里，有202名新患者和1355次门诊就诊。对89例患者的91条肢体进行了复杂神经缺血性伤口的治疗。在67%（91条肢体中的61条）的肢体中，伤口在转诊前已存在超过6周。39%（91条肢体中的31条）有既往血管重建史，28%（91条肢体中的22条）有既往小截肢史。41%的伤口（91条肢体中的38条）仅限于脚趾或前足，而24%（91条肢体中的22条）累及后足或踝关节。共进行了151次足病治疗和86次血管干预，血管内和开放性血管重建分布均匀。在观察期内（中位随访时间207天；范围56 - 561天），59%的伤口（91条肢体中的54条）完全愈合，完全愈合的平均时间为12周。后足伤口是愈合失败的预测因素（比值比，0.21；P < 0.01；95%置信区间，0.06 - 0.68）。19%的患者（91例中的17例）在随访期间同侧腿部出现新伤口。进行了3次大截肢手术（2例膝下截肢和1例膝上截肢），大/小截肢比例为0.06。74%（91例中的67例）的患者行走状态得以保留或改善。30天再入院率为11%，低于我们机构同期进行的所有下肢血管重建手术患者的观察再入院率（21%）。
多学科肢体挽救团队能有效治愈肢体威胁性神经缺血性伤口患者的伤口并维持其行走状态。患者的特定因素，如后足或踝关节伤口，可能对结果产生不利影响。即使积极治疗，愈合时间仍可能延长，预计相当一部分患者会复发，因此后续监测必不可少。我们的数据还表明，协调的截肢预防计划可能有助于将这一高危人群的医院再入院率降至最低。
