Wukich Dane K, Ahn Junho, Raspovic Katherine M, Gottschalk Frank A, La Fontaine Javier, Lavery Larry A
1 Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
2 Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC, USA.
Foot Ankle Int. 2017 Apr;38(4):388-396. doi: 10.1177/1071100716688073. Epub 2017 Jan 19.
The primary purpose of this retrospective study was to report on a consecutive series of 102 patients with diabetes mellitus (DM) who underwent transtibial amputation (TTA) for chronic infections and nonreconstructable lower extremity deformities. A secondary aim was to compare the outcomes of TTA patients with end-stage renal disease on dialysis (ESRD) to patients without ESRD, and to identify risk factors for mortality after TTA.
This cohort involved a consecutive series of patients who were treated by a single surgeon. The TTA patients were divided into 2 groups for analysis. The study group included those patients with ESRD who underwent TTA, and the control group included those patients who did not have ESRD.
At the time of final follow-up, 64 of 102 patients were ambulatory with a prosthesis. There was a significant improvement in ambulatory status after amputation (preoperatively 45.1%, postoperatively 62.7%, P = .02). Wound healing complications (infection and/or dehiscence) occurred in 31 of 102 patients and led to a transfemoral amputation in 4 patients. After TTA patients with ESRD were significantly more likely to die (52.4% vs. 23.5%, p <0.05) and significantly less like to ambulate (42.9% vs. 67.9%, p <0.05) than patients without ESRD. Contralateral foot problems after the TTA occurred in 33 of 97 patients and resulted in 10 patients undergoing a contralateral transtibial amputation. Excluding patients with bilateral amputations (5 prior to and 10 after the index amputation), 64 of 87 patients with successful unilateral transtibial amputations were able to ambulate with a prosthesis. Thirty of 102 patients (29.4%) died during the follow-up period, and 6 of these deaths occurred during the perioperative period (within 30 days of surgery). There were no significant differences between the 2 groups with regard to the use of staged TTA, need for transfemoral amputation, or wound healing problems at the amputation site. Patients who were unable to walk postoperatively had a calculated 5-year survival rate of 30.1%, whereas those who were ambulatory had a 5-year survival rate of 68.8%. Cox proportional hazards model demonstrated a 62% reduced risk of mortality in patients who were able to ambulate after LEA compared with those patients who were not able to ambulate.
TTA in patients with diabetes was associated with substantial morbidity and mortality. Risk factors that were significantly associated with an increased rate of mortality were the presence of ESRD, age ≥56 years, and inability to ambulate postoperatively.
Level III, retrospective case controlled study.
本回顾性研究的主要目的是报告连续102例因慢性感染和不可修复的下肢畸形而接受经胫骨截肢（TTA）的糖尿病（DM）患者。次要目的是比较接受透析的终末期肾病（ESRD）的TTA患者与无ESRD患者的结局，并确定TTA术后的死亡危险因素。
该队列包括由单一外科医生治疗的连续系列患者。TTA患者分为2组进行分析。研究组包括接受TTA的ESRD患者，对照组包括无ESRD的患者。
在最后随访时，102例患者中有64例使用假肢可行走。截肢后行走状态有显著改善（术前为45.1%，术后为62.7%，P = 0.02）。102例患者中有31例发生伤口愈合并发症（感染和/或裂开），其中4例导致经股截肢。与无ESRD的患者相比，ESRD的TTA患者术后死亡的可能性显著更高（52.4%对23.5%，p <0.05），行走的可能性显著更低（42.9%对67.9%，p <0.05）。97例患者中有33例在TTA后出现对侧足部问题，导致10例患者接受对侧经胫骨截肢。排除双侧截肢患者（指数截肢前5例和截肢后10例），87例成功进行单侧经胫骨截肢的患者中有64例能够使用假肢行走。102例患者中有30例（29.4%）在随访期间死亡，其中6例在围手术期（手术30天内）死亡。两组在分期TTA的使用、经股截肢的必要性或截肢部位的伤口愈合问题方面无显著差异。术后无法行走的患者计算得出的5年生存率为30.1%，而能够行走的患者5年生存率为68.8%。Cox比例风险模型显示，与无法行走的患者相比，低位截肢后能够行走的患者死亡风险降低62%。
糖尿病患者的TTA与较高的发病率和死亡率相关。与死亡率增加显著相关的危险因素是存在ESRD、年龄≥56岁以及术后无法行走。
III级，回顾性病例对照研究。
