Scher K S, Steele F J
Department of Surgery, Wright State University School of Medicine, Dayton, Ohio.
Surgery. 1988 Oct;104(4):661-6.
Sixty-five lower-extremity amputations were performed as a result of sepsis in diabetic patients during a 3-year period. Chronic plantar ulcer was the most frequent cause of infection. Other causes of infection included ischemic gangrene, trauma, and web space fissures. Advanced ischemia was infrequent; only 21 (32.3%) had ankle-brachial indices (ABI) less than 0.5. Eight (23.5%) deaths and 12 (35.3%) stump failures followed 34 amputations where the stump was closed, compared with no deaths and 4 (12.9%) stump failures when open amputations were done (p less than 0.02). Partial foot amputations with aggressive local debridement resulted in healing in 10 (71.4%) of 14 cases with revision or grafting. Guillotine transmalleolar amputation is advised when foot salvage is not possible, because only 1 (5.9%) of 17 such procedures could not be revised to the below-knee (B-K) level, whereas 8 (33.3%) of 24 definitive, closed B-K amputations were unsuccessful (p less than 0.02). Infections were polymicrobial, with 5.8 bacterial isolates and 2.3 anaerobes recovered per patient. Anaerobic antibiotic coverage, however, failed to alter outcome. Sepsis, often without advanced ischemia, is an important cause of limb loss in patients with diabetes. Open amputations are recommended, with foot salvage possible in many cases.
在3年期间，65例糖尿病患者因败血症接受了下肢截肢手术。慢性足底溃疡是最常见的感染原因。其他感染原因包括缺血性坏疽、创伤和趾蹼间隙裂伤。严重缺血情况并不常见；只有21例（32.3%）踝肱指数（ABI）低于0.5。34例残端闭合的截肢手术后有8例（23.5%）死亡，12例（35.3%）残端愈合不良；而开放性截肢手术后无死亡病例，4例（12.9%）残端愈合不良（p<0.02）。14例行积极局部清创的部分足部截肢手术中，10例（71.4%）经翻修或植皮后愈合。当无法挽救足部时，建议行断头式经踝关节截肢术，因为17例此类手术中只有1例（5.9%）无法翻修为膝下（B-K）截肢，而24例确定性闭合B-K截肢手术中有8例（33.3%）不成功（p<0.02）。感染为多微生物感染，每位患者平均分离出5.8种细菌和2.3种厌氧菌。然而，厌氧抗生素覆盖并未改变结果。败血症，通常无严重缺血，是糖尿病患者肢体丧失的重要原因。建议行开放性截肢术，在许多情况下有可能挽救足部。
