Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
Michael E. DeBakey VA Medical Center, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, VA Health Services Research & Development, Houston, TX, USA.
J Endovasc Ther. 2024 Aug;31(4):687-696. doi: 10.1177/15266028221144587. Epub 2022 Dec 24.
Transmetatarsal amputation (TMA) with primary closure has long been an option for limb salvage in patients with advanced chronic limb-threatening ischemia (CLTI) with extensive tissue loss of the forefoot. However, TMA healing and closure techniques are challenging, specifically in high-risk patients. Guillotine transmetatarsal amputations (gTMA) with staged closure may provide an alternative treatment in this population. We report long-term outcomes of such technique.
A single-center retrospective cohort study of CLTI patients undergoing gTMA between 2017 and 2020 was performed. Limb salvage, wound healing, and survival rates were quantified using Kaplan-Meier (KM) analysis. Multivariate regression was used to identify the effect of patient characteristics on the outcomes.
Forty-four gTMA procedures were reviewed. Median follow-up was 381 (interquartile range [IQR], 212-539.75) days. After gTMA, 87.8% (n=36) of the patients were able to ambulate after a median interval of 2 (IQR, 1-3) days. Eventual coverage was achieved in a personalized and staged approach by using a combination of skin substitutes (88.6%, n=39) ± split thickness skin grafts (STSG, 61.4%, n=27). KM estimates for limb salvage, wound healing, and survival were 84.1%, 54.5%, and 88.6% at 1 year and 81.8%, 63.8%, and 84.1% at 2 years. Wound healing was significantly associated with STSG application (p=0.002, OR=16.5, 95% CI 2.87-94.81).
gTMA resulted in high limb salvage rates during long-term follow-up in CLTI patients. Adjunctive STSG placement may enhance wound healing at the gTMA site, thus leading to expedited wound closure. Surgeons may consider gTMA as an alternative to reduce limb loss in CLTI patients at high risk of major amputation.
Currently, the clinical presentation of CLTI is becoming more complex to deal with due to the increasing comorbidities as the society becomes older. The data shown in this article means for clinicians that when facing diffused forefoot gangrene and extensive tissue loss, limb preservation could still be considered instead of major amputation. Guillotine transmetatarsal amputations in the setting of an aggressive multidisciplinary group, can be healed by the responsibly utilization of dermal substitutes and skin grafts leading to the preservation of the extremity, allowing mobility, avoiding of sarcopenia, and decreasing frailty. This will equate to maintenance of independent living and preservation of lifespan.
对于伴有前足部广泛组织缺失的慢性肢体威胁性缺血（CLTI）的晚期患者，经跖骨截断术（TMA）一期闭合一直是保肢的一种选择。然而，TMA 的愈合和闭合技术具有挑战性，尤其是在高危患者中。阶梯式闭合的截趾式经跖骨截断术（gTMA）可能为该人群提供一种替代治疗方法。我们报告了这种技术的长期结果。
对 2017 年至 2020 年间接受 gTMA 的 CLTI 患者进行了单中心回顾性队列研究。使用 Kaplan-Meier（KM）分析来量化保肢、伤口愈合和生存率。使用多变量回归来确定患者特征对结果的影响。
共回顾了 44 例 gTMA 手术。中位随访时间为 381（四分位距[IQR]，212-539.75）天。gTMA 后，87.8%（n=36）的患者在中位数为 2（IQR，1-3）天的时间后能够行走。通过使用皮肤替代物（88.6%，n=39）± 断层皮片（61.4%，n=27）的个性化分期方法实现了最终覆盖。1 年时的 KM 估计保肢、伤口愈合和生存率分别为 84.1%、54.5%和 88.6%，2 年时分别为 81.8%、63.8%和 84.1%。伤口愈合与 STSG 应用显著相关（p=0.002，OR=16.5，95%CI 2.87-94.81）。
在 CLTI 患者的长期随访中，gTMA 导致了较高的保肢率。辅助 STSG 放置可能会增强 gTMA 部位的伤口愈合，从而加速伤口闭合。外科医生可能会考虑 gTMA 作为一种降低 CLTI 患者高截肢风险的保肢选择。
目前，由于社会老龄化导致合并症的增加，CLTI 的临床表现变得更加复杂。本文中的数据意味着，对于临床医生来说，当面临弥漫性前足坏疽和广泛组织缺失时，仍然可以考虑保肢而不是进行大截肢。在积极的多学科团队中，阶梯式经跖骨截断术可以通过负责任地利用真皮替代物和皮片来愈合，从而保留肢体，允许活动，避免肌肉减少症，减少脆弱性。这将等同于维持独立生活和延长寿命。
