Yeager R A, Moneta G L, Edwards J M, Williamson W K, McConnell D B, Taylor L M, Porter J M
Portland Department of Veteran's Affairs Medical Center, Department of Surgery, Oregon Health Sciences University, 97207, USA.
Am J Surg. 1998 May;175(5):388-90. doi: 10.1016/s0002-9610(98)00045-2.
Surprisingly little is known about the long-term outcome of forefoot surgery for limb salvage.
From January 1, 1992 through December 31, 1996, patients requiring toe amputation or forefoot surgery were prospectively entered into a computerized database and followed up for healing, need for repeat foot surgery, or major amputation (below or above knee).
A total of 162 patients (mean age 65 years), 72% diabetic, 10% with end-stage renal disease (ESRD), and 73% without palpable pulses, were entered into the study. Mean follow-up was 25 months. Of patients without palpable pulses (n = 98), 83% underwent concomitant or subsequent limb revascularization. Eleven of 98 revascularization procedures (11%) were hemodynamically unsuccessful. Nonhealing of the initial forefoot procedure occurred in 14%, and late repeat foot surgery (following initial healing) was required in an additional 14%. Major amputation was eventually required in 30 (18.5%) patients. Multivariate analysis indicated that unsuccessful revascularization, but not diabetes or ESRD, predicted nonhealing and major amputation (P <0.0001). Patients presenting with palpable pulses and neuropathic ulcers were at risk for late, repeat foot surgery, but not major amputation (P = 0.0015).
In patients requiring toe or partial forefoot amputation, success of revascularization is the primary predictor of initial healing and freedom from major amputation. Neuropathic ulceration predicts need for repeat foot surgery following healing.
令人惊讶的是，对于保肢的前足手术的长期结果了解甚少。
从1992年1月1日至1996年12月31日，将需要进行趾截肢或前足手术的患者前瞻性地录入计算机数据库，并随访伤口愈合情况、是否需要再次进行足部手术或大截肢（膝下或膝上）。
共有162例患者（平均年龄65岁）纳入研究，其中72%为糖尿病患者，10%为终末期肾病（ESRD）患者，73%触不到脉搏。平均随访时间为25个月。在触不到脉搏的患者（n = 98）中，83%接受了同期或随后的肢体血管重建术。98例血管重建手术中有11例（11%）血流动力学效果不佳。初次前足手术伤口不愈合的发生率为14%，另有14%的患者在伤口初步愈合后需要进行晚期再次足部手术。最终有30例（18.5%）患者需要进行大截肢。多因素分析表明，血管重建失败而非糖尿病或ESRD可预测伤口不愈合和大截肢（P <0.0001）。有可触及脉搏且患有神经性溃疡的患者有晚期再次足部手术风险，但无大截肢风险（P = 0.0015）。
在需要进行趾截肢或部分前足截肢的患者中，血管重建的成功是伤口初步愈合和避免大截肢的主要预测因素。神经性溃疡预示着愈合后需要再次进行足部手术。
