One-stage versus two-stage amputation for wet gangrene of the lower extremity: A randomized study

• Published in: Journal of vascular surgery Vol. 8; no. 4; pp. 428 - 433
• Main Authors: Fisher, Daniel F., Clagett, G.Patrick, Fry, Richard E., Humble, Theodore H., Fry, William J.
• Format: Journal Article Conference Proceeding
• Language: English
• Published: New York, NY Mosby, Inc 01-10-1988; Elsevier
• Subjects: Aged; Amputation - methods; Biological and medical sciences; Blood and lymphatic vessels; Cardiology. Vascular system; Clindamycin - therapeutic use; Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous; Foot Diseases - surgery; Gangrene - surgery; Gentamicins - therapeutic use; Humans; Medical sciences; Middle Aged; Premedication; Prospective Studies; Random Allocation; Reoperation; Surgical Wound Infection - prevention & control; Human; Chronic; Surgical amputation; Surgery; Gangrene; Lower limb; Cardiovascular disease; Arterial disease of the limb; Arterial occlusive disease; Level
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/0741-5214(88)90106-1

Although the two-stage amputation technique entails an additional operation, several authors have advocated this approach to deal with wet gangrene because it allows primary wound closure with a reduced chance of wound infection. To examine this issue, 47 patients with necrotizing wet gangrene of the foot were randomized prospectively to receive either a one-stage amputation (definitive below- or above-knee amputation with delayed secondary skin closure in 3 to 5 days) or a two-stage amputation (open ankle guillotine amputation followed by definitive, closed below- or above-knee amputation). Antibiotic coverage was standardized with clindamycin and gentamicin used in all patients. Preoperative blood cultures and intraoperative foot cultures were obtained, as well as cultures from the deep muscle and lymphatic area along the saphenous vein to determine the presence of bacteria at the level of initial amputation. Twenty-four patients (11 diabetic and 13 nondiabetic) were randomized to the one-stage procedure. Twenty-three patients (14 diabetic and nine nondiabetic) were randomized to the two-stage procedure. Five of 24 patients in the one-stage group (21%) had positive muscle cultures vs 10 of 23 patients in the two-stage group (43%). Two of 24 patients in the one-stage group (8%) had positive lymphatic cultures vs 7 of 23 patients in the two-stage group (30%). Five of 24 patients in the one-stage group (21%) had wound complications attributable to the amputation technique vs none of 23 patients in the two-stage group (p = 0.05). Risk factors in patients with wound complications (n = 5) were the one-stage amputation technique (five of five patients), the presence of diabetes (three of five), lack of a popliteal pulse (four of five), and leukocyte counts exceeding 12,000/mm3 (four of five). The incidence of death and complications unassociated with amputation between the two amputation techniques was not statistically significant.