Transmetatarsal and Minor

Amputation Versus Major Leg

Amputation: 30-Day Readmissions, Latifah
Reamputations, and Complications Fakultas Kedokteran
Universitas Indonesia
- RSCM
Jakarta 2022
  Amputasi diartikan sebagai tindakan memisahkan
Definisi bagian tubuh sebagian seperti kaki, tanggan, lutut,
atau seluruh bagian ekstremitas
 Dead limb

Indikasi Dangerous

Damn nuisance
 Amputasi minor
• melibatkan anggota gerak dari jari
kaki sampai dengan pergelangan
Jenis Amputasi kaki

Amputasi mayor
• semua amputasi di atas sendi
pergelangan kaki
Level
Amputasi
  In this study, we attempted to compare the risk of short-term
Tujuan complications associated with minor amputation (TMA, Chopart,
Lisfranc) versus major amputation (BKA)
  Patients were selected from the National Surgical Quality
Improvement Program (NSQIP) data from 2012 to 2014.
 More than 700,000 cases were recorded in 2014
Methods  into the 2 study groups: minor amputation and major amputation.
 The demographic variables collected were age (those with age
>90 years were coded as being 90), gender, race, ethnicity, and
body mass index (BMI)
  Comorbidities:
 Presence of bleeding disorder
 Preoperative steroid use
 Presence of open wound at the time of surgery
 Dialysis
 Functional status (coded as dependent, partially dependent, or
independent)

Methods  Smoking
 Diabetes mellitus
 Several perioperative variables:
 American Society of Anesthesiologists (ASA) class (1/2, 3, or 4/5),
 Wound class
 Length of stay (LOS)
 Operative time
 Time from operation until discharge
  Primary outcomes :
 Reamputation
 Occurrence of wound complication or irrigation and debridement
within 30 days of surgery
Methods  Secondary outcomes:
 Occurrence of urinary tract infection (UTI)
 Deep venous thrombosis/pulmonary embolism
 Wound complications (surgical site infection or wound disruption),
or blood transfusion, within the same time frame
  All variables were described in the amputation patients 
univariate statistics
 The 2 types of amputation were compared in terms of
demographics and comorbidities using bivariate tests
Methods  Student’s t tests and Fisher’s exact/chi-squared tests compared
continuous and discrete variables, respectively.
 Associations between demographic and comorbid factors and the
outcomes of interest were assessed using bivariate analyses
 For each outcome  a logistic regression model
  To account for underlying differences in indication for the 2
amputation types, the 2 amputation samples were matched by
propensity score
 A conditional logistic regression model for each of our outcomes
Methods assessed the impact of amputation type
 The propensity score matching and subsequent conditional
logistic regression were repeated after restricting to patients with
diabetes.
 All analyses were executed in the R statistical package
Hasil
Hasil
Hasil
  Wound complications and reoperations are the most common
reasons for readmission after lower-extremity amputations
 In general, patients would strongly prefer to preserve their foot,
even if it does require a higher number of operations, more
hospital time, or no benefits and function.
Diskusi  Aggressive attempts at limb salvage, or at minimizing the level of
amputation  unnecessary reoperation and readmission
 Proximal amputation (major amputation) did not yield higher
rates of wound-healing complications, reamputation, or
readmission compared with more distal amputations. Although
major amputations were more likely to be associated with UTI
 The increased risk of transfusion after major amputation is
important to acknowledge because of several factors. More
proximal amputations involve larger vessels and naturally
predispose to higher risk for blood loss
 the lack of differences in wound complication and reoperation
between these 2 groups before propensity score matching
suggests that minor amputations may be more prone to these
short-term complications
 Distal perfusion is less ideal for healing than proximal perfusion 
predisposing minor amputation patients to increased wound-
healing complications.
 Patients with diabetes classically have infrapopliteal disease 
impact healing for minor amputations compared with major
amputations.
 A major amputation, the tissue margins are much more likely to
be free of edema, infection, and inflammation as opposed to the
margins achieved with foot amputations  Eradication of
infection and achieving uninfected tissue margins are paramount
to achieving optimal wound healing
 In emergency or sepsis situations, staged open amputation (i.e.,
circular or guillotine) or more proximal amputation have been
shown to yield better results.
 Proximity to inflammation, infection, and edema  important
factors to consider  deciding level of amputation.
 Patients undergoing minor amputation have infection in the digit
or even at the distal metatarsal level.
 Although it may appear grossly that all the necrotic tissue has
been resected, surrounding inflammation, edema, and
microscopic contamination  wound-healing complications 
mitigated with more proximal amputation.
 We found that patients undergoing minor amputation were 2.66
times more likely to return to the operating room for irrigation
and debridement than patients undergoing major amputation
 Partial foot amputations, such as TMA, Lisfranc, Chopart, and
Syme, are performed to avoid major amputation.
 When performing a TMA:
 it is critical to maintain the metatarsal bases to avoid an equinovarus
deformity.
 Studies suggest that the functional difference between these foot
amputation levels may be minimal  rehabilitate with a
functional prosthesis
 avoid an AKA, because increased energy requirements to
ambulate are »60% to 70% higher than baseline
  In many cases, the decision is made based on the vascular status
of the lower extremity and its potential to heal after the
amputation is performed
 When vascular supply is adequate, based on a noninvasive or
Kesimpulan invasive study, amputation is often performed just proximal to the
infection or other relevant pathology
 long-term function, overall health condition, comorbidities,
socioeconomic state, and perhaps cost effectiveness in a health
care system should also be considered in decision making.
TERIMA KASIH