Prevention of major amputations in nonischemic lower limb lesions

BACKGROUND: Major lower limb amputations continue to be performed at an increasing rate, the major cause being the rising prevalence of adult onset diabetes. It can be demonstrated that a reduction in amputation rate can be achieved at institutes with a higher level of academic and specialty interest, by avoiding errors of management and by newer technical innovations in wound closure. STUDY DESIGN: A simpler method of wound closure that is easily taught and learned and is readily available to the medical community and the patient population can play a substantial role in reducing the number of amputations. Satisfactory closure of open lesions by full-thickness skin and subcutaneous tissue carries with it a lower incidence of recurrence, reduces costs by avoiding or reducing length of hospitalization, and minimizes use of general anesthesia, a serious matter in immunocompromised older patients. Avoiding errors of technique will additionally reduce amputation rate. RESULTS: In the last 10 years, 125 patients, mostly diabetic and elderly, with major and recurrent lesions of the lower extremities, have been treated by closure of the debrided wound with a combination of external tissue expansion and wound toilette. Major lower limb amputations have been avoided. CONCLUSIONS: Experience confirms that the relationship between high hospital volume, specialty interest, higher level of academic care; avoiding technical errors; and simplifying the methodology, lead to a reduction in need for major amputations. A lower mortality in the patient population at risk is achieved and a reduction in costs, which have risen beyond the $132 billion level, can be expected.