Why stage your limb preservation...
Transcript of Why stage your limb preservation...
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WHY STAGE YOUR LIMB PRESERVATION SURGERIES?
Mario Ponticello DPM FACFAS FAPWCA
Chief, Limb Preservation Service
Madigan Army Medical Center
Tacoma WA
PNEC
May 2019
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DISCLOSURES
• No financial disclosures
• The views expressed herein are my views and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government
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OBJECTIVES• What does
staged surgery entail?
• Discuss literature support for a staged surgical approach
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CAPOBIANCO, STAPLETON AND ZGONIS. OCT 2010
“Limb salvage among the diabetic population, when feasible, can improve function with fewer ionotropic cardiac effects than a major limb amputation.”
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DO WHAT
YOU KNOW?
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STAGED SURGERY
• Infection control
•Vascular assessment
•Reconstructive surgery
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INFECTION CONTROL• Infection control aids in
medical stabilization
• Focus on the Here and Now, not the What will Be
• Thorough examination of all involved tissues
• Resection of ALLinfected soft tissue and bone
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Debridement Completion
After 3 days of packing
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VASCULAR ASSESSMENT
• Preoperative assessment
• Palpation of pulses
• Bedside doppler exam
• Intraoperative assessment
• Gross tissue bleeding
• Fluorescent angiography
• Postoperative assessment
• ABI/TBI
Vascular
Surgeon Consult
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WHAT ELSE?
• Medical
• Glucose control/Comorbidity management
• Antibiotic administration
• Discharge planning
• Surgical
• Serial debridements
• Bandage changes
• Edema management
• Immobilization
• Offloading
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SOFT TISSUE RECONSTRUCTION
Negative Pressure
Wound Therapy
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OSSEOUS RECONSTRUCTION
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COMBINED RECONSTRUCTION
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LITERATURE SUPPORT FOR STAGED SURGERY
• Silva et al., Annals of Vascular Surgery (2018)
• One-stage amputations vs staged amputations
• Retrospective
• N=185 pts with critical limb ischemia (207 amputations)
• 106 one-stage
• 101 staged
• Staged amputations had higher success rate, lower
perioperative mortality rate, lower 30 day mortality rate
• The level of amputation was higher using the one-stage
method
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LITERATURE SUPPORT FOR STAGED SURGERY
Berceli et al.(2006)
• Open amputations vs Staged amputations vs One-staged closed amputations
• Staged closure healed faster without negatively impacting the risk of major limb amputation
Fisher et al.(1988)
• One-stage vs Two-stage amputations
• One-stage amputations had more wound complications
Altindas et al.(2011)
• Staged transtibial amputations
• Risk of unnecessary tissue sacrifice and failure rate of the secondary transtibial amputation was reduced
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OSTEOMYELITIS TREATMENT FAILURE
• Treatment failure of 20%-35%
• Barshes et al.(2016)
• 184 cases of foot osteomyelitis with 23.4% were repeat offenders
• 339 organisms were identified in total = 2.4 organisms per bone culture
• E coli and Pseudomonus aeruginosa had increased treatment failures
• MRSA was not associated with higher rates of treatment failure
• Staged closure had lower rate of failure (p=0.01)
• Severe PAD,PAD that was incompletely assessed, or occluded bypass grafts had higher rates of treatment failure
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CONCLUSIONS
• Staged surgery for the infected diabetic foot has been shown to be a safe option that reduces risk for further return to the OR
• Vascular evaluation is key
• Proper source control is vital to the success of the process
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LITERATURE CITED
1. Capobianco CM,Stapleton JJ, and T Zgonis. Surgical Management of Diabetic Foot and Ankle Infections. 2010. Foot and Ankle Specialist; 3(5):223-230.
2. Silva LR et al. Results of One-Stage or Staged Amputations of Lower Limbs Consequent to Critical Limb Ischemia and Infection. 2018. Annals of VascSurg;46:218-225.
3. Barshes NR et al. Treatment Failure and Leg Amputation among Patients with Foot Osteomyelitis. 2016. Int J Lower Extremity Wounds;15(4):303-312.