Role of disarticulation and guillotine amputation of the shin in the lower limb ischemic gangrene surgical treatment strategy

Ischemic foot gangrene is one of the most common reasons of nontraumatic low limb amputations all over the world.
Objective: to analyze the clinical effectiveness of an individual treatment strategy application for patients with absolute indications for high limb amputation, aimed to reduce amputation level, the number of postoperative complications and mortality.
Materials and methods. This article presents the results of comparative clinical trial executing a lower-extremity amputation in 992 patients with ischemic gangrene. Applied in this study strategy of surgical treatment included usual below-knee, above-knee amputations and guillotine amputations in the lower third of the shin also the shin exarticulation without wound plastic. Guillotine amputations was used as an intermediate stage of treatment in cases where due to the severe general condition of patients to perform a classic myoplastic amputation with stump formation was impossible, since it is accompanied by a very high risk of postoperative complications and mortality.
Results. Using guillotine amputations and shin exarticulation as the first stage of complex surgical strategy aimed to rapid elimination of the purulent focus with minimal risks and the speedy stabilization of the patients general condition, emaciated and weakened by developing gangrene, led to reduce general lethality by 17.1 % and increased the quantity of below-knee amputations by 23.0 % compared with the comparison group.
Conclusion. Patients with ischemic gangrene require the development of an individual strategy for surgical treatment (taking into account the severity of the patients general condition, the prevalence of the purulent-necrotic process in the lower limb, the nature and degree of peripheral macroangiopathy), which can reliably and significantly reduce the number of amputations at the hip level (by 46.2%), as well as reduce mortality after high amputations of the lower extremities (by 17.1%) in an emergency city hospital. We consider it extremely important to reduce the number of primary amputations at the hip level!

1. Степанов Н. Г. Ампутация нижних конечностей: Дис. … докт. мед. наук. СПб., 2005. 300 с. [Stepanov N. G. Amputation of the lower extremities = Stepanov N. G. Amputatsiya nizhnikh konechnostey: Dis. … dokt. med. nauk. SPb., 2005. 300 s. (In Russ.)]

2. Шор Н. А. Хирургическая тактика при диабетической ангиопатии нижних конечностей с гнойно-некротическими поражениями. Хирургия. 2001; 6: 29–33. [Shor N. A. Surgical tactics for diabetic angiopathy of the lower extremities with purulent-necrotic lesions = Shor N. A. Khirurgicheskaya taktika pri diabeticheskoy angiopatii nizhnikh konechnostey s gnoyno-nekroticheskimi porazheniyami. Khirurgiya. 2001; 6: 29–33. (In Russ.)]

3. Trautner C., Haastert B., Spraul M., et al. Unchanged incidence of lower-limb amputations in a German city, 1990–1998. Diabetes Care. 2001; 24 (5): 855–859.

4. Воробихина Н. В., Зеленина Т. А., Петрова Т. М. Влияние метода оперативного лечения больных с гнойно-некротическими формами синдрома диабетической стопы на частоту рецидивирования, риск повторных ампутаций и выживаемость. Инфекции в хирургии. 2009; 4: 41–46. [Vorobikhina N. V., Zelenina T. A., Petrova T. M. Influence of the method of surgical treatment of patients with purulent-necrotic forms of diabetic foot syndrome on the recurrence rate, the risk of repeated amputations and survival = Vorobikhina N. V., Zelenina T. A., Petrova T. M. Vliyaniye metoda operativnogo lecheniya bol'-nykh s gnoyno-nekroticheskimi formami sindroma diabeticheskoy stopy na chastotu retsidi-virovaniya, risk povtornykh amputatsiy i vyzhivayemost'. Infektsii v khirurgii. 2009; 4: 41–46. (In Russ.)]

5. Леменев В. Л., Михайлов И. П., Жулин Д. В., Иофик В. В. Хирургическое лечение больных старших возрастных групп с критической ишемией нижних конечностей при окклюзионных поражениях аорты и подвздошных артерий. Хирургия. 2002; 6: 52–56. [Lemenev V. L., Mikhailov I. P., Zhulin D. V., Iofik V. V. Surgical treatment of patients of older age groups with critical ischemia of the lower extremities in occlusive lesions of the aorta and iliac arteries = Lemenev V. L., Mikhaylov I. P., Zhulin D. V., Iofik V. V. Khirurgicheskoye lecheniye bol'nykh starshikh vozrastnykh grupp s kriticheskoy ishemiyey nizhnikh konechnostey pri okklyuzionnykh porazheniyakh aorty i podvzdoshnykh arteriy. Khirurgiya. 2002; 6: 52–56. (In Russ.)]

6. Сосудистая хирургия по Хаймовичу: руководство в 2-х т.; пер. с англ. / под ред. А. В. Покровского. М.: БИНОМ. Лаборатория знаний, 2010. Т. 2: Ампутации нижних конечностей: основные положения. С. 496– 507. [Vascular surgery according to Haimovich = Sosudistaya khirurgiya po Khaymovichu: rukovodstvo v 2-kh t.; per. s angl. / pod red. A. V. Pokrovskogo. M.: BINOM. Laboratoriya znaniy, 2010. T. 2: Amputatsii nizhnikh konechnostey: osnovnyye polozheniya. S. 496–507. (In Russ.)]

7. De Godoy J. M. P., de Godoy M. F., Batigalia F., et al. Lower-extremity amputation: a 6-year follow up in Brazil. J Orthopaed Surg (Hong Kong). .2005; 13 (2): 164–165.

8. Eskelinen E., Lepantalo M., Hietala E. M., et al. Lower limb amputations in southern Finland in 2000 and trends up to 2001. Eur J Vasc Endovasc Surg. 2004; 27 (2): 193–200.

9. Ploeg A. J., Lardenoye J. W., Vranken P. M., et al. Contemporary series of morbidity and mortality after lower limb amputation. Eur J Vasc Endovasc Surg. 2005; 29 (6): 633–637.

10. Гаибов А. Д., Калмыков Е. Л., Камолов А. Н. Ампутации нижних конечностей при их хронической критической ишемии. Обзор литературы. Кардиология и сердечнососудистая хирургия. 2009; 2: 40–46. [Gaibov A. D., Kalmykov E. L., Kamolov A. N. Amputations of the lower extremities in their chronic critical ischemia = Gaibov A. D., Kalmykov Ye. L., Kamolov A. N. Amputatsii nizhnikh konechnostey pri ikh khronicheskoy kriticheskoy ishemii. Obzor literatury. Kardiologiya i serdechno-sosudistaya khirurgiya. 2009; 2: 40–46. (In Russ.)]

11. Митиш В. А., Светухин А. М., Чупин А. В. Способ ампутации голени в условиях критической ишемии нижних конечностей. Ангиология и сосудистая хирургия. 1997; 4: 96–102. [Mitish V. A., Svetukhin A. M., Chupin A. V. A method of amputation of the lower leg in conditions of critical ischemia of the lower extremities = Mitish V. A., Svetukhin A. M., Chupin A. V. Sposob amputatsii goleni v usloviyakh kriticheskoy ishemii nizhnikh konechnostey. Angiologiya i sosudistaya khirurgiya. 1997; 4: 96–102. (In Russ.)]