What is included in the preprocedural evaluation of lower-extremity amputations?

Updated: Apr 29, 2021
  • Author: Janos P Ertl, MD; Chief Editor: Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS  more...
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Answer

In patients with peripheral vascular disease (PVD), the diagnosis is usually known because these individuals have had extensive vascular studies and have most often undergone attempts at revascularization. With progressive small-vessel occlusion and neuropathy, toes become gangrenous and pressure points develop trophic ulcers, allowing bacteria to take hold and eventually invade the bone.

Throughout treatment, costly measures are undertaken in attempts to salvage a marginally viable extremity, with the patient losing valuable productive time. The patient has often undergone multiple foot amputations and multiple debridements and is often wheelchair-bound for pain relief or for relief of pressure on the extremity. Additionally, the patient often has an ascending cellulitis due to venostasis or constant pain due to ischemic disease.

For trauma patients, the amputation may be the result of direct limb transection or a severe open fracture with an associated unreconstructable neurovascular injury. The limb is so severely injured that reconstruction is less functional than an amputation. The other end of the spectrum includes an unsuccessful prolonged limb-salvage attempt that leaves the patient with a painful nonfunctional limb. The salvaged limb often requires a protracted course of treatment that takes a psychological toll on the patient and absorbs significant emotional energy. The resulting limb may be less functional than a prosthesis would have been.

Osteomyelitis may be the result of systemic disease or of open fractures. Cultures or biopsy can often be used to identify the infecting organism. Gas gangrene is a very serious infection due to the Clostridium species, often resulting in amputation. Clostridial myonecrosis infections develop rapidly, and patients present with symptoms of pain, sepsis, and delirium. Examination on palpation often reveals a brownish discharge and crepitation within the soft tissues.

Streptococcal myonecrosis infections develop more slowly than clostridial infections. Persons with diabetes mellitus often develop polymicrobial infections that involve anaerobic gas-forming gram-negative organisms.

Malignancies often manifest with pain. The patient is often referred for amputation following a workup for a tumor, after limb salvage is excluded as an option.

Congenital limb deficiencies and malformations are evident and are present since birth. With growth, functional difficulties and limitations develop that limit the patient's mobility.


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