Revision Surgery of Major Limb Amputations, Indications, Surgical Management and Outcome

Abstract

Background: The rate of revision following major limp amputations remains high despite the availability of a variety of methods to select amputation level. The purpose of this study was to outline the common indications, surgical management and outcome of revision surgery of major limb amputations in Khartoum teaching hospital, and to compare our experience with that of other published data. Methods: This is a prospective cross sectional hospital based study conducted in Khartoum teaching hospital (KTH) during the period November 2012 to January 2014. Results: A total of 62 patients required revision surgery for their major limb amputation were entered into the study. Their ageranged between 3-90 years with mean age of 47.35 years and standard deviation of 19.06 years. Males outnumbered females by a ratio of 2.8:1. Diabetes found in 34 patients (54.8%), hypertension in 22 (35.5%), and 8 patients (12.9%) had other comorbid diseases including cardiovascular disease and renal impairment. The most common cause of initial amputation was diabetes related sepsis (46.8%), followed by trauma (32.3%) and peripheral vascular disease (17.7%). Lower limbs were involved in 75.8% of cases and upper limbs in 24.2% of cases giving a lower limb to upper limb ratio of 3.12:1. Below knee amputation was the most common level performed (54.8%). There was one bilateral lower limb amputation. Most of the revision surgeries performed in the first six weeks after the amputation (87.7%). The most common indication for revision surgery was wound infection (53.2%). Other more frequent indications include prominent bone (19.4%), stump necrosis (11.3%), and fissuring & ulceration (9.7%). Less frequent indications include painful neuroma (3.2%) and prosthesis unfitting (3.2%). The most common revision procedures performed was wound debridement & secondary suture (25.8%), followed by skin grafting (22.6%), wedge resection (16.1%), muscle flap (9.7%), and excision of neuroma (3.2%). Reamputation was required in 14 patients (22.6%). Staged operations were required in 25 of patients (40.3%). Complete relieve of the complication that required revision was achieved in 51 patients (82.26%) and partial relieve in 11 patients (17.74%). The length of hospital stay ranged between 14 and 35 days with mean of 21.35 days and standard deviation of 4.88 days. The perioperative mortality rate was 12.9%. Conclusion: Revision surgery is necessary if the primary amputation fails to heal, or the residual limb is unsatisfactory for prosthetic fitting. In our study diabetes related sepsis and peripheral vascular disease were the most common cause of initial amputation, and the commonest indication for revision was wound infection. Revision surgery had good outcome in our study. Better education, more research, and additional refinement of surgical technique are needed to avoid unnecessary revision surgery.