Below-Knee Amputation Failure and Poor Functional Outcomes Are Higher Than Predicted in Contemporary Practice
Below-Knee Amputation Failure and Poor Functional Outcomes Are Higher Than Predicted in Contemporary Practice
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DOI：
10.1177/1538574416682159
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发表时间：
2016-11-01
影响因子：
0.9
通讯作者：
Stone, David H.
中科院分区：
文献类型：
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作者：
Columbo, Jesse A.;Nolan, Brian W.;Stone, David H.
目的：必须仔细权衡膝下截肢术 (BKA) 的功能获益与潜在的重新干预的需要。本研究旨在探讨血管内时代接受 BKA 患者的当代临床和功能结果。方法：对2008年1月至2014年12月在同一三级医疗中心接受BKA的所有患者进行回顾性分析。记录人口统计学、合并症、行走状态和经皮血氧饱和度 (TcPO2) 值。研究终点包括免于转为膝上截肢 (AKA)、免于转为 AKA 或死亡、BKA 愈合和下床活动。进行统计建模以确定与 BKA 失败的关联。结果：在研究期间，120 名患者的 130 条肢体接受了 BKA。 65% 的患者进行了经皮血氧饱和度研究（n = 85）。所有 BKA 患者中有 38% (n = 46) 继续康复并下床行走。 25% (n = 33) 需要重新干预，其中 24 人需要转换为 AKA，9 人需要进行 BKA 修订。一年内未转为 AKA 的率为 76%，并且 TcPO2 水平较低的患者中转为 AKA 的几率有所降低（60% TcPO2 < 40 vs 81% TcPO2 >= 40；P - .04）。一年复合无转化为 AKA/死亡的率为 60%，并且在 TcPO2 读数较低的患者中下降（39% TcPO2 < 40 vs 69% TcPO2 >= 40；P = .01）。结论：尽管在大截肢时存在对膝关节挽救的功能偏见，但大多数患者术后未能下床活动。 TcPO2 水平降低（< 40 mm Hg）的患者 AKA 转化或死亡的风险高出 2 倍，而无论 TcPO2 水平如何，所有 BKA 患者中近四分之一的人都会遭受相同的命运。这表明，血管内时代的许多 BKA 患者在指数截肢时未能感受到膝关节挽救的益处。这些发现强调了在这个脆弱人群中仔细选择患者和建立共同决策模型的必要性。
Objective: The perceived functional benefit of below-knee amputation (BKA) must be carefully weighed against the need for potential reinterventions. This study sought to examine the contemporary clinical and functional outcomes of patients undergoing BKA in the endovascular era. Methods: All patients who underwent BKA from January 2008 to December 2014 at a single tertiary medical center were retrospectively reviewed. Demographics, comorbidities, ambulation status, and transcutaneous oximetry (TcPO2) values were recorded. Study end points included freedom from conversion to above-knee amputation (AKA), freedom from conversion to AKA or death, BKA healing, and ambulation. Statistical modeling was performed to determine associations with BKA failure. Results: Over the study interval, 130 limbs underwent BKA in 120 patients. Transcutaneous oximetry studies were obtained in 65% (n = 85). Thirty-eight percent (n = 46) of all BKA patients went on to heal and ambulate. Twenty-five percent (n = 33) required reintervention, 24 with conversion to AKA, and 9 with BKA revision. One-year freedom from conversion to AKA was 76% and was decreased among those with lower TcPO2 levels (60% TcPO2 < 40 vs 81% TcPO2 >= 40; P - .04). One-year composite freedom from conversion to AKA/death was 60% and was decreased among those with lower TcPO2 readings (39% TcPO2 < 40 vs 69% TcPO2 >= 40; P = .01). Conclusion: Despite a perceived functional bias toward knee salvage at the time of major amputation, most patients failed to postoperatively ambulate. Those with decreased TcPO2 levels (< 40 mm Hg) have a 2-fold higher risk of AKA conversion or death, while nearly one-fourth of all BKA patients will succumb to the same fate irrespective of TcPO2. This suggests that many BKA patients in the endovascular era fail to derive the perceived benefit of knee salvage at the time of their index amputation. These findings highlight the need for careful patient selection and for a shared decision-making model in this frail population.