Forefoot Amputation with Limb Revascularization: The Effects of Amputation, Timing, and Wound Closure on the Peripheral Vascular Bypass Graft Site

BACKGROUND: Much has been written about the effects of successful arterial bypass on forefoot surgery for ulceration and gangrene. This study examined the effects of the amputation site and timing on the arterial bypass graft site. METHODS: We reviewed the records of all patients who had successful vascular bypass graft surgery and amputation at our institution, between October, 1995 and May, 2002. Thirty-eight procedures in 35 patients fit the criteria and were included in the study. RESULTS: Thirty-five patients had successful vascular bypass graft surgery and forefoot amputation for gangrene or nonhealing ulceration. Three of these patients developed gangrene on the contralateral side and received similar treatment for that side. All of the wounds eventually healed. Healing time, rate of graft infection, and rate of wound dehiscence did not differ noticeably between patients with amputation immediately after arterial bypass and patients with amputation one or more days after arterial bypass. Infection at the bypass site occurred in two patients; their amputation sites were closed primarily. Wound dehiscence developed at the bypass site in one patient whose amputation site was closed by secondary intention. Although not statistically significant, the median healing time in patients treated with primary closure (37 days) was less than that in patients treated with closure by secondary intention (61 days; p = 0.09), and rates of graft infection and wound dehiscence did not differ between these two groups of patients. CONCLUSIONS: Amputation site wound closure may adversely affect the bypass graft, but results were not statistically significant. Treatment requires a closely coordinated team approach between the vascular surgeon and the orthopedic surgeon.