FOREFOOT GANGRENE AND DISTAL BYPASS - SIM ULTANEOUS AMPUTATION

Patients presented for amputation mostly have chronic limb ischaemia c aused by atherosolerosis, with signs of severe arterial insufficiency including rest pain, non-healing skin lesions, ulceration or gangrene. Foot infections, especially in diabetic patients, are often multimicr obial, deeply invasive and frequently require aggressive measures, lik e debridement and drainage or partial open forefoot amputation in addi tion to broad-spectrum antibiotics, In patients with critical limb isc haemia and limited necrosis and forefoot gangrene, distal bypass surge ry is the treatment of choice. The main question is whether amputation should be performed simultaneously or in a secondary stage. Our own e xperience deals with 342 femorocrural and femoropedal bypass grafts fo r the treatment of critical limb ischaemia. The results showed no sign ificant difference in graft patency between crural and pedal grafts. C linical factors like diabetes mellitus, poor distal run-off and site o f the distal anastomosis had no adverse effect on the functioning and patency of the graft. In this series we found that in diabetic patient s significantly more amputations were required because of persistent f oot infection. Since in these patients amputation was performed in a s econdary stage, we changed our policy to simultaneous amputation. Afte r completion of the bypass, closure and coverage of all the wounds, th e gangrenous part is amputated. In case of deep, wet or infectious gan grene of the forefoot, an open transmetatarsal amputation is performed . Using this approach we have further increased limb-salvage and espec ially the number of usuable limbs.