title: Outcomes of neuroischemic wounds treated by a multidisciplinary amputation prevention service.
abstract: BACKGROUND
  Multidisciplinary amputation prevention teams decrease the frequency of major amputations by increasing the use of revascularization procedures and minor amputations. The outcomes of wound healing, wound recurrence, and ambulatory status are assumed to be improved but are not routinely reported. This study investigates the midterm outcomes of neuroischemic wounds treated by our multidisciplinary team.
  
  
  METHODS
  A retrospective review of patients with neuroischemic wounds treated at a single institution amputation prevention clinic from March 2012 to July 2013. Patient demographics, wound characteristics, procedural details, and clinical and functional outcomes were reviewed. Clinical end points under study included time to wound healing, reulceration rate, and ambulatory status.
  
  
  RESULTS
  Over 16 months, there were 202 new patients and 1,355 clinic visits. Ninety-one limbs from 89 patients were treated for complex neuroischemic wounds. In 67% (61 of 91) of limbs, wounds were present for >6 weeks before referral. A history of previous revascularization was present in 39% (31 of 91), and 28% (22 of 91) had a previous minor amputation. Forty-one percent of wounds (38 of 91) were limited to the toes or the forefoot whereas 24% (22 of 91) involved the hindfoot or ankle. A total of 151 podiatric and 86 vascular interventions were performed, with an equal distribution of endovascular and open revascularizations. Complete healing was observed for 59% of wounds (54 of 91) over the observation period (median follow up, 207 days; range 56-561 days), and the average time to full healing was 12 weeks. Hindfoot wounds were predictive of failure to heal (odds ratio, 0.21; P < 0.01; 95% confidence interval, 0.06-0.68). Nineteen percent of patients (17 of 91) developed a new wound in the ipsilateral leg during follow-up. Three major amputations were performed (2 below-knee amputation and 1 above-knee amputation) for a major/minor amputation ratio of 0.06. Ambulatory status was preserved or improved in 74% (67 of 91) of patients. The 30-day readmission rate was 11%, which was lower than that observed (21%) in a contemporaneous but all-inclusive population of lower extremity revascularization procedures performed at our institution.
  
  
  CONCLUSIONS
  Multidisciplinary limb salvage teams effectively heal wounds and maintain ambulatory status in patients with limb-threatening neuroischemic wounds. Patient specific factors, such as hindfoot or ankle wounds, can adversely influence the outcome. Even with aggressive care, healing can be prolonged and a substantial proportion of patients can be expected to have a recurrence, making subsequent surveillance mandatory. Our data also suggest that a coordinated amputation prevention program may help to minimize hospital readmissions in this high-risk population.
authors.affiliation: Center for Limb Preservation, University of California, San Francisco, San Francisco, CA. Electronic address: shant.vartanian@ucsfmedctr.org.
authors.forename: Shant M
authors.initials: SM
authors.lastname: Vartanian
authors.affiliation: Center for Limb Preservation, University of California, San Francisco, San Francisco, CA.
authors.forename: Kristin D
authors.initials: KD
authors.lastname: Robinson
authors.affiliation: Center for Limb Preservation, University of California, San Francisco, San Francisco, CA.
authors.forename: Kene
authors.initials: K
authors.lastname: Ofili
authors.affiliation: Center for Limb Preservation, University of California, San Francisco, San Francisco, CA.
authors.forename: Charles M
authors.initials: CM
authors.lastname: Eichler
authors.affiliation: Center for Limb Preservation, University of California, San Francisco, San Francisco, CA.
authors.forename: Jade S
authors.initials: JS
authors.lastname: Hiramoto
authors.affiliation: Center for Limb Preservation, University of California, San Francisco, San Francisco, CA.
authors.forename: Alex M
authors.initials: AM
authors.lastname: Reyzelman
authors.affiliation: Center for Limb Preservation, University of California, San Francisco, San Francisco, CA.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Conte
mesh_terms: D000368:Aged; D000671:Amputation, Surgical / Q000009:adverse effects / Q000191:economics / Q000379:methods*; D016009:Chi-Square Distribution; D003299:Cooperative Behavior; D005260:Female; D017721:Hospital Costs; D006801:Humans; D033183:Interdisciplinary Communication; D007511:Ischemia / Q000175:diagnosis / Q000191:economics / Q000601:surgery / Q000628:therapy*; D007871:Leg Ulcer / Q000175:diagnosis / Q000191:economics / Q000601:surgery / Q000628:therapy*; D023821:Limb Salvage / Q000009:adverse effects / Q000191:economics / Q000379:methods*; D016015:Logistic Models; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D051346:Mobility Limitation; D016017:Odds Ratio; D010348:Patient Care Team / Q000191:economics; D020127:Recovery of Function; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D012495:San Francisco; D013997:Time Factors; D016896:Treatment Outcome; D014945:Wound Healing