Delayed Closure Is Associated with Decreased Infection Rate in Amputations after Trauma

Amputations associated with trauma carry significant morbidity in addition to risk of limb loss due to tissue damage, contamination, and risk of infection. The timing of formal amputation closure in this situation varies among surgeons, with some allowing the wound to remain open for some time after debridement, whereas others perform formal amputation and closure at the index operation if debridement is adequate. The presence of infection after closure of an amputation has the potential to result in a higher amputation (i.e., a below-knee amputation to an above-knee amputation). Our goal was to examine the relationship of timing of closure to stump infection and eventual level of amputation. A review was performed of all patients admitted to a Level I trauma center over a six-year period with amputations during the initial admission after trauma. Amputations of either an arm (above or below the elbow) or a leg (above or below the knee) were included. The number of days between adequate debridement as judged by the operating surgeon and closure of the amputation and whether there was an infection after closure were evaluated. Also investigated was the relationship between infection after closure and a higher level of amputation. Between January 1, 2010, and December 31, 2015, 63 patients (ages 15-81 years, mean age 45.1 ± 18.4) underwent an amputation of a leg or an arm. Fifty-four were male, nine were female, the mean injury severity score was 20.9 ± 10.4, and the mean lactate level at admission was 3.4 ± 1.7. Of the 63 patients, 53 patients had an amputation of a leg and 10 had an amputation of an arm. The overall infection rate was 32 per cent, and the mean time until closure was 6.7 ± 11.1 days. Comparing closure times in those with and without infection after closure, the mean intervals were 3.1 ± 9.7 and 8.4 ± 11.4 days, respectively (P = 0.01). The receiver operating characteristic curve c-statistic was 0.69 (P = 0.04). Sensitivity of various times to closure for avoiding infection was examined and was optimized at five days with infection rates above five days of 5.3 per cent versus at or below five days to closure of 43.2 per cent (P = 0.0029). Infection resulted in a higher level of amputation in 40 per cent of those who had an infection. Based on these data, delay in closure of an amputation even after debridement appears adequate was associated with a lower rate of infection and the presence of infection resulted in a higher amputation level in more than a third of studied patients. Delay of formal amputation closure for at least five days after adequate debridement is acheived is associated with a significantly reduced rate of infection.