Skip to main content

Advertisement

SpringerLink
Log in

Minoramputationen bei diabetischem Fußsyndrom

Minor amputations for diabetic foot syndrome

  • Leitthema
  • Published:
Der Orthopäde Aims and scope Submit manuscript

Zusammenfassung

Bei neuroischämischen oder neuropathischen Läsionen im Rahmen des diabetischen Fußsyndroms (DFS) wird häufig eine „Minoramputation“ notwendig. Diese kann je nach Definition von der Zehenamputation bis zur Syme-Amputation reichen. Häufig ist sie mit einer Nekrosektomie oder einem Débridement kombiniert. Es soll dabei möglichst viel vitales Gewebe v. a. des Fußskeletts erhalten werden, um ein frühes und optimales Rehabilitationsergebnis zu ermöglichen („Grenzzonenamputation“). Die Minoramputation ist zur Verhinderung von aszendierenden Infektionen von vitaler Bedeutung. Die stationäre und ambulante Behandlungsdauer werden abgekürzt.

Minoramputationen sind nur bei ausreichender arterieller Durchblutung und guter Blutzuckereinstellung sinnvoll. Sie sollten nicht von Anfängern durchgeführt werden, das Amputationsausmaß sollte so sparsam wie möglich sein, und es muss sich eine strukturierte, interdisziplinäre postoperative Nachsorge anschließen. Kontroversen bestehen bezüglich folgender Aspekte: Verwendung eines Tourniquets, Entfernung oder Belassen von Gelenkknorpel, primärer Wundverschluss oder offene Amputation, Entfernung der Sesambeine, Platzhalterfunktion von Zehen, aseptische proximale Sehnendurchtrennung, postoperative Wundbehandlung, Vakuumversiegelungstherapie, Antibiotikatherapie. Vor dem Hintergrund dieser offenen Fragen werden die wichtigsten Minoramputationstechniken beschrieben und diskutiert.

Abstract

Minor amputations are frequently performed for neuroischemic or neuropathic lesions of the diabetic foot. Depending on the definition used, minor amputations can range from toe to Syme amputations. Minor amputations are often combined with necrosectomy and débridement. For early and optimal rehabilitation, as much vital tissue as possible should be conserved, especially considering the skeletal structures of the foot (borderline amputation). Minor amputations are of utmost importance for the prevention of ascending infections and reduce the duration of clinical and outpatient treatment.

Minor amputations should be performed only by experienced surgeons and only if arterial perfusion is sufficient. They should be as tissue-conserving as possible and structured interdisciplinary postoperative care is mandatory. Metabolic control should be optimized. Controversial opinions exist with respect to the use of tourniquets, conservation or resection of cartilage and sesamoid bones, open amputation or primary closure of the wound, interdigital spacer function of toes, aseptic proximal transection of tendons, postoperative wound care, negative-pressure wound treatment and antibiotic therapy. In view of these controversies the most important minor amputation techniques are described and discussed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2

Literatur

  1. Albrektsen SB, Henriksen BM, Hilstein PE (1997) Minor amputations on the feet after revascularization for gangrene. A consecutive series of 95 limbs. Acta Orthop Scand 68:291–293

    Article  CAS  PubMed  Google Scholar 

  2. Armstrong, DG, Lavery LA (2005) Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. Lancet 366:1704–1710

    Article  PubMed  Google Scholar 

  3. Armstrong DG, Rosales MA, Gashi A (2005) Efficacy of fifth metatarsal head resection for treatment of chronic diabetic foot ulceration. J Am Podiatr Med Assoc 95:353–356

    PubMed  Google Scholar 

  4. Apelquist J, Larsson J, Agadon CD (1993) Long-term prognosis for diabetic patients with foot ulcers. J Int Med Res 233:485–491

    Article  Google Scholar 

  5. Bauer H, Germann G, Gries FA et al (2007) Nationale VersorgungsLeitlinie Typ-2-Diabetes – Prävention und Therapie von Fußkomplikationen. Dtsch Ärztebl 104:591–598

    Google Scholar 

  6. Baumgartner R, Botta P (1995) Amputation und Prothesenversorgung der unteren Extremität, 2.Aufl. Enke, Stuttgart

  7. Bercelli SA, Chan AK, Pomposelli FB et al (1999) Efficacy of dorsal pedal artery bypass in limb salvage for ischemic heel ulcers. J Vasc Surg 30:499–508

    Article  Google Scholar 

  8. Blume PA, Walters J, Payne W et al (2007) Comparison of negative pressure wound therapy using vacuum-assisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcers. A multicenter randomized controlled trial. Diabetes Care 27:631–636

    Google Scholar 

  9. Brodsky JW (1993) Amputations of the foot and ankle. In: Mann RA, Coughlin MJ (eds) Surgery of the Foot and Ankle, 6th edn. Mosby, St. Louis, pp 959–990

  10. Brodsky JW, Chambers RB (1991) Effect of tourniquet use on amputation healing in diabetic and dysvascular patients. Perspect Orthop Surg 2:71–76

    Google Scholar 

  11. Calle-Pascual AL, Garcia-Torbe N, Moraga I et al (2001) Epidemiology of nontraumatic lower-extremity amputation in area 7, Madrid, between 1989 and 1999. A population-based study. Diabetes care 24:1686–1689

    Article  CAS  PubMed  Google Scholar 

  12. Castanzariti AR, Mendicino R, Haverstock B (2000) Ostectomy for diabetic neuroarthropathy involving the midfoot. J Foot Ankle Surg 39:291–300

    Article  Google Scholar 

  13. Chang BB, Brock DEM, Jacobs RL et al (1994) Increased limb salvage by the use of unconventional foot amputations. J Vasc Surg 19:341–349

    CAS  PubMed  Google Scholar 

  14. Chaturvedi N, Stevens LK, Fuller JH et al (2001) Risk factors, ethnic differences, and mortality associated with lower-extremity gangrene and amputation in diabetes. The WHO multinational study of vascular disease in diabetes. Diabetologia 44:65–71

    Article  Google Scholar 

  15. Dalla Paola L, Faglia E, Caminiti M et al (2003) Ulcer recurrence following first ray amputation in diabetic patients. Diabetes Care 26:1874–1878

    Article  Google Scholar 

  16. Durham JR, McCoy DM, Sawchuk AP et al (1989) Open transmetatarsal amputation in the treatment of severe foot infections. Am J Surg 158:127–13018

    Article  CAS  PubMed  Google Scholar 

  17. Eckardt A (2005) Operative Verfahren. In: Eckardt A, Lobmann R (Hrsg) Der diabetische Fuß. Springer, Berlin Heidelberg New York, S 126–147

  18. Fry DE, Marek JM, Langsfeld M (1998) Infection in the ischemic lower extremity. Surg Clin North Am 78:465–479

    Article  CAS  PubMed  Google Scholar 

  19. Frykberg RG, Abraham S, Tierney E, Hall J (2007) Syme amputation for limb salvage: early experience with 26 cases. J Foot Ankle Surg 46:93–100

    Article  PubMed  Google Scholar 

  20. Giurini JM, Basile P, Chrzan JS et al (1993) Panmetatarsal head resection. A viable alternative to the transmetatarsal amputation. J Am Podiatr Med Assoc 83:101–107

    CAS  PubMed  Google Scholar 

  21. Gooden MA, Gentile AT, Mills JL et al (1997) Free tissue transfer to extend the limits of limb salvage for lower extremity tissue loss. Am J Surg 174:644–649

    Article  CAS  PubMed  Google Scholar 

  22. Greitemann B (1999) Der diabetische Fuß: Ursachen – Prophylaxe – konservative und operative Therapie. In: Reike H (Hrsg) Diabetisches Fuß-Syndrom. DeGruyter, Berlin, S 165–182

  23. Griffiths GD, Wieman TJ (1990) Metatarsal head resection for diabetic foot ulcers. Arch Surg 125:832–835

    CAS  PubMed  Google Scholar 

  24. Hachmöller A (2007) Ergebnisse der Minoramputation am diabetischen Fuß in Relation zur Knochenhistologie: eine klinische Bestandsaufnahme. Zentralbl Chir 132:491–496

    Article  PubMed  Google Scholar 

  25. Heller G, Günster C, Swart E (2005) Über die Häufigkeit von Amputationen unterer Extremitäten in Deutschland. Dtsch Med Wochenschr 130:1698–1790

    Article  Google Scholar 

  26. Hepp W (1996) Minoramputationen beim diabetischen Fuß. In: Hepp W (Hrsg) Der diabetische Fuß. Blackwell, Oxford, S 152–160

  27. Hinchliffe RJ, Valk GD, Apelquist J et al (2008) A systematic review of the effectiveness of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev 24:119–144

    Article  Google Scholar 

  28. Holstein P, Ellitsgaard N, Olsen BB, Ellitsgaard V (2000) Decreasing incidence of major amputations in people with diabetes. Diabetologia 43:844–847

    Article  CAS  PubMed  Google Scholar 

  29. Jeffcoate WJ (2005) The incidence of Amputation in Diabetes. Acta Chir Belg 105:140–144

    CAS  PubMed  Google Scholar 

  30. Jeffcoate WJ, van Houtum WH (2004) Amputation as a marker of the quality of foot care in diabetes. Diabetologia 47:2051–2058

    Article  CAS  PubMed  Google Scholar 

  31. Jung V (1996) Fuß-Erhalt bei diabetischer Gangrän. Zentralbl Chir 121:387–393

    CAS  PubMed  Google Scholar 

  32. Kraus O, Neufang A, Eckardt A et al (2002) Interdisziplinäre Diagnostik und Therapie des ischämisch-osteomyelitischen Fußsyndroms. Med Klin 97:244–255

    Article  Google Scholar 

  33. Largiadèr J, Brunner UV (1982) Ischämiebedingte Amputationen am Fuß. In: Brunner U (Hrsg) Der Fuß. Huber, Bern, S 130–144

  34. Lepäntalo M, Biancari F, Tukiarinen E (2000) Never amputate without consultation of a vascular surgeon. Diabetes Metab Res Rev 16:27–32

    Article  Google Scholar 

  35. McIntyre KE (1987) Control of infection in the diabetic foot: The role of microbiology, immunopathology, antibiotics, and guillotine amputation. J Vasc Surg 5:787–790

    Article  CAS  PubMed  Google Scholar 

  36. Miller N, Dardik H, Wolodiger F et al (1991) Transmetatarsal amputation: The role of adjunctive revascularization. J Vasc Surg 13:705–711

    Article  CAS  PubMed  Google Scholar 

  37. Mueller MJ, Sinacore DR, Kent Hastings M et al (2003) Effect of achilles tendon lengthening on neuropathic plantar ulcers. J Bone Joint Surg Am 85:1436–1445

    PubMed  Google Scholar 

  38. Murdoch DP, Armstrong DG, Dacus JB et al (1997) The natural history of great toe amputation. J Foot Ankle Surg 36:204–208

    Article  CAS  PubMed  Google Scholar 

  39. Nehler MR, Whitehill TA, Bowers SP et al (1999) Intermediate-term outcome of primary digit amputations in patients with diabetes mellitus who have forefoot sepsis requiring hospitalization and presumed adequate circulatory status. J Vasc Surg 30:509–517

    Article  CAS  PubMed  Google Scholar 

  40. Norgren L, Hiatt WR, Dormandy JA et al (2007) Inter-society consensus for the management of peripheral arterial disease (TASC II). Eur J Vasc Endovasc Surg 33(Suppl 1):24

    Article  Google Scholar 

  41. Orendurff MS, Rohr ES, Sangeorzan BJ et al (2006) An equinus deformity of the ankle accounts for only a small amount of the increased forefoot plantar pressure in patients with diabetes. J Bone Joint Surg Br 88:65–68

    CAS  PubMed  Google Scholar 

  42. Patel VG, Wieman TJ (1994) Effect of metatarsal head resection for diabetic foot ulcers on the dynamic plantar pressure distribution. Am J Surg 167:297–301

    Article  CAS  PubMed  Google Scholar 

  43. Peters E, Childs MR, Wunderlich RP et al (2001) Functional status of persons with diabetes-related lower-extremity amputations. Diabetes Care 1799–1804

  44. Pittet D, Wyssa B, Herter-Clavel C et al (1999) Outcome of diabetic foot infections treated conservatively. Arch Intern Med 159:851–856

    Article  CAS  PubMed  Google Scholar 

  45. Porter JM (2001) The Year Book of Vascular Surgery 2001. Mosby, St. Louis, pp 317

  46. Prompers L, Huijberts M, Apelquist J et al (2008) Delivery of care to diabetic patients with foot ulcers in daily practice: results of the Eurodiale Study, a prospective cohort study. Diabet Med 25:700–707

    Article  CAS  PubMed  Google Scholar 

  47. Rademacher T (1999) Septische Knochenchirurgie am neuropathischen diabetischen Vorfuß – Nutzen und Risiken. Akt Chir 32:101–103

    Google Scholar 

  48. Rauner MS, Heidenberger K, Pesendorfer EM (2005) Model-based evaluation of diebetic foot prevention strategies in Austria. Health Care Manag Sci 8:253–265

    Article  PubMed  Google Scholar 

  49. Rogers LC, Bevilacqua NJ, Frykberg RG, Armstrong DG (2007) Predictors of postoperative complications of Ilizarov external ring fixators in the foot and ankle. J Foot Ankle Surg 46:372–375

    Article  PubMed  Google Scholar 

  50. Rümenapf G (2003) Grenzzonenamputation bei Diabetikern – offene Fragen und kritische Bewertung. Zentralbl Chir 128:726–733

    Article  PubMed  Google Scholar 

  51. Sämann A, Tajiyeva O, Müller N et al (2008) Prevalence of the diabetic foot syndrome at the primary care level in Germany: a cross-sectional study. Diabet Med 25:557–563

    Article  PubMed  Google Scholar 

  52. Senneville E, Morant H, Descamps D et al (2009) Needle puncture and transcutaneous bone biopsy cultures are inconsistent in patients with diabetes and suspected osteomyelitis of the foot. Clin Infect Dis 48:888–893

    Article  PubMed  Google Scholar 

  53. Stone PA, Back MR, Armstrong PA et al (2005) Midfoot amputations expand limb salvage rates for diabetic foot infections. Ann Vasc Surg 19:805–811

    Article  PubMed  Google Scholar 

  54. Towne JB (1990) Discussion. Arch Surg 125:835

    Google Scholar 

  55. Tseng CL, Helmer D, Rajan M et al (2007) Evaluation of regional variation in total, major, and minor amputation rates in a national health-care system. Int J Qual Health Care 19:368–376

    Article  PubMed  Google Scholar 

  56. Toursarkissian B, Hagino RT, Khan K et al (2005) Healing of transmetatarsal amputation in the diabetic patient: is angiography predictive? Ann Vasc Surg 19:769–773

    Article  PubMed  Google Scholar 

  57. IQWIG (2006) Vakuumversiegelungstherapie von Wunden. Abschlussbericht Auftrag N04-03 v.13.03.2006. IQWIG-Berichte 2006 Nr.4. IQWIG, Köln

  58. Vollmar J (1996) Rekonstruktive Chirurgie der Arterien, 4.Aufl. Thieme, Stuttgart

Download references

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

  1. Oberrheinisches Gefäßzentrum Speyer-Mannheim, Klinik für Gefäßchirurgie, Diakonissen-Stiftungs-Krankenhaus, Hilgardstraße 26, 67346, Speyer, Deutschland

    G. Rümenapf

  2. Abteilung für Gefäßchirurgie, Chirurgische Universitätsklinik, Erlangen-Nürnberg, Deutschland

    W. Lang

  3. Abteilung für Diabetologie und Angiologie, Marienkrankenhaus gGmbH, Soest, Deutschland

    S. Morbach

Authors
  1. G. Rümenapf
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. W. Lang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. S. Morbach
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to G. Rümenapf.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Rümenapf, G., Lang, W. & Morbach, S. Minoramputationen bei diabetischem Fußsyndrom. Orthopäde 38, 1160–1170 (2009). https://doi.org/10.1007/s00132-009-1502-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00132-009-1502-y

Schlüsselwörter

Keywords

Search

Navigation