Primary Partial Closure in Below-Knee Amputation for Diabetic Foot Disease: A Single-Arm Prospective Observational Study
DOI:
https://doi.org/10.61561/ssbgjms.v7i03.158Keywords:
Below-knee amputation, diabetic foot, primary partial closure, stump healing, surgical site infection, vascular surgeryAbstract
Background: Below-knee amputation (BKA) in advanced diabetic foot disease is often complicated by stump wound problems. The best closure strategy remains unresolved, and outcome data for primary partial closure (PPC), in which a dependent segment is left open for drainage, are sparse.
Objective: This study aims to describe wound-healing and short-term postoperative outcomes following primary partial closure in below-knee amputation for diabetic foot disease.
Methods: This single-arm prospective observational study was conducted at Ibrahim Cardiac Hospital & Research Institute, Dhaka, from January 2023 to December 2025. Sixty-four consecutive adults with type 2 diabetes (HbA1c ≤10%) undergoing non-emergency BKA all received PPC. Co-primary outcomes were complete healing within 90 days and time to healing. Secondary outcomes included surgical site infection (SSI), revision, re-amputation, systemic complications, hospital stay, and 30-day mortality.
Results: Mean age was 60.59 ± 10.42 years; 67.2% were male, and 92.2% were ASA III–IV. Two patients (3.1%) died within 30 days. Of 62 survivors at 90 days, 56 (90.3%) achieved complete healing, with a median time of 42 days (IQR 34–57). SSI occurred in 7.8%, stump revision in 7.8%, and above-knee re-amputation in 4.7%. At least one complication occurred in 18.8%. Mean hospital stay was 10.16 ± 4.83 days.
Conclusion: In this high-risk cohort, about nine in ten survivors healed within 90 days, with few conversions to above-knee amputations. Lacking a comparator and with wide confidence intervals, the study cannot establish superiority over other closure methods; comparative studies are needed.
References
1. I., S. K., & Pathak, A. L. (2024). Study of below knee amputation in patients with diabetic foot ulcer in a tertiary care centre in India . International Surgery Journal, 11(12), 2024–2029. https://doi.org/10.18203/2349-2902.isj20243463
2. Zhang Y, Lazzarini PA, McPhail SM, van Netten JJ, Armstrong DG, Pacella RE. Global disability burdens of diabetes-related lower-extremity complications in 1990 and 2016. Diabetes care. 2020 May 1;43(5):964-74.
3. Magliano DJ, Boyko EJ. IDF diabetes atlas.
4. Armstrong DG, Boulton AJ, Bus SA. Diabetic foot ulcers and their recurrence. New England Journal of Medicine. 2017 Jun 15;376(24):2367-75.
5. Viswanathan V, Kumpatla S. Pattern and causes of amputation in diabetic patients—a multicentric study from India. J Assoc Physicians India. 2011 Mar 1;59(3):148-51.
6. Swaminathan N, Awuah WA, Bharadwaj HR, Roy S, Ferreira T, Adebusoye FT, Ismail IF, Azeem S, Abdul‐Rahman T, Papadakis M. Early intervention and care for Diabetic Foot Ulcers in Low and Middle Income Countries: Addressing challenges and exploring future strategies: A narrative review. Health science reports. 2024 May;7(5):e2075.
7. Walicka M, Raczyńska M, Marcinkowska K, Lisicka I, Czaicki A, Wierzba W, Franek E. Amputations of lower limb in subjects with diabetes mellitus: reasons and 30‐day mortality. Journal of diabetes research. 2021;2021(1):8866126.
8. Cascini S, Agabiti N, Davoli M, Uccioli L, Meloni M, Giurato L, Marino C, Bargagli AM. Survival and factors predicting mortality after major and minor lower-extremity amputations among patients with diabetes: a population-based study using health information systems. BMJ open diabetes research & care. 2020 Jul;8(1):e001355.
9. Rehman ZU, Mudabbir RM, Ahmed SM, Sidddiqui NA. Outcomes of primary vs staged wound closure for major lower limb amputations in diabetic patients: A propensity score matched study. Pakistan Journal of Medical Sciences. 2026 Apr;42(411AASC):S77.
10. Cheun TJ, Jayakumar L, Sideman MJ, Ferrer L, Mitromaras C, Miserlis D, Davies MG. Short-term contemporary outcomes for staged versus primary lower limb amputation in diabetic foot disease. Journal of vascular surgery. 2020 Aug 1;72(2):658-66.
11. Katiyar AK, Agarwal H, Priyadarshini P, Kumar A, Kumar S, Gupta A, Mishra B, Aggarwal R, Soni KD, Mathur P, Sagar R. Primary vs delayed primary closure in patients undergoing lower limb amputation following trauma: A randomised control study. International Wound Journal. 2020 Apr;17(2):419-28.
12. Labeeq M, Tariq MA, Tung SA, Yar MA, Rehman W, Ehsan SB. The economic impact of lower extremity amputations in diabetics. A retrospective study from a tertiary care hospital of Faisalabad, Pakistan. A Retrospective Study From a Tertiary Care Hospital of Faisalabad, Pakistan (February 1, 2020). Labeeq M, Tariq MA, Tung SA, Yar MA, Rehman W, Ehsan SB. The Economic impact of lower extremity amputations in diabetics. A retrospective study from a tertiary care hospital of Faisalabad, Pakistan. Pak J Surg Med. 2020;1(1):18-22.
13. Nather A, Bee CS, Huak CY, Chew JL, Lin CB, Neo S, Sim EY. Epidemiology of diabetic foot problems and predictive factors for limb loss. Journal of Diabetes and its Complications. 2008 Mar 1;22(2):77-82.
14. Ngim NE, Ndifon WO, Udosen AM, Ikpeme IA, Isiwele E. Lower limb amputation in diabetic foot disease: experience in a tertiary hospital in southern Nigeria. Afr. J. Diabetes Med. 2012 May 1;13.
15. Ammar AS, Khalid R, Malik U, Zeb M, Abbas HM, Khattak SB. Predictors of lower limb amputations in patients with diabetic foot ulcers presenting to a tertiary care hospital of Pakistan. J Pak Med Assoc. 2021 Sep 1;71(9):2163-6.
16. Francia P, Gualdani E, Policardo L, Bocchi L, Franconi F, Francesconi P, Seghieri G. Mortality risk associated with diabetic foot complications in people with or without history of diabetic foot hospitalizations. Journal of Clinical Medicine. 2022 Apr 27;11(9):2454.
17. Wong KL, Nather A, Liang S, Chang Z, Wong TT, Lim CT. Clinical outcomes of below knee amputations in diabetic foot patients. Ann Acad Med Singapore. 2013 Aug 1;42(8):388-94.
18. Sailer M, Wergeland H, Randsborg PH. Implementation of a clinical pathway for diabetes‐related foot ulcers reduced the number of amputations and shortened hospital stay. Journal of Foot and Ankle Research. 2025 Mar;18(1):e70024.
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