PubMedDate not supplied
Gangrene is the usual reason for admission to a surgical unit in elderly patients with peripheral vascular disease. It is often the first sign of arterial disease occurring in a foot with satisfactory skin and may be triggered off by trauma or infection. Obstruction at various levels of the profunda femoris artery, of the main leg arteries with calcification of the media, are the usual characteristics, whether the patient is diabetic or not. This explains why reconstructive vascular surgery is rarely possible but this, nevertheless, remains the best chance for obtaining healing of trophic disorders with limited removal of the toes. No failure was observed in cases of axillo-femoral or femoro-femoral by-pass. But, as in diabetics, one may, in elderly patients with gangrene, attempt to conserve weight-bearing areas thanks to medical treatment in association in some cases with lumbar sympathectomy when the patient's general condition makes this possible. The mortality is low when patients are selected for operation and depending on the surgical technique adopted, e.g. sub-cutaneous by-pass or surgery of the origin of the profunda femoris. The mortality is less than 7 p. 100 during the first month (one death in 31 vascular operations, one death in 40 sympathectomies), but the mortality during the first 6 months exceeds 20 p. 100 due to cardiac, or cerebral complications or urinary infection. The prevention of digestive symptoms, nutritional, renal or urinary complications, and electrolyte disturbances is essential together with physiotherapy and reduction in time spent in hospital, for example, the patient may be sent home and treated by the district nurse. 135 patients with arteritis, including 48 diabetics, aged over 70 years, admitted to hospital in 1971 at the Saint-Joseph hospital, illustrate these findings. 109 patients with 114 diseased limbs, had gangrene or ischemic ulcer. Out of 80 survivors, beyond 6 months, i.e. 84 limbs, in 75 cases the weight bearing areas were preserved, in 9 cases amputation was necessary but in 8 of these it was possible to carry out amputation below the knee and walking was possible. These functional results justify attempts to maintain weight bearing areas or, at least, the knee, whatever the duration of healing or amputation of a toe or of the metatarsus; in Syme's amputation of the leg, healing requires 2 to 4 months.