Foot Ulceration in the Immosuppressed Population: Surgeon Beware!

Background: Over the past 3 decades, advances in transplant surgery has allowed life-saving renewal of solid organ function. Many of these patients are predisposed to the development of lower extremity wounds. There is a paucity of data describing treatment, utilization, and outcomes of this complex patient population.

Purpose: The purpose of this study is to examine the surgical outcomes of these patients and overall limb salvage rates in a tertiary care center with a multi-disciplinary team focused on limb salvage. 

Methods: Medical records were reviewed for all patients who presented with a foot wound and functioning solid organ transplant who received surgery (including debridement or toe/foot/limb amputation) at our institution from 2010-2017.

Results: Fifty-nine patients were identified, 40 with a kidney transplant (KTx), 13 with combined kidney-pancreas transplant (KPTx), and 6 with a liver transplant (LTx). The average solid organ transplant patient received 6.5 (±4.8) procedures during the follow-up period (46mos, 6.8-149.4). Thirty-two patients (54.2%) required toe amputations, 15/32 (46.9%) of these healed, 14/32 (43.8%) progressed to a midfoot amputation, and 8/32 (25%) progressed to a below-knee amputation (BKA). Of patients with hind foot wounds 11/15 (73.3%) required calcanectomy, of these 7/11 (63.6%) progressed to a below-knee amputation. Overall, there were 19/59 (32.2%) patients which required below knee amputations, including the 15 which progressed from lesser procedures; two of the nineteen patients requiring BKA progressed to an above knee amputation.

Conclusions: This retrospective study highlights the morbidity associated with foot ulceration in the immunosuppressed patient population with an overall BKA rate of 32.2%. Solid organ transplant patients who develop lower extremity wounds require a high level of surgical care. A large proportion of these patients will eventually require a major lower extremity amputation. Further research is needed to develop more effective strategies to salvage the lower extremity in the immunosuppressed patient.