Risk Factors for Early Failure of Surgical Amputations: An Analysis of 8,878 Isolated Lower Extremity Amputation Procedures

Exploring the Relationship Between SVS WIfI and IWGDF Scoring Systems and Reamputation Risk in Patients With Diabetic Foot and Peripheral Artery Disease

Determining the optimal amputation level in diabetic foot (DF) and peripheral artery disease (PAD) patients is crucial for minimizing reamputation risk while preserving functionality. The Society for Vascular Surgery Wound, Ischemia, and Foot Infection (SVS WIfI) and International Working Group on Diabetic Foot (IWGDF) scoring systems are widely used for risk stratification, but their predictive value for reamputation remains unclear. The current study aimed to evaluate the predictive utility of these scoring systems for reamputation risk in patients undergoing amputations due to DF or PAD. A retrospective cohort study was conducted on 108 patients who underwent unilateral amputations due to DF or PAD between 2016 and 2021. Patients were categorized based on WIfI and IWGDF classifications, and clinical outcomes, including reamputation rates, ICU admissions, and mortality, were analyzed using logistic regression and post hoc analyses. Reamputation occurred in 41 (38%) patients. Higher WIfI (OR: 3.85, 95% CI: 2.10-7.05, P = .001) and severe IWGDF scores (OR: 3.25, 95% CI: 1.80-5.88, P = .008) significantly correlated with increased reamputation risk. Patients with high-risk scores also exhibited higher ICU admission (P = .03) and mortality rates (P = .01). Male gender (OR: 3.47, 95% CI: 1.45-8.31, P = .005), diabetes (OR: 2.32, 95% CI: 1.10-4.90, P = .027), and prolonged hospitalization (OR: 1.04, 95% CI: 1.01-1.08, P = .021) were independent predictors, while above-ankle amputations were protective for reamputation (OR: 0.22, 95% CI: 0.11-0.43, P < .001). Both scoring systems are effective in predicting reamputation risk, with WIfI providing a more comprehensive risk assessment. Combining these tools may enhance decision-making and improve patient outcomes in terms of reamputation prevention, hospital stay, ICU admission, and mortality.

Risk factors for failed below knee amputation in patients with diabetes

Complications from below knee amputations (BKA), such as wound dehiscence and infections, incur high healthcare costs due to multiple and extended hospitalizations. Due to the significant morbidity still associated with proximal amputations, a careful patient selection process should be considered. This retrospective cohort study aimed to identify risk factors associated with failure of below-knee amputation (BKA), defined as progression to above-knee amputation (AKA), in patients with diabetes. Eligible patients were those who underwent primary BKA due to diabetic complications. Patients were divided into two groups: BKA and failed BKA group. Demographic variables were age, gender, BMI, smoking status, presence of vascular disease, dialysis status, nutritional status, pre-surgery hemoglobin, hemoglobin A1c, culture biopsies and use of antibiotics. Outcome variables included failure (i.e., above-knee amputation) and time to failure. Variables associated with failure of BKA included higher hemoglobin levels, prior vascular procedures, smoking, and perioperative use of oral antibiotics. Notably, oral antibiotics were linked to a higher risk of BKA failure, with patients on oral antibiotics experiencing failure more quickly than those treated with intravenous antibiotics. In addition, in the BKA group, there was a lower percentage of patients treated with PO antibiotics compared to the failed BKA group, 12 % and 19 %, respectively (P = 0.0037). This study highlights that prior vascular procedures and smoking also elevate the risk of BKA failure.

[Translated article] Reamputation prevalence after minor feet amputations in patients with diabetic foot: A cross sectional study

INTRODUCTION

Reported prevalence for reamputation in diabetic foot is diverse, risk factors are not clear for minor amputations. This study aims to determine the prevalence for reamputation in diabetic foot from minor amputations and to evaluate associated factors for such outcome.

METHODS

Cross sectional study developed in 2 hospitals. Patients hospitalized for diabetic foot ulcer requiring a minor amputation were included. A descriptive analysis of all variables is presented, as well as prevalence ratios (PR) and a multivariate logistic regression.

RESULTS

The prevalence was of 48% for 15 years. Toes were the most frequent minor amputation that required reamputation and above the knee amputation was the most frequent reamputation level (45%). Variables whose PR was associated to reamputation risk were: smoking history (PR 1.32, CI 95%: 1.02-1.67, p=0.03), vascular occlusion in doppler (PR 1.47, CI 95%: 1.11-1.73, p=0.01), revascularization (PR 1.73, CI 95%: 1.31-2.14, p=0.00002), Wagner>3 (PR 1.75, CI 95%: 1.16-1.84, p=0.01) and leucocytosis>11,000 (PR 1.39, CI 95%: 1.07-1.68, p=0.01). Leucocytosis>11,000, Wagner>3, vascular occlusion in doppler and revascularization were the variables that best predicted the outcome. Furthermore, leucocytosis was the best variable for predicting reamputation (OR 2.4, CI 95%: 1.1-5.6, p=0.04).

CONCLUSIONS

Reamputation prevalence was 48%. The toes were the minor amputation more frequently requiring reamputation and above the knee was the most frequent reamputation level. Risk for reamputation was associated with variables related to vascular compromise and infection.

Reamputation Rate, Mortality, and the Incidence of Risk Factors for Ipsilateral Reamputation Among Patients with Dysvascular Major Lower Limb Amputation

BACKGROUND

A major lower limb amputation (LLA) for dysvascular disease carries the risk of disturbed wound healing necessitating reamputation at a higher level. A reamputation causes a delay in prosthetic fitting and recovery of walking ability. The combination of a prolonged open wound and inability to walk can worsen the physical and psychological situation. Prevention of reamputation seems therefore important. This study aims to identify risk factors for reamputation, and to evaluate a possible altered mortality rate after a dysvascular major LLA. These issues are crucial for shared decision-making prior to surgery.

METHODS

Retrospective study investigating a Dutch regional cohort of patients with a dysvascular below-knee, through-knee, or above-knee LLA.

RESULTS

Five hundred sixteen dysvascular major LLAs were included (2014-2018). One hundred reamputations were performed within 1 year after initial amputation (19.4%). Risk factors for ipsilateral reamputation were diabetes mellitus, lipid-lowering drugs usage, and lower level of amputation (P ≤ 0.01, 0.037, and < 0.01, respectively). The 30-day mortality rates were 1% and 12% for the reamputation group and the nonreamputation group, respectively (P ≤ 0.01). The 1-year mortality rates were 23% and 27% for the reamputation group and the nonreamputation group, respectively (P = 0.423).

CONCLUSIONS

Ipsilateral reamputation within 1 year after initial amputation is common. Several risk factors for reamputation were identified. The 30-day and 1-year mortality rate is high, but not significantly different after 1 year. A clinical decision tool for dysvascular patients needs to be developed to improve shared decision-making, reduce reamputation rates, and improve survival.

Reamputation prevalence after minor feet amputations in patients with diabetic foot, a cross sectional study

INTRODUCTION

Reported prevalence for reamputation in diabetic foot is diverse, risk factors are not clear for minor amputations. This study aims to determine the prevalence for reamputation in diabetic foot from minor amputations and to evaluate associated factors for such outcome.

METHODS

Cross sectional study developed in 2hospitals. Patients hospitalized for diabetic foot ulcer requiring a minor amputation were included. A descriptive analysis of all variables is presented, as well as prevalence ratios (PR) and a multivariate logistic regression.

RESULTS

The prevalence was of 48% for 15 years. Toes were the most frequent minor amputation that required reamputation and above the knee amputation was the most frequent reamputation level (45%). Variables whose PR was associated to reamputation risk were: smoking history (PR 1.32, CI 95%: 1.02-1.67, P=0.03), vascular occlusion in doppler (PR 1.47, CI 95%: 1.11-1.73, P=0.01), revascularization (PR 1.73, CI 95%: 1.31-2.14, P=0.00002), Wagner> 3 (PR 1.75, CI 95%: 1.16-1.84, P=0.01) and leucocytosis> 11,000 (PR 1.39, CI 95%: 1.07-1.68, P=0.01). Leucocytosis> 11,000, Wagner> 3, vascular occlusion in doppler and revascularization were the variables that best predicted the outcome. Furthermore, leucocytosis was the best variable for predicting reamputation (OR 2.4, CI 95%: 1.1-5.6, P=0.04).

CONCLUSIONS

Reamputation prevalence was 48%. The toes were the minor amputation more frequently requiring reamputation and above the knee was the most frequent reamputation level. Risk for reamputation was associated with variables related to vascular compromise and infection.

High mortality rate and restricted mobility in above knee amputation following periprosthetic joint infection after total knee arthroplasty: A systematic review

PURPOSE

To systematically review the literature on the outcomes of above knee amputation as a salvage procedure after periprosthetic joint infection in total knee arthroplasty.

METHODS

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Medline, Scopus, Web of Science, and Embase electronic databases were utilized to identify all studies evaluating clinical outcomes of patients with above knee amputation following PJI from inception to June 24, 2023. Studies were excluded for failure to report functional outcomes specifically related to AKA in PJI following TKA, utilizing surgical interventions other than amputation, AKA indicated for other reasons than PJI, technical studies, conference abstracts, case reports and non-English language. The quality of studies was assessed with the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

Seven retrospective studies, categorized as Therapeutic Level III evidence, were analyzed, involving a total of 188 patients who underwent AKA following PJI after TKA. The findings consistently indicate that post-AKA, patients experienced a notable decline in their level of independence and reported worsening ambulatory status. Infection and wound complications were common post-AKA, leading to revision surgeries, while the mortality rate ranged from 9 to 50% in the included studies. Polymicrobial organisms were frequently found in pre-AKA PJI, with MRSA being a common causative organism.

CONCLUSIONS

AKA due to PJI following TKA is associated with restricted mobility and high mortality rate. Polymicrobial infections and MRSA were identified as common infecting organisms, emphasizing the complexities and challenges associated with managing these infections. The reported functional outcomes, ambulatory status, complications, reoperations, and mortality rates highlight the importance of providing comprehensive, individualized care to these patients.

Risk factors and predictors of prolonged hospital stay in the clinical course of major amputations of the upper and lower extremity a retrospective analysis of a level 1-trauma center

PURPOSE

The objective was to analyze the treatment and complications of the patients after a major amputation of the upper and lower extremities. Risk factors and predictors of a prolonged hospital stay should be outlined.

METHODS

This is a retrospective study of a national Level-1 Trauma center in Germany. In a 10-year period, patients were identified by major amputations in the upper and lower extremities. The medical reports were considered and the results were split into four main groups with analysis on basic-, clinical data, the course on intensive care unit and the outcome. A recovery index was established. The patients' degree of recovery was summed up. Statistical analysis was performed.

RESULTS

81 patients were included. A total of 39 (48.1%) major amputations were carried out on the lower leg and 34 (42.0%) involved the thigh. There were two instances (2.5%) of hip joint disarticulation. 6 major amputations were done on the upper extremities (n = 3 on the upper arm, n = 3 on the forearm). 13.83 ± 17.10 days elapsed between hospital admission and major amputation. The average length of hospital stay was 38.49 ± 26,75 days with 5.06 ± 11.27 days on intensive care unit. Most of the patients were discharged home followed by rehabilitation. A significant correlation was found between the hospital length of stay and the increasing number of operations performed (p = 0.001). The correlation between the hospital length of stay and the CRP level after amputation was significant (p = 0.003).

CONCLUSIONS

Major amputations in trauma patients lead to a prolonged stay in hospital due to severe diseases and complications. Especially infections and surgical revisions cause such lengthenings.

Predicting Functional Outcomes Following Dysvascular Lower Limb Amputation: An Evidence Review of Personalizing Patient Outcomes

Most research on people undergoing lower limb amputations for dysvascular disease summarizes average patient outcome risks and average associations between patient factors and these outcomes. More recently, the importance of predicting patient-specific outcomes based on individual factors (ie, personalized rehabilitation) has become evident. This article reviews the evidence and discusses the importance of the following: (1) predicting outcomes to facilitate amputation-level and prosthesis prescription decisions and (2) how prediction models can be leveraged to develop decision support tools to facilitate provider/patient shared decision-making to ensure decisions considering each individual patient's priorities and preferences. Examples of these tools are discussed and referenced.

Effectiveness of Risk Analysis Index Frailty Scores as a Predictor of Adverse Outcomes in Lower Extremity Reconstruction

BACKGROUND

 The rising clinical importance of assessing frailty is driven by its predictive capability for postoperative outcomes. This study assesses the effectiveness of RAI-rev (Revised Risk Analysis Index) in predicting adverse outcomes in lower extremity (LE) flap reconstruction.

METHODS

 Analyzing NSQIP (National Surgical Quality Improvement Program) data from 2015 to 2020, we compared demographics, perioperative factors, and 30-day outcomes in all locoregional and free-flap cases. Frailty scores, calculated using RAI-rev, were categorized with <15 as nonfrail and >35 as the most frail. Adjusted odds ratios (aORs) for specific complications were calculated using nonfrail as the reference group. Frailty scores in locoregional flaps were compared with those in free flaps.

RESULTS

 We identified 270 locoregional and 107 free-flap cases. Higher RAI-rev scores in locoregional flaps correlated with increased complications, such as deep surgical site infection (1% nonfrail vs. 20% RAI 31-35), stroke (0% nonfrail vs. 17% most frail), and mortality (0% nonfrail vs. 17% most frail). Locoregional flap cases with RAI-rev scores in the most frail group had a significantly elevated aOR for stroke (51.0, 95% confidence interval [CI]: 1.8-1402.5, p = 0.02), mortality (43.1, 95% CI: 1.6-1167.6, p = 0.03), and any complication (6.8, 95% CI: 1.2-37.4, p = 0.03). In free-flap cases, higher RAI-rev scores were associated with increased complications, with only sepsis showing a statistically significant difference (6% nonfrail vs. 100% most frail; aOR: 42.3, CI: 1.45-1245.3, p = 0.03). Free-flap cases had a significantly lower RAI-rev score compared with locoregional flap cases (14.91 vs. 17.64, p = 0.01).

CONCLUSION

 Elevated RAI-rev scores (>35) correlated with more complications in locoregional flaps, while free-flap reconstruction patients had generally low RAI-rev scores. This suggests that free flaps are less commonly recommended for presumed higher risk patients. The study demonstrates that RAI-rev may be able to serve as a risk calculator in LE reconstruction, aiding in the assessment of candidates for limb salvage versus amputation.

Above-ankle Reamputation and Mortality following Transmetatarsal Amputation in Diabetic and Nondiabetic Peripheral Artery Disease

The risk of above-ankle reamputation following a transmetatarsal amputation is around 30%. Patient selection may be crucial to achieve good outcomes, and to avoid futile operations and suffering. We are aware of no previous comparison between the two largest patient groups that undergo lower extremity amputations: patients with diabetes, and patients with non-diabetic peripheral artery disease. Patients with diabetes or nondiabetic peripheral artery disease who had undergone a transmetatarsal amputation from 2004 to 2018 at our institution were included. Patient characteristics and perioperative details were analyzed retrospectively. Subjects with diabetes were compared with subjects with nondiabetic peripheral artery disease regarding above-ankle reamputation, reamputation level, and mortality. Five-hundred-and-sixty transmetatarsal amputations in 513 subjects were included. The majority of transmetatarsal amputations (86%) occurred in diabetic subjects. Subjects with non-diabetic PAD had a higher risk of above-ankle reamputation (p = .008), and death (p < .001). At the time of data collection, only multiple-ray amputation (vs. single-ray) was an independent risk factor for above-ankle reamputation. Only age, medical comorbidity in general, and chronic heart failure were independent risk factors of death. To our knowledge, this study is the first to report marked differences in above-ankle reamputation rates and mortality following transmetatarsal amputation, comparing diabetics with non-diabetic patients with peripheral artery disease. However, the differences may be attributed to non-diabetics being older, having more medical comorbidities, and having more advanced foot ulcers at the time of transmetatarsal amputation. In patients exhibiting several of these risk factors, transmetatarsal amputation may be futile.

Factors Associated with Urgent Amputation Status and Its Impact on Mortality

BACKGROUND

Thirty-day mortality is higher after urgent major lower extremity amputations compared to elective lower extremity amputations. This study aims to identify factors associated with urgent amputations and to examine their impact on perioperative outcomes and long-term mortality.

METHODS

Patients undergoing major lower limb amputation from 2013 to 2020 in the Vascular Quality Initiative were included. Urgent amputation was defined as occurring within 72 hr of admission. Associations with sociodemographic characteristics, comorbidities, and outcomes including postoperative complication, inpatient death, and long-term survival were compared using univariable tests and multivariable logistic regression. Long-term survival between groups was compared using Kaplan-Meier analysis.

RESULTS

Of the 12,874 patients included, 4,850 (37.7%) had urgent and 8,024 (62.3%) had elective amputations. Non-White patients required urgent amputation more often than White patients (39.8% vs. 37.9%, P = 0.03). A higher proportion of Medicaid and self-pay patients presented urgently (Medicaid: 13.0% vs. 11.0%; self-pay: 3.4% vs. 2.5%, P < 0.001). Patients requiring urgent amputation were less often taking aspirin (55.6% vs. 60.1%, P < 0.001) or statin (62.2% vs. 67.2%, P < 0.001), had fewer prior revascularization procedures (41.0% vs. 48.8%, P < 0.001), and were of higher American Society of Anesthesiologists (ASA) class 4-5 (50.9% vs. 40.1%, P < 0.001). Urgent amputations were more commonly for uncontrolled infection (48.1% vs. 29.4%, P < 0.001) or acute limb ischemia (14.3% vs. 6.2%, P < 0.001). Postoperative complications were higher after urgent amputations (34.7% vs. 16.6%, P < 0.001), including need for return to operating room (23.8% vs. 8.4%, P < 0.001) and need for higher revision (15.2% vs. 4.5%, P < 0.001). Inpatient mortality was higher after urgent amputation (8.9% vs. 5.4%, P < 0.001). Multivariable analysis revealed non-White race, self-pay, homelessness, current smoking, ASA class 4-5, and amputations for uncontrolled infection or acute limb ischemia were associated with urgent status, whereas living in a nursing home or prior revascularization were protective. Furthermore, urgent amputation was associated with an increased odds of postoperative complication or death (odds ratio 1.86 [1.69-2.04], P < 0.001) as well as long-term mortality (odds ratio: 1.24 [1.13-1.35], P < 0.001). Kaplan-Meier analysis corroborated that elective status was associated with improvement of long-term survival.

CONCLUSIONS

Patients requiring urgent amputations are more often non-White, uninsured, and less frequently had prior revascularization procedures, revealing disparities in access to care. Urgency was associated with a higher postoperative complication rate, as well as increased long-term mortality. Efforts should be directed toward reducing these disparities to improve outcomes following amputation.

Development of the AMPDECIDE Decision Aid to Facilitate Shared Decision Making in Patients Facing Amputation Secondary to Chronic Limb Threatening Ischemia

INTRODUCTION

We developed a patient decision aid to enhance patient participation in amputation level decision making when there is a choice between a transmetatarsal or transtibial amputation.

METHODS

In accordance with International Patient Decision Aid Standards, we developed an amputation level patient decision aid for patients who are being considered for either a transmetatarsal or transtibial amputation, incorporating qualitative literature data, quantitative literature data, qualitative provider and patient interviews, expert panel input and iterative patient feedback.

RESULTS

The rapid qualitative literature review and qualitative interviews identified five domains outcome priority domains important to patients facing amputation secondary to chronic limb threatening ischemia: 1) the ability to walk, 2) healing and risk for reamputation, 3) rehabilitation program intensity, 4) ease of prosthetic use, and 5) limb length after amputation. The rapid quantitative review identified only two domains with adequate evidence comparing differences in outcomes between the two amputation levels: mobility and reamputation. Patient, surgeon, rehabilitation and decision aid expert feedback allowed us to integrate critical facets of the decision including addressing the emotional context of loss of limb, fear and anxiety as an obstacle to decision making, shaping the decision in the context of remaining life years, and how to facilitate patient knowledge of value tradeoffs.

CONCLUSIONS

Amputation level choice is associated with significant outcome trade-offs. The AMPDECIDE patient decision aid can facilitate acknowledgment of patient fears, enhance knowledge of amputation level outcomes, assist patients in determining their personal outcome priorities, and facilitate shared amputation level decision making.

Comparative evaluation of transcutaneous oxygen tension and ankle-brachial index as predictors of reoperation following below-knee amputation

OBJECTIVE

Decision-making regarding level of lower extremity amputation is sometimes challenging. Selecting an appropriate anatomic level for major amputation requires consideration of tradeoffs between postoperative function and risk of wound complications that may require additional operations, including debridement and/or conversion to above-knee amputation (AKA). We evaluated the utility of common, non-invasive diagnostic tests used in clinical practice to predict the need for reoperations among patients undergoing primary, elective, below knee-amputations (BKAs) by vascular surgeons.

METHODS

Patients undergoing elective BKA over a 5-year period were identified using Current Procedural Terminology codes. Medical records were reviewed to characterize demographics, pre-amputation testing transcutaneous oxygen tension (TcPO2), and ankle-brachial index (ABI). The need for ipsilateral post-BKA reoperation (including BKA revision and/or conversion to AKA) regardless of indication was the primary outcome. Associations were evaluated using univariable and multivariable logistic regression models. Cutpoints for TcPO2 values associated with amputation reoperation were evaluated using receiver operating characteristic curves.

RESULTS

We identified 175 BKAs, of which 46 (26.3%) required ipsilateral reoperation (18.9% BKA revisions and 14.3% conversions to AKA). The mean age was 63.3 ± 14.8 years. Most patients were male (65.1%) and White (72.0%). Mean pre-amputation calf TcPO2 was 40.0 ± 20.5 mmHg, and mean ABI was 0.64 ± 0.45. In univariable models, post-BKA reoperation was associated with calf TcPO2 (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.94-0.99; P = .013) but not ABI (OR, 0.53; 95% CI, 0.19-1.46; P = .217). Univariable associations with reoperation were also identified for age (OR, 0.97; 95% CI, 0.94-0.990; P = .003) and diabetes (OR, 0.43; 95% CI, 0.21-0.87; P = .019). No associations with amputation revision were identified for gender, race, end-stage renal disease, or preoperative antibiotics. Calf TcPO2 remained associated with post-BKA reoperation in a multivariable model (OR, 0.97; 95% CI, 0.94-0.99; P = .022) adjusted for age (OR, 0.98; 95% CI, 0.94-1.01; P = .222) and diabetes (OR, 0.98; 95% CI, 0.94-1.01; P = .559). Receiver operating characteristic analysis suggested a TcPO2 ≥38 mmHg as an appropriate cut-point for assessing risk for BKA revision (area under the curve = 0.682; negative predictive value, 0.91).

CONCLUSIONS

Reoperation after BKA is common, and reoperation risk was associated with pre-amputation TcPO2. For patients undergoing elective BKA, higher risk of reoperation should be discussed with patients with an ipsilateral TcPO2 <38 mmHg.

Clinical Effects of Tourniquet Use for Nontraumatic Major Lower Limb Amputation: A Two-Center Retrospective Cohort Study

BACKGROUND

To investigate the effect of tourniquet use on outcomes after major lower limb amputation (MLLA) due to peripheral arterial disease or complications from diabetes mellitus.

METHODS

In this 2-center retrospective observational study, vascular patients who underwent MLLA between January 1, 2016 and December 31, 2020 at 2 UK hospitals were identified using operating theater databases. Hospital databases were used to access medical records, operation notes, and laboratory reports. The use of a tourniquet in each MLLA was noted. The primary outcome was postoperative hemoglobin (Hb) drop (g/L). Secondary outcomes were units of allogeneic blood transfused perioperatively, 90-day revision rates, 90-day wound breakdown rates, surgical site infection (SSI) rates (at 30 days), and 90-day mortality. A follow-up index (a measure of follow-up completeness) was calculated for all 30-day and 90-day outcomes.

RESULTS

Four hundred seventy two patients underwent MLLA, of which 124 had a tourniquet applied. The median postoperative Hb drop was significantly lower in the tourniquet group compared to the nontourniquet group (13 [interquartile range 5-22] g/L vs. 20 [interquartile range 11-28] g/L; P ≤ 0.001). Thirty three point one percent (41) of tourniquet patients received a blood transfusion perioperatively, compared to 35.6% (124) of nontourniquet patients (P = 0.82). Sixteen percent (76) of patients required surgical revision within 90 days, with no significant difference between the tourniquet and nontourniquet group (20.2% tourniquet vs. 14.7% no tourniquet; P = 0.15). SSI rates (12.0% tourniquet vs. 10.6% no tourniquet, P = 0.66) and 90-day mortality (6.5% tourniquet vs. 10.1% no tourniquet; P = 0.23) were similar. Multivariable regression demonstrated that tourniquet use was independently associated with a reduced hemoglobin drop (β = -4.671, 95% confidence interval -7.51 to -1.83, P ≤ 0.001) but was not associated with wound breakdown, revision surgery, or SSI. Hypertension, SSI, and below-knee amputation using the skew flap technique were all significant predictors of revision surgery. All follow-up indices were ≥ 0.97.

CONCLUSIONS

Tourniquet use in MLLA was associated with a significantly lower fall in postoperative Hb without evidence of harm in terms of SSI, wound breakdown/revision rates, or mortality.

Can Early Post-Operative Scoring of Non-Traumatic Amputees Decrease Rates of Revision Surgery?

Background and Objectives: Medical registries evolved from a basic epidemiological data set to further applications allowing deriving decision making. Revision rates after non-traumatic amputation are high and dramatically impact the following rehabilitation of the amputee. Risk scores for revision surgery after non-traumatic lower limb amputation are still missing. The main objective was to create an amputation registry allowing us to determine risk factors for revision surgery after non-traumatic lower-limb amputation and to develop a score for an early detection and decision-making tool for the therapeutic course of patients at risk for non-traumatic lower limb amputation and/or revision surgery. Materials and Methods: Retrospective data analysis was of patients with major amputations lower limbs in a four-year interval at a University Hospital of maximum care. Medical records of 164 patients analysed demographics, comorbidities, and amputation-related factors. Descriptive statistics analysed demographics, prevalence of amputation level and comorbidities of non-traumatic lower limb amputees with and without revision surgery. Correlation analysis identified parameters determining revision surgery. Results: In 4 years, 199 major amputations were performed; 88% were amputated for non-traumatic reasons. A total of 27% of the non-traumatic cohort needed revision surgery. Peripheral vascular disease (PVD) (72%), atherosclerosis (69%), diabetes (42%), arterial hypertension (38%), overweight (BMI > 25), initial gangrene (47%), sepsis (19%), age > 68.2 years and nicotine abuse (17%) were set as relevant within this study and given a non-traumatic amputation score. Correlation analysis revealed delayed wound healing (confidence interval: 64.1% (47.18%; 78.8%)), a hospital length of stay before amputation of longer than 32 days (confidence interval: 32.3 (23.2; 41.3)), and a BKA amputation level (confidence interval: 74.4% (58%; 87%)) as risk factors for revision surgery after non-traumatic amputation. A combined score including all parameters was drafted to identify non-traumatic amputees at risk for revision surgery. Conclusions: Our results describe novel scoring systems for risk assessment for non-traumatic amputations and for revision surgery at non-traumatic amputations. It may be used after further prospective evaluation as an early-warning system for amputated limbs at risk of revision.

Major lower extremity amputations - risk of re-amputation, time to re-amputation, and risk factors: a nationwide cohort study from Denmark

BACKGROUND AND PURPOSE

Re-amputation after lower extremity amputation is frequent. The primary aim of our study was to investigate cumulative re-amputation risk after transtibial amputation (TTA), knee disarticulation (KD), and transfemoral amputation (TFA) and secondarily to investigate time to re-amputation, and risk factors.

METHODS

This observational cohort study was based on data from the Danish Nationwide Health registers. The population included first-time major lower extremity amputations (MLEA) performed in patients ≥ 50 years between 2010 and 2021. Both left and right sided MLEA from the same patient were included as index procedures.

RESULTS

11,743 index MLEAs on 10,052 patients were included. The overall cumulative risks for re-amputation were 29% (95% confidence interval [CI] 27-30), 30% (CI 26-35), and 11% (CI 10-12) for TTA, KD, and TFA, respectively. 58% of re-amputations were performed within 30 days after index MLEA. Risk factors for re-amputation within 30 days were dyslipidemia (hazard ratio [HR] 1.2, CI 1.0-1.3), renal insufficiency (HR 1.2, CI 1.1-1.4), and prior vascular surgery (HR 1.3, CI 1.2-1.5).

CONCLUSION

The risk of re-amputation was more than twice as high after TTA (29%) and KD (30%) compared with TFA (11%). Most re-amputations were conducted within 30 days of the index MLEA. Dyslipidemia, renal insufficiency, and prior vascular surgery were associated with higher risk of re-amputation.

A scoping review on nutritional intake and nutritional status in people with a major dysvascular lower limb amputation

PURPOSE

To systematically review literature on nutritional intake, nutritional status and nutritional interventions, and to study their association with short- and long-term clinical outcomes in people with a major dysvascular lower limb amputation.

METHODS

PubMed, Ovid, CINAHL, and The Cochrane Library were searched. Studies were included if nutritional intake, nutritional status, or nutritional interventions in people with a major dysvascular lower limb amputation were analyzed.

RESULTS

Of the 3038 unique papers identified, 30 studies were included. Methodological quality was moderate (1 study) or weak (29 studies). Limited information was available on nutritional intake (2 studies) and nutritional interventions (1 study). Nutritional intake and nutritional status were assessed by diverse methods. The percentage of people with a poor nutritional status ranged from 1% to 100%. In some studies, measures of poor nutritional status were associated with adverse short- and long-term clinical outcomes.

CONCLUSIONS

The percentage of people with a poor nutritional status is inconclusive in the major dysvascular lower limb amputation population, because of the heterogeneity of the assessment methods used. Some included studies reported a negative association between poor nutritional status and clinical outcomes. However, these results should be interpreted with caution, because of the limited quality of the studies available. Studies high in methodological quality and high in hierarchy of evidence are needed.IMPLICATIONS FOR REHABILITATIONThe proportion of people with a poor nutritional status in the major dysvascular lower limb amputation population is inconclusive.Poor nutritional status seems to affect clinical outcomes negatively.More uniformity in assessment of malnutrition in the major dysvascular lower limb amputation population is needed.

Comparing Patient and Provider Priorities Around Amputation Level Outcomes Using Multiple Criteria Decision Analysis

BACKGROUND

Patients with chronic limb threatening ischemia may require a transmetatarsal amputation (TMA) or a transtibial amputation. When making an amputation-level decision, these patients face a tradeoff-a TMA preserves more limb and may provide better mobility but has a lower probability of primary wound healing and may therefore result in additional same or higher level amputation surgeries with an associated negative impact on function. Understanding differences in how patients and providers prioritize these tradeoffs and other outcomes may enhance shared decision-making.

OBJECTIVES

Compare patient priorities with provider perceptions of patient priorities using Multiple Criteria Decision Analysis (MCDA).

METHODS

The MCDA Analytic Hierarchy Process was chosen due to its low cognitive burden and ease of implementation. We included 5 criteria (outcomes): ability to walk, healing after amputation surgery, rehabilitation program intensity, limb length, and ease of use of prosthetic/orthotic device. A national sample of dysvascular lower-limb amputees and providers were recruited from the Veterans Health Administration with the MCDA administered online to providers and telephonically to patients.

RESULTS

Twenty-six dysvascular amputees and 38 providers participated. Fifty percent of patients had undergone a TMA; 50%, a transtibial amputation. When compared to providers, patients placed higher value on TMA (72% vs. 63%). Patient versus provider priorities were ability to walk (47% vs. 42%), healing (18% vs. 28%), ease of prosthesis use (17% vs. 13%), limb length (11% vs. 13%), and then rehabilitation intensity (7% vs. 6%).

LIMITATIONS

Our sample may not generalize to other populations.

CONCLUSIONS

Provider perceptions aligned with patient values on amputation level but varied around the importance of each outcome.

IMPLICATIONS

These findings illuminate some differences between patients' values and provider perceptions of patient values, suggesting a role for shared decision-making. Embedding this MCDA framework into a future decision aid may facilitate these discussions.

Risk factors for reamputation in patients with diabetic foot: A case-control study

BACKGROUND

Reamputation as a complication of diabetic foot ulcers presents a high economic burden and represents a therapeutic failure. It is paramount to identify as early as possible patients in whom a minor amputation may not be the best option. The purpose of this investigation was to do a case-controlled study to determine risk factors associated with re-amputation in patients with DFU (diabetic foot ulcers) at two University Hospitals.

METHODS

Multicentric, observational, retrospective, case-control study from clinical records of 2 university hospitals. Our study included 420 patients, with 171 cases (re-amputations), and 249 controls. We performed a multivariate logistic regression analysis and time-to-event survival analysis to identify re-amputation risk factors.

RESULTS

Statistically significant risk factors were artery history of tobacco use (p = 0.001); male sex (p = 0.048); arterial occlusion in Doppler ultrasound (p = 0.001); percentage of stenosis in arterial ultrasound >50 % (p = 0.053); requirement of vascular intervention (p = 0.01); and microvascular involvement in photoplethysmography (p = 0.033). The most parsimonious regression model suggests that history of tobacco use, male sex, arterial occlusion in ultrasound, and percentage of stenosis in arterial ultrasound >50 % remained statistically significant. The survival analysis identified earlier amputations in patients with larger occlusion in arterial ultrasound, high leukocyte count, and elevated ESR.

CONCLUSION

Direct and surrogate outcomes in patients with diabetic foot ulcers identify vascular involvement as an important risk factor for reamputation.

LEVEL OF EVIDENCE

III.

Risk Factors for a Failed Transmetatarsal Amputation in Patients with Diabetes

BACKGROUND

Transmetatarsal amputation (TMA) is a well-recognized limb-salvage procedure, often indicated for the treatment of diabetic foot infections. Currently, there is no widespread agreement in the literature with regard to the factors associated with failure of TMA. This study aimed to define risk factors for the failure of TMA, defined as below-the-knee or above-the-knee amputation, in patients with diabetes.

METHODS

This retrospective cohort study included 341 patients who underwent primary TMA. Patients who had a revision to a higher level (the failed TMA group) were compared with those who did not have failure of the initial amputation (the successful TMA group).

RESULTS

This study showed a higher frequency of renal impairment, defined as a high creatinine level and/or a previous kidney transplant or need for dialysis, in the failed TMA group (p = 0.002 for both). Furthermore, a Charlson Comorbidity Index (CCI) threshold value of 7.5 was identified as the optimal predictive value for failure of TMA (p = 0.002), and patients with a CCI of >7.5 had a median time of 1.13 months until the initial amputation failed.

CONCLUSIONS

TMA is associated with a high risk of revision. CCI may be used as a preoperative selection criterion, as 71.8% of patients with a CCI of >7.5 had failure of the TMA.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Determinants of healing and readiness for prosthetic fitting after transtibial amputation: Integrative literature review

BACKGROUND

Healing after an amputation is a critical step in the recovery process. Delayed wound healing can lead to deconditioning and flexion contractures which reduce a patient's ability to use a prosthesis, ambulate independently, and return to community participation. The purpose of this integrative literature review was to determine the evidence-based physiological factors, comorbidities, postoperative management, and outcome measures associated with healing after transtibial amputation and address how these factors clinically guide readiness for prosthetic intervention.

METHODS

Authors completed Google Scholar searches to identify the most effective search terms to locate salient publications. Authors also completed literature searches of Ovid MEDLINE and Epub Ahead of Print, In-Process, and Other Nonindexed Citations and Daily <1946 to August 6, 2020>; Embase Classic + Embase <1947 to August 6, 2020>; and CINAHL Complete <1946 to August 6, 2020> databases using the following search terms: "transtibial," "trans-tibial," "below knee," "BKA," "amputation," amputation stump," "amputee," "wound healing," and "heal/s/ed/ing." The authors decided to include all levels of evidence to capture the maximum number of articles related to the determinants of healing and readiness for prosthetic fitting after transtibial amputation.

RESULTS

The searches identified 2067 potential articles for review, and after removing articles not relevant to the topic, authors completed full-text assessment on 20 articles. These included review and synthesis on three randomized controlled trials and 12 cohort studies.

CONCLUSION

Preamputation assessment is most critical in patients who present with a longer list of comorbidities and suboptimal physiologic factors known to predict wound complications. Clinical judgment is most subjective when determining the degree of healing over time. Readiness for prosthetic treatment need not wait for complete healing of the residuum. Future research is needed to assess transcutaneous oxygen profusion along with other noninvasive measures of blood flow and perfusion as a more objective way to track progression of healing over time. This objective methodology would quantify healing, reduce subjectivity, and promote research to compare different enhanced recovery after surgery protocols for their impact on healing after amputation.

Transmetatarsal amputations in patients with diabetes mellitus: A contemporary analysis from an academic tertiary referral centre in a developing community

Transmetatarsal amputation (TMA) involves the surgical removal of the distal portion of metatarsals in the foot. It aims to maintain weight-bearing and independent ambulation while eliminating the risk of spreading soft tissue infection or gangrene. This study aimed to explore the risk factors and surgical outcomes of TMA in patients with diabetes at an academic tertiary referral center in Jordan. Medical records of all patients with diabetes mellitus who underwent TMA at King Abdullah University Hospital, Jordan, between January 2017 and January 2019 were retrieved. Patient characteristics along with clinical and laboratory findings were analyzed retrospectively. Pearson’s chi-square test of association, Student’s t-test, and multivariate regression analysis were used to identify and assess the relationships between patient findings and TMA outcome. The study cohort comprised 81 patients with diabetes who underwent TMA. Of these, 41 (50.6%) patients achieved complete healing. Most of the patients were insulin-dependent (85.2%). Approximately half of the patients (45.7%) had severe ankle-brachial index (ABI). Thirty patients (37.1%) had previous revascularization attempts. The presence of peripheral arterial disease (P<0.05) exclusively predicted poor outcomes among the associated comorbidities. Indications for TMA included infection, ischemia, or both. The presence of severe ABI (≤0.4, P<0.01) and a previous revascularization attempt (P<0.05) were associated with unfavorable outcomes of TMA. Multivariate analysis that included all demographic, clinical, and laboratory variables in the model revealed that insulin-dependent diabetes, low albumin level (< 33 g/L), high C-reactive protein level (> 150 mg/L), and low score of Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC, <6) were the main factors associated with poor TMA outcomes. TMA is an effective technique for the management of diabetic foot infection or ischemic necrosis. However, attention should be paid to certain important factors such as insulin dependence, serum albumin level, and LRINEC score, which may influence the patient’s outcome.

Temporal trends in major, minor and recurrent lower extremity amputations in people with and without diabetes in Belgium from 2009 to 2018

AIMS

This study assessed temporal trends in the incidence of lower extremity amputations (LEA) in Belgium from 2009 to 2018, and subsequent secondary amputation rates.

METHODS

Nationwide data on LEA were collected. Sex- and age-adjusted annual incidence rates were calculated. Time trends were analysed in negative binomial models. The incidence of secondary interventions, defined as either any ipsilateral reamputation or any contralateral amputation, was studied with death as competing risk.

RESULTS

41 304 amputations were performed (13 247 major, 28 057 minor). In individuals with diabetes, the amputation rate (first amputation per patient per year) decreased from 143.6/100.000 person-years to 109.7 (IRR 0.97 per year, 95 %CI 0.96-0.98, p < 0.001). The incidence of major LEAs decreased from 56.2 to 30.7 (IRR 0.93, 95 %CI 0.91-0.94, p < 0.001); the incidence of minor amputations showed a non-significant declining trend in women (54.3 to 45.0/100 000 person years, IRR 0.97 per year, 95 %CI 0.96-0.99), while this remained stable in men with diabetes (149.2 to 135.3/100 000 person years, IRR 1.00 per year, 95 %CI 0.98-1.01). In individuals without diabetes, the incidence of major amputation didn't change significantly, whereas minor amputation incidence increased (8.0 to 10.6, IRR 1.04, 95 %CI 1.03-1.05, p < 0.001). In individuals with diabetes, one-year secondary intervention rates were high (31.3% after minor, 18.4% after major LEA); the incidence of secondary amputations didn't change.

CONCLUSIONS

A significant decline in the incidence rate of major LEA was observed in people with diabetes. This decline was not accompanied by a significant rise in minor LEA. The incidence of secondary interventions remained stable.

Transmetatarsal Amputation Results in Higher Frequency of Revision Surgery and Higher Ambulation Rates Than Below-Knee Amputation

Background:

Selecting the level of amputation for patients with severe foot pathology can be challenging. The surgeon is sometimes confronted with an option between transmetatarsal amputation (TMA) and below-knee amputation (BKA). Recent studies have suggested that minor foot amputations have high revision rates and need for higher level of amputation. This study sought to compare the revision rates, need for higher level of amputation, postoperative ambulatory rate, and the demographic factors between these 2 operations.

Methods:

We retrospectively reviewed the records of patients undergoing either BKA or TMA at a single academic institution during an 8-year period. Demographic characteristics and medical history were collected and included in a binary logistic regression model to evaluate for independent predictors of needing revision surgery or needing higher-level amputation. Secondary outcomes included ambulatory status and wound status at last follow-up.

Results:

There was a total of 367 patients who underwent either BKA (n=293) or TMA (n=74). On binary logistic regression, the only significant independent predictor of needing revision surgery was undergoing TMA (odds ratio [OR] 2.30, CI 1.199-4.146, P = .011). The presence of PAD trended toward significance (OR 2.12, CI 0.99-4.493, P = .051). Similarly, significant independent predictors of needing higher level amputation were undergoing TMA (OR 4.117, CI 1.9-8.9, P < .001) and presence of PAD (OR 4.85, CI 1.59-14.85, P = .006). More TMA patients were ambulatory (56.8%) on last follow-up compared with BKA patients (30.9%).

Conclusion:

Transmetatarsal amputation has a higher risk of reoperation and need for revision amputation compared with below-knee amputation. Transmetatarsal amputation has a higher chance of returning patients to independent ambulation. Patients with peripheral arterial disease are at a higher risk of revision surgery and higher-level amputation with both operations.

Level of Evidence:

Level III, retrospective case review.

Assessment of Flap Viability for Complex Transmetatarsal Amputation Using Indocyanine Green Fluorescent Angiography: A Case Study

Despite advancements in the treatment of diabetic patients with "at-risk" limbs, minor and major amputations remain commonplace. The diabetic population is especially prone to surgical complications from lower extremity amputation because of comorbidities such as renal disease, hypertension, hyperlipidemia, microvascular and macrovascular disease, and peripheral neuropathy. Complication occurrence may result in increases in hospital stay duration, unplanned readmission rate, mortality rate, number of operations, and incidence of infection. Skin flap necrosis and wound healing delay secondary to inadequate perfusion of soft tissues continues to result in significant morbidity, mortality, and cost to individuals and the health-care system. Intraoperative indocyanine green fluorescent angiography for the assessment of tissue perfusion may be used to assess tissue perfusion in this patient population to minimize complications associated with amputations. This technology provides real-time functional assessment of the macrovascular and microvascular systems in addition to arterial and venous flow to and from the flap soft tissues. This case study explores the use of indocyanine green fluorescent angiography for the treatment of a diabetic patient with a large dorsal and plantar soft-tissue deficit and need for transmetatarsal amputation with nontraditional rotational flap coverage. The authors theorize that the use of indocyanine green may decrease postoperative complications and cost to the health-care system through fewer readmissions and fewer procedures.

Avoiding the Deep Plantar Arterial Arch in Transmetatarsal Amputations: A Cadaver Study

BACKGROUND

The deep plantar arterial arch (DPAA) is formed by an anastomosis between the deep plantar artery and the lateral plantar artery. The potential risk of injury to the DPAA is concerning when performing transmetatarsal amputations, and care must be taken to preserve the anatomy. We sought to determine the positional anatomy of the DPAA based on anatomical landmarks that could be easily identified and palpated during transmetatarsal amputation.

METHODS

In an effort to improve our understanding of the positional relationship of the DPAA to the distal metatarsal parabola, dissections were performed on 45 cadaveric feet to measure the location of the DPAA with respect to the distal metatarsal epiphyses. Images of the dissected specimens were digitally acquired and saved for measurement using in-house-written software. The mean, SD, SEM, and 95% confidence interval were calculated for all of the measurement parameters and are reported on pooled data and by sex. An independent-samples t test was used to assess for sex differences. Interrater reliability of the measurements was estimated using the intraclass correlation coefficient.

RESULTS

The origin of the DPAA was located a mean ± SD of 35.6 ± 3.9 mm (95% confidence interval, 34.5-36.8 mm) proximal to the perpendicular line connecting the first and fifth metatarsal heads. The average interrater reliability across all of the measurements was 0.921.

CONCLUSIONS

This study provides the positional relationship of the DPAA with respect to the distal metatarsal parabola. This method is easily reproducible and may assist the foot and ankle surgeon with surgical planning and approach when performing partial pedal amputation.

Understanding the experience of veterans who require lower limb amputation in the veterans health administration

Purpose

There is limited qualitative research on the experience of patients undergoing lower limb amputation due to chronic limb threatening ischemia (CLTI) and their participation in amputation-level decisions. This study was performed to understand patient lived experiences related to amputation and patient involvement in shared decision making.

Materials and methods

Phenomenological interviews were conducted with Veterans 6–12 months post transtibial or transmetatarsal amputation due to CLTI. Interviews were read and summarized by two analysts who discussed the contents of each interview and relationships between interviews to identify emergent, cross-cutting elements of patient experience.

Results

Twelve patients were interviewed between March and August 2019. Three cross cutting elements of patient lived experience and participation in shared decision making were identified: 1) Lacking a sense of decision making; 2) Actively working towards recovery as response to a perceived loss of independence; and 3) Experiencing amputation as a Veteran.

Conclusions

Patients did not report a high level of involvement in shared decision making about their amputation or amputation level. Understanding patient experiences and priorities is crucial to supporting shared decision making for Veterans with amputation due to CLTI.

Bilateral brachial plexus block as alternative to general anaesthesia in high-risk patient; a case report and literature review

Introduction

Bilateral brachial plexus blocks can be an alternative to general anaesthesia in the surgery of arm, forearm, wrist, or hand. This study aims to report a case in which a risky patient underwent amputation surgery under regional anaesthesia.

Case presentation

A 64-year-old male was admitted to the hospital for an amputation operation. Ultrasonography revealed normal findings regarding internal organs, aside from grade II increased echogenicity of both kidneys and a small bladder cyst. Echocardiography revealed mildly left ventricular dilation, moderate systolic left ventricular dysfunction, ejection fraction 38%, left ventricular wall hypokinesia with left ventricular dilation. The amputation was performed under a bilateral supraclavicular brachial plexus block with the guidance of ultrasound.

Discussion

Theoretically, there are some advantages to regional anaesthesia in comparison to general anaesthesia, such as decreasing the ordinary body response to stress in the presence of low levels of cortisol and catecholamines, increasing blood flow and peripheral vasodilatation, decreasing hypercoagulability, lower risk of arterial and venous thrombosis and it aids to prevent endotracheal intubation and mechanical ventilation.

Conclusion

Bilateral brachial plexus blocks, as a type of regional anaesthesia under ultrasound guidance, can be depended upon as a reliable substitute for general anaesthesia in perilous conditions.

•

Bilateral brachial plexus blocks (BBPB) are a kind of regional anaesthesia that can be used instead of general anaesthesia.

•

Several complications may be encountered during the process of BBPB, including diaphragmatic paralysis.

•

In this study, BBPB has been discussed with literature review.

Analysis of Early Lower Extremity Re-amputation

BACKGROUND

Data is scarce regarding the need for early re-amputation to a higher anatomic level. This study seeks to define outcomes and risk factors for re-amputation.

METHODS

Patients undergoing primary major lower extremity amputation were identified within the 2012-2016 ACS-NSQIP database. Demographics, outcomes, and peri-operative characteristics were compared, and multivariable logistic regression model was used to determine association with early re-amputation.

RESULTS

Over a four-year period, 8306 below knee amputations and 6367 above knee amputations were identified. Thirty-day re-amputation occurred in 262 patients (1.8%) and was associated with increased length of stay (12.9 vs. 7.3 days, p<0.001), higher rates of readmission (64.9% vs. 13.6%, p<0.001), and overall complications (69.5% vs. 39.3%, p<0.01). On multivariable analysis, advanced age (OR 1.02, CI 1.01-1.03), smoking (OR 1.75, CI 1.32-2.33), dialysis dependence (OR 1.67, CI 1.23-2.26), preoperative septic shock (OR 2.53, CI 1.29-4.97), and bleeding disorders (OR 1.72, CI 1.34-2.22) were associated with early re-amputation.

CONCLUSIONS

Thirty-day re-amputation rates are low, but are associated with significant morbidity, prolonged hospitalization, and frequent readmissions.

The Development and Usability of the AMPREDICT Decision Support Tool: A Mixed Methods Study

OBJECTIVE

Amputation level decision making in patients with chronic limb threatening ischaemia is challenging. Currently, evidence relies on published average population risks rather than individual patient risks. The result is significant variation in the distribution of amputation levels across health systems, geographical regions, and time. Clinical decision support has been shown to enhance decision making, especially complex decision making. The goal of this study was to translate the previously validated AMPREDICT prediction models by developing and testing the usability of the AMPREDICT Decision Support Tool (DST), a novel, web based, clinical DST that calculates individual one year post-operative risk of death, re-amputation, and probability of achieving independent mobility by amputation level.

METHODS

A mixed methods approach was used. Previously validated prediction models were translated into a web based DST with additional content and format developed by an expert panel. Tool usability was assessed using the Post-Study System Usability Questionnaire (PSSUQ; a 16 item scale with scores ranging from 1 to 7, where lower scores indicate greater usability) by 10 clinician end users from diverse specialties, sex, geography, and clinical experience. Think aloud, semi-structured, qualitative interviews evaluated the AMPREDICT DST's look and feel, user friendliness, readability, functionality, and potential implementation challenges.

RESULTS

The PSSUQ overall and subscale scores were favourable, with a mean overall total score of 1.57 (standard deviation [SD] 0.69) and a range from 1.00 to 3.21. The potential clinical utility of the DST included (1) assistance in counselling patients on amputation level decisions, (2) setting outcome expectations, and (3) use as a tool in the academic environment to facilitate understanding of factors that contribute to various outcome risks.

CONCLUSION

After extensive iterative development and testing, the AMPREDICT DST was found to demonstrate strong usability characteristics and clinical relevance. Further evaluation will benefit from integration into an electronic health record with assessment of its impact on physician and patient shared amputation level decision making.

Popliteal artery patency is an indicator of ambulation and healing after below-knee amputation in vasculopaths

BACKGROUND

The posterior flap is a conventional technique for closing a below-knee amputation (BKA) that uses the gastrocnemius and soleus muscle and relies on the popliteal and posterior compartment arteries. If the prior mentioned arterial blood supply is compromised, this flap likely relies on collateral flow. The purpose of this study is to identify and differentiate any significant associations between preoperative popliteal and tibial arterial flow and BKA outcomes and patient-reported function.

METHODS

A retrospective review identified patients from a single tertiary wound care center who received BKAs and angiogram between 2010 and 2017 by a single surgeon. BKA complications, wound healing, and amputee ambulatory status at latest follow-up were all stratified for differences according to baseline tibial vessel run-off (VRO) status, popliteal artery patency, and popliteal angioplasty outcome. Chi-square, Fisher's exact, and Wilcoxon rank sum tests were used with significance defined as p ≤ 0.05.

RESULTS

BKAs were performed on 313 patients, of which, 167 underwent preoperative angiography. Thirty-two were excluded due to lack of adequate follow-up leaving a total of 135 patients in the studied population. Diabetes was present in 87%, and 36% had end-stage renal disease. By the study's conclusion, 92% of BKAs had fully healed, with median time-to-healing of 79 days (range 19-1314 days). 60% of patients were ambulatory at 9.5 months. Higher VRO was associated with higher healing rates and lower complications and time-to-healing. The conversion rate of BKA to above-knee amputation (AKA) was 4%. Preoperative popliteal patency was associated with higher postoperative ambulation rates when compared to patients without popliteal flow preoperatively (patent: 71/109, 65%; occluded: 10/26, 40%; p = 0.02) and independently increased the likelihood of postoperative ambulation.

CONCLUSIONS

The posterior flap design for BKA works even in the setting of popliteal occlusion. Complication rates are higher in patients with more compromised blood flow, which may ultimately lead to AKA. Given poor ambulation rates in patients who undergo AKA, the results of this study should encourage surgeons to consider a more functional BKA, even in instances when the popliteal artery is occluded.

Transmetatarsal and Minor Amputation Versus Major Leg Amputation: 30-Day Readmissions, Reamputations, and Complications

AIMS

The optimal level of lower-extremity amputation, particularly in diabetic patients with ulceration, is debated. Proximal amputations more greatly decrease function versus distal amputations, but healing and complication rates may differ between the 2 types. This study compares early postoperative outcomes after transmetatarsal and other partial foot amputations and major leg amputations.

METHODS

Data were derived from National Surgical Quality Improvement Program datasets covering 2012 to 2014. Outcomes studied include 30-day rates of readmission to hospital for wound complications. We matched the 2 types of amputation patients by propensity score to fairly compare between levels of amputation when either type of amputation might be indicated. The same analysis was then performed with emphasis on diabetic patients.

RESULTS

Major amputation patients were more likely to have dependent functional status, although their surgeries tended to be more complicated. Minor amputation patients had 2.5 times the odds of irrigation and debridement compared with major amputation patients, but only 0.49 and 0.47 times the odds of urinary tract infection or transfusion, respectively.

CONCLUSIONS

Although short-term complications, readmissions, and reoperations were more common in distal amputation, UTI and the need for transfusion were higher in major amputation.

Retrograde Transamputation Revascularization: A Case Report

Below-knee amputation remains the most common level of amputation in patients with lower extremity gangrene and critical limb ischemia. Failure to heal, requiring additional operative debridement or conversion to an above-knee amputation remains a significant cause of patient morbidity. There remains no definitive diagnostic test that can accurately predict healing of the amputation site. We report a case utilizing a hybrid technique of retrograde transamputation revascularization via balloon angioplasty. This proximal, retrograde approach allows for relatively easy crossing and treatment of the infrainguinal chronic total occlusions (CTOs), improving arterial inflow for optimal wound healing.

Free Tissue Transfer after Open Transmetatarsal Amputation in Diabetic Patients

BACKGROUND

 Transmetatarsal amputation (TMA) preserves functional gait while avoiding the need for prosthesis. However, when primary closure is not possible after amputation, higher level amputation is recommended. We hypothesize that reconstruction of the amputation stump using free tissue transfer when closure is not possible can achieve similar benefits as primarily closed TMAs.

METHODS

 Twenty-eight TMAs with free flap reconstruction were retrospectively reviewed in 27 diabetic patients with a median age of 61.5 years from 2004 to 2018. The primary outcome was limb salvage rate, with additional evaluation of flap survival, ambulatory status, time until ambulation, and further amputation rate. In addition, subgroup analysis was performed based on the microanastomosis type.

RESULTS

 Flap survival was 93% (26 of 28 flaps) and limb salvage rate of 93% (25 of 27 limbs) was achieved. One patient underwent a second free flap reconstruction. In the two failed cases, higher level amputation was required. Thirteen flaps had partial loss or other complications which were salvaged with secondary intension or skin grafts. Median time until ambulation was 14 days following reconstruction (range: 9-20 days). Patients were followed-up for a median of 344 days (range: 142-594 days). Also, 88% of patients reported good ambulatory function, with a median ambulation score of 4 out of 5 at follow-up. There was no significant difference between the subgroups based on the microanastomosis type.

CONCLUSION

 TMA with free flap reconstruction is an effective method for diabetic limb salvage, yielding good functional outcomes and healing results.

Blood Cell Count Biomarkers, Risk, and Outcomes of Ischemia-Related Lower Limb Amputations: Systematic Review

Lower limb amputations due to ischemia represent an important health care and social issue. However, there are currently no specific biomarkers able to predict the risk of amputation and postamputation complications and prognosis. We conducted a systematic review of studies investigating whether blood cell count indexes of systemic inflammation are linked to the risk and the outcome of lower limb amputations due to ischemia. Overall, in 22 studies involving 8832 patients selected for review, several blood cell count indexes, particularly the neutrophil lymphocyte ratio, showed some promise in terms of predicting amputations and general outcomes of conservative and surgical treatments, as well as postamputation complications and prognosis. However, largely due to methodological limitations, further prospective studies are required to establish the clinical utility and applicability of blood cell indexes in the routine management of patients with ischemia-related lower limb amputations.

Risks and Risk Factors for Ipsilateral Re-Amputation in the First Year Following First Major Unilateral Dysvascular Amputation

OBJECTIVE

To identify timing, incidence, and risk factors for ipsilateral re-amputation within 12 months of first dysvascular amputation and to determine specific subgroups of patients at each amputation level that are at increased risk.

METHODS

A retrospective cohort study evaluating 7187 patients with first unilateral transmetatarsal (TM), transtibial (TT), or transfemoral (TF) amputation secondary to diabetes and/or peripheral artery disease (PAD) were identified in the VA Surgical Quality Improvement Program database between 2004 and 2014. Re-amputation was defined as any subsequent ipsilateral soft tissue/bony revision or amputation to a higher level. Twenty-three potential pre-operative risk factors (and nine potential interactions) were identified. A backward stepwise Cox regression was used to identify risk factors. Incidence rates and hazard ratios (HR) with 95% confidence intervals (CI) were computed.

RESULTS

The median time to highest level of re-amputation in the first year was 33 (interquartile range, 13-73) days. Risk of requiring at least one re-amputation was 41% (TM), 25% (TT), and 9% (TF). Risk factors associated with requiring re-amputation included chronic obstructive pulmonary disease, elevated white blood cell count, abnormal ankle brachial index (ABI), history of revascularisation, and alcohol misuse. TM patients who had diabetes only (HR 1.9; 95% CI 1.4-2.5), diabetes with an abnormal ankle brachial index (ABI) score (HR 2.4; 95% CI 1.8-3.2), and kidney failure (HR 1.7; 95% CI 1.3-2.1) were at the greatest risk of re-amputation. TT amputees who were smokers were also at an increased risk (HR 1.4; 95% CI 1.2-1.6).

CONCLUSION

This research identified important risk factors for failure of primary healing and need for re-amputation at the TM and TT level. If considering a TM amputation, caution should be exercised in patients with diabetes, in particular those with an abnormal ABI and/or renal failure. At the TT level, caution should be exercised in those who smoke.

A Novel Use of Next-Generation Closed Incision Negative Pressure Wound Therapy After Major Limb Amputation and Amputation Revision

We report our experience with next-generation incisional negative pressure wound therapy (iNPWT) applied after major limb amputation or amputation revision. In this high-risk patient population, the need for reliable post-operative soft tissue management is imperative. In both cases reported, healing was uncomplicated. Using the next generation iNPWT in this unique way optimizes the post-operative residual limb by improved incision healing, residual limb edema reduction, and reduced risk of surgical site infection (SSI). This is the first case report of its kind reporting a novel use of next-generation iNPWT, and it demonstrates a need to examine this particular use further.

Present-day analysis of early failure after forefoot amputation

BACKGROUND

Forefoot transmetatarsal amputation is performed commonly to achieve limb salvage, but transmetatarsal amputations have a high rate of failure, requiring more proximal amputations. Few contemporary studies have examined the incidence of major amputation (transtibial or transfemoral) after transmetatarsal amputation. The goal of this study is to determine risk factors and outcomes for a more proximal amputation after forefoot amputation.

METHODS

We queried the 2012 to 2016 database of the American College of Surgeons National Quality Improvement Program for patients undergoing a complete transmetatarsal amputation with wound closure by Current Procedural Terminology code. Patients requiring early (within 30 days) more proximal amputation after transmetatarsal amputation were compared with those who did not need further amputation. Characteristics of patients requiring more proximal amputation were examined, and a multivariable logistic regression model was created to identity risk factors for early more proximal amputation.

RESULTS

In the study, 1,582 transmetatarsal amputation were identified. Most patients were male (70%), white (59%), and diabetic (74%), with a median age of 63 years. More proximal amputation occurred in 4.2% of patients within the first 30 days postoperatively. This early failure was associated with greater hospital stays postoperatively (10 days vs 7 days), more wound complications (29% vs 11%), pneumonia (8% vs 2%), stroke (3% vs 0.1%), and overall complications (50% vs 28%; P ≤ .025 each). Although there was no difference in 30-day mortality (P = .27), there was a marked increase in unplanned readmission (59% vs 14%; P < .0001) for those undergoing reamputation. On multivariable analysis, preoperative systemic inflammatory response, sepsis, or septic shock (odds ratio 2.1; 95% confidence interval, 1.2-3.6) were independent predictors of more proximal amputation.

CONCLUSION

Early below-knee or above-knee amputation early after transmetatarsal amputation leads to increased morbidity. Because patients with preoperative sepsis may be at increased risk of failure after transmetatarsal amputation, the level of amputation should be considered carefully in these patients.

Wound Complications and Reoperations after Transtibial Amputation of the Leg

BACKGROUND

Transtibial amputations (TTAs) of the leg have been associated with high rates of wound complications. We assessed outcomes of TTAs to determine if bundled interventions implemented at our hospital had an impact on lowering wound complications, including surgical site infections.

METHODS

We assessed the impact of a surgical site infection prevention bundle (negative-pressure wound therapy, minimizing the use of staples, and a decontamination protocol for methicillin-resistant Staphylococcus aureus) on 90-day wound complications. The year of implementation of the prevention bundle was excluded, and the pre-eras and posteras were defined as the four-year period before and after implementation. The study sample consisted of a single-center cohort, with TTA cases identified using operating room scheduling software.

RESULTS

A total of 182 TTAs were performed: 110 in the pre-era and 72 in the postera. The wound complication rate decreased from 22 to 17% despite fewer two-stage operations, less imaging to identify peripheral artery disease, and an increased proportion of patients with end-stage renal disease. Wound complications and revision to a higher level of amputation were more associated with indication (especially no-option peripheral artery disease with ischemic rest pains) than with any particular aspect of surgical technique. The use of drains was associated with reoperations but not higher level revision.

CONCLUSIONS

Higher rates of wound complications and revision to a higher level of amputations should be expected among patients with no-option peripheral artery disease with ischemic rest pains undergoing TTAs. Drains should be avoided.

Revision After Total Transmetatarsal Amputation

Total transmetatarsal amputation (TMA) can be an option for foot salvage in gangrene, sepsis, or infected necrosis. However, the literature concerning predictive outcome factors and bacterial sampling is scarce. To identify potential associations between revision surgery and underlying bacteria or other preoperative selection criteria, we reviewed all patients with TMA who were treated at our institution. We compared the patients with remissions with surgical revisions. Among 96 adult patients with TMA (105 amputations), 42 required a revision surgery (40%), 18 had a further minor proximal surgical reamputation (17%) and 18 had a major proximal surgical reamputation (14%). In group comparisons, a previous infection with Staphylococcus aureus was protective with a lower revision risk (4/26 with revision surgery vs 22/26 without revisions; p = .03). This was the opposite for postoperative persistent soft tissue or bone infections (p < .01) and delayed wound healing (p < .01), which were positively associated with a revision risk. The American Society of Anesthesiologists Score, sex, age, body mass index, diabetes, polyneuropathy, chronic renal failure, dialysis, peripheral arterial disease, smoking status, and antibiotic regimen did not influence this revision risk. These results must be interpreted cautiously because no multiple variable calculations could be conducted as a result of the paucity of cases and confounding could not be evaluated sufficiently. TMA is an option to prevent major amputations, but it may be associated with a subsequent revision risk of 40% in adult patients. In our cohort study, persistent postamputation infection and delayed wound healing were associated with revision. However, no preoperative selection criteria were found that lead to revision surgery except for an infection with Staphylococcus aureus, which protected against revision surgery.

Renal Function as a Predictor of Early Transmetatarsal Amputation Failure

Chronic kidney disease (CKD) is a major concern in patients with foot disease because it is associated with high rates of neuropathy, peripheral vascular disease, and poor wound healing. The purpose of this study was to evaluate renal dysfunction as a risk factor for reamputation after initial transmetatarsal amputation (TMA). Patients who underwent a TMA were retrospectively identified in the American College of Surgeons National Surgical Quality Improvement Program database. Of 2018 patients, reamputation after TMA occurred in 4.4%. End-stage renal disease (ESRD) was associated with 100% increased odds of TMA failure (adjusted odds ratio [OR] = 2.00; 95% CI = 1.10, 3.52), 128% increased odds of major amputation (adjusted OR = 2.28; 95% CI = 1.27, 3.96), and 182% increased odds of 30-day mortality (adjusted OR = 2.82; 95% CI = 1.69, 4.64). In addition, white blood cell count >10 000/mm³ and deep infection at the time of surgery were independently associated with TMA failure. In conclusion, severe renal dysfunction is associated with TMA failure in the short-term, perioperative period. There was no incremental increase in risk of TMA failure with worsening level of renal function before ESRD. A multidisciplinary approach should be implemented in patients with CKD to prevent foot-related pathologies that may necessitate lower-extremity amputation. Levels of Evidence: Level III: Retrospective cohort study.

Outcome of trans-metatarsal amputations in patients with diabetes mellitus

BACKGROUND

This retrospective case series reports the reoperation rate, survival rate and mobility status in patients with diabetes mellitus who had undergone a trans-metatarsal amputation (TMA) managed within a diabetic foot care service.

METHODS

Forty-one consecutive patients (37 men, 4 women) underwent a TMA with primary wound closure between January 2008 and December 2017. Eighty-eight per cent (36/41) of the patients were followed-up for a mean of 2.3 years. The outcomes were retrospectively reviewed.

RESULTS

Four (11%) of the 36 patients required reoperation, including three (8%) major amputations. All of the patients requiring a reoperation had peripheral vascular disease. Eleven patients died giving a four-year survival rate of 69% (25/36). Of the surviving patients who had not required revision to a major amputation 96% (21/22) were fully mobile in bespoke orthoses. A third used a walking cane.

CONCLUSION

This study shows that a TMA with primary wound closure in patients with diabetes mellitus, is effective for limb salvage with low reoperation and major amputation rates. A well healed TMA stump provides independent mobility in the majority of patients. The failures occurred in patients with peripheral vascular disease who, even after percutaneous trans-luminal angioplasty, had a 19% major amputation rate.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

GUIDELINE SUMMARY

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Predicting reamputation risk in patients undergoing lower extremity amputation due to the complications of peripheral artery disease and/or diabetes

BACKGROUND

Patients undergoing amputation of the lower extremity for the complications of peripheral artery disease and/or diabetes are at risk of treatment failure and the need for reamputation at a higher level. The aim of this study was to develop a patient-specific reamputation risk prediction model.

METHODS

Patients with incident unilateral transmetatarsal, transtibial or transfemoral amputation between 2004 and 2014 secondary to diabetes and/or peripheral artery disease, and who survived 12 months after amputation, were identified using Veterans Health Administration databases. Procedure codes and natural language processing were used to define subsequent ipsilateral reamputation at the same or higher level. Stepdown logistic regression was used to develop the prediction model. It was then evaluated for calibration and discrimination by evaluating the goodness of fit, area under the receiver operating characteristic curve (AUC) and discrimination slope.

RESULTS

Some 5260 patients were identified, of whom 1283 (24·4 per cent) underwent ipsilateral reamputation in the 12 months after initial amputation. Crude reamputation risks were 40·3, 25·9 and 9·7 per cent in the transmetatarsal, transtibial and transfemoral groups respectively. The final prediction model included 11 predictors (amputation level, sex, smoking, alcohol, rest pain, use of outpatient anticoagulants, diabetes, chronic obstructive pulmonary disease, white blood cell count, kidney failure and previous revascularization), along with four interaction terms. Evaluation of the prediction characteristics indicated good model calibration with goodness-of-fit testing, good discrimination (AUC 0·72) and a discrimination slope of 11·2 per cent.

CONCLUSION

A prediction model was developed to calculate individual risk of primary healing failure and the need for reamputation surgery at each amputation level. This model may assist clinical decision-making regarding amputation-level selection.

Global vascular guidelines on the management of chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.