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Alahakoon C, Thanigaimani S, Singh TP, Drovandi A, Charles J, Fernando M, Lazzarini PA, Moxon JV, Golledge J. Association of remoteness and ethnicity with major amputation following minor amputation to treat diabetes-related foot disease. PLoS One 2024; 19:e0302186. [PMID: 38968185 PMCID: PMC11226033 DOI: 10.1371/journal.pone.0302186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 03/28/2024] [Indexed: 07/07/2024] Open
Abstract
INTRODUCTION Minor amputation is commonly needed to treat diabetes-related foot disease (DFD). Remoteness of residence is known to limit access to healthcare and has previously been associated with poor outcomes. The primary aim of this study was to examine the associations between ethnicity and remoteness of residency with the risk of major amputation and death following initial treatment of DFD by minor amputation. A secondary aim was to identify risk factors for major amputation and death following minor amputation to treat DFD. RESEARCH DESIGN AND METHODS This was a retrospective analysis of data from patients who required a minor amputation to treat DFD between 2000 and 2019 at a regional tertiary hospital in Queensland, Australia. Baseline characteristics were collected together with remoteness of residence and ethnicity. Remoteness was classified according to the 2019 Modified Monash Model (MMM) system. Ethnicity was based on self-identification as an Aboriginal and Torres Strait Islander or non-Indigenous person. The outcomes of major amputation, repeat minor amputation and death were examined using Cox-proportional hazard analyses. RESULTS A total of 534 participants were included, with 306 (57.3%) residing in metropolitan or regional centres, 228 (42.7%) in rural and remote communities and 144 (27.0%) were Aboriginal or Torres Strait Islander people. During a median (inter quartile range) follow-up of 4.0 (2.1-7.6) years, 103 participants (19.3%) had major amputation, 230 (43.1%) had repeat minor amputation and 250 (46.8%) died. The risks (hazard ratio [95% CI]) of major amputation and death were not significantly higher in participants residing in rural and remote areas (0.97, 0.67-1.47; and 0.98, 0.76-1.26) or in Aboriginal or Torres Strait Islander people (HR 1.44, 95% CI 0.96, 2.16 and HR 0.89, 95% CI 0.67, 1.18). Ischemic heart disease (IHD), peripheral artery disease (PAD), osteomyelitis and foot ulceration (p<0.001 in all instances) were independent risk factors for major amputation. CONCLUSION Major amputation and death are common following minor amputation to treat DFD and people with IHD, PAD and osteomyelitis have an increased risk of major amputation. Aboriginal and Torres Strait Islander People and residents of remote areas were not at excess risk of major amputation.
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Affiliation(s)
- Chanika Alahakoon
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Shivshankar Thanigaimani
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
| | - Tejas P. Singh
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
- The Department of Vascular and Endovascular Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Aaron Drovandi
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, West Yorkshire, United Kingdom
| | - James Charles
- First Peoples Health Unit, Griffith University, Brisbane, Queensland, Australia
| | - Malindu Fernando
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- The Department of Vascular and Endovascular Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia
- Faculty of Health and Medicine, School of Health Sciences, University of Newcastle, Newcastle, New South Wales, Australia
| | - Peter A. Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Allied Health Research Collaborative, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Joseph V. Moxon
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
- The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
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Kipp J, Vesely BD, Fram M, Russell G, Kim-Shapiro JW, Medda AW, Gangopadhyay P. Comparison of Two Techniques for Proximal Margin Analysis of Toe Amputations: A Retrospective Review. J Foot Ankle Surg 2024; 63:464-467. [PMID: 38438099 DOI: 10.1053/j.jfas.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 09/26/2023] [Accepted: 02/17/2024] [Indexed: 03/06/2024]
Abstract
Toe amputations are a common podiatric procedure for treatment of osteomyelitis. Whether or not the surgeon obtains a surgical cure, thus resolving the infection, can be difficult to assess. Obtaining a proximal bone margin can assist the treatment team in deciding the duration of postoperative antibiotics, need for reoperation, and postoperative care. The two senior surgeons use different methods to analyze proximal bone margins. The first surgeon obtains a microbiologic culture from the remaining bone, either at the proximal phalanx or metatarsal head, following the removal of the toe to be reviewed for osteomyelitis. Per the second surgeon's technique, the pathologist only analyzes the proximal aspect of the amputated toe for presence of osteomyelitis. Our goal is to analyze the reoperation and reamputation rates between the techniques in which the proximal margin specimens are obtained. A retrospective chart review was performed on all isolated toe or partial toe amputations from March 2017 to September 2022. There were 115 patients who met inclusion criteria. Reoperation and reamputation rates were analyzed for positive and negative infection margins from intraoperative cultures. Our study found an overall 28% reoperation rate and 26% reamputation rate for the negative margins group. In the positive proximal margin group, there was an overall 48% reoperation rate and 44% reamputation rate. Our analysis did not find a statistically significant difference between the reamputation rate in the negative margins group and the reamputation rate in the positive margins group. In conclusion, our study found that a positive proximal margin for osteomyelitis exhibited a nearly double reoperation and reamputation rate compared to patients with a negative margin, and that one margin analysis technique was not inferior to the other in regards to the need for additional surgeries.
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Affiliation(s)
- Jennifer Kipp
- Resident Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC
| | - Bryanna D Vesely
- Resident Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC.
| | - Madeline Fram
- Medical Student, Wake Forest University School of Medicine, Winston Salem, NC
| | - Greg Russell
- Senior Biostatistician, Wake Forest University School of Medicine, Winston Salem, NC
| | - Jung Wha Kim-Shapiro
- Assistant Professor, Pathology Department, Wake Forest Baptist Medical Center, Winston Salem, NC
| | - Ashleigh W Medda
- Attending Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC
| | - Paula Gangopadhyay
- Attending Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC
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Essien SK, Zucker-Levin A. Comorbidity and risk factors of subsequent lower extremity amputation in patients diagnosed with diabetes in Saskatchewan, Canada. Chronic Illn 2023; 19:779-790. [PMID: 36366747 PMCID: PMC10655619 DOI: 10.1177/17423953221137891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 10/14/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Subsequent limb amputation (SLA) may be necessary due to disease progression, infection, or to aid prosthesis fit. SLA in Saskatchewan has increased 3.2% from 2006 to 2019 with minor SLA increasing 9.6% during that period. Diabetes affects a large proportion of patients who require SLA; however, the impact of additional comorbidities is not clear. METHODS First-episode subsequent lower extremity limb amputation (SLEA) cases with the presence/absence of diabetes, other comorbidities, and demographic characteristics from 2006-2019 were retrieved from Saskatchewan's Discharge Abstract Database. Logistic regression was performed to examine the magnitude of the odds of SLEA. RESULTS Among the 956 first-episode SLEA patients investigated, 78.8% were diagnosed with diabetes. Of these, 76.1% were male and 83.0% were aged 50 + years. Three comorbidities: renal failure (AOR = 1.9, 95% Cl 1.1 - 3.0), hypertension (AOR = 3.0, 95% Cl 2.0 - 4.5), and congestive heart failure (AOR = 2.0, 95% CI 1.2 - 3.2), conferred the highest odds of SLEA. The odds of SLEA is greatest for those aged 50-69 years, males, Registered Indians, and associated with a prolonged hospital stay. DISCUSSION These data are important as they may help medical providers identify patients at the highest risk of SLEA and target interventions to optimize outcomes.
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Affiliation(s)
- Samuel Kwaku Essien
- School of Rehabilitation Science, University of Saskatchewan, Saskatoon, Canada
| | - Audrey Zucker-Levin
- School of Rehabilitation Science, University of Saskatchewan, Saskatoon, Canada
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4
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Iijima H, Eguchi R, Aya Y, Terabe Y, Takahashi M. Compensatory gait mechanics in person with multiple toe amputation: A single case report. Clin Case Rep 2023; 11:e7675. [PMID: 37621725 PMCID: PMC10444944 DOI: 10.1002/ccr3.7675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 06/16/2023] [Accepted: 06/23/2023] [Indexed: 08/26/2023] Open
Abstract
This case highlights the biomechanical influence of toe amputation on contralateral limb force elevation, possibly through reduced ipsilateral plantar flexor torque production. These findings provide insight into toe amputation-related compensatory gait mechanics with greater inter-limb asymmetry, which may increase the risk of musculoskeletal comorbidities, including osteoarthritis in contralateral limb.
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Affiliation(s)
- Hirotaka Iijima
- Institute for Advanced ResearchNagoya UniversityNagoyaJapan
- Biomedical and Health Informatics Unit, Graduate School of MedicineNagoya UniversityNagoyaJapan
| | - Ryo Eguchi
- Graduate School of Science and TechnologyKeio UniversityYokohamaJapan
| | - Yamamoto‐Kon Aya
- Division of Fundamental Nursing, Faculty of Nursing and Medical CareKeio UniversityKanagawaJapan
| | - Yuta Terabe
- Kasukabe Chuo General Hospital Limb Salvage CenterSaitamaJapan
| | - Masaki Takahashi
- Department of System Design Engineering, Faculty of Science and TechnologyKeio UniversityYokohamaJapan
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Norvell DC, Thompson ML, Baraff A, Biggs WT, Henderson AW, Moore KP, Turner AP, Williams R, Maynard CC, Czerniecki JM. AMPREDICT PROsthetics-Predicting Prosthesis Mobility to Aid in Prosthetic Prescription and Rehabilitation Planning. Arch Phys Med Rehabil 2023; 104:523-532. [PMID: 36539174 PMCID: PMC10073310 DOI: 10.1016/j.apmr.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/19/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To develop and validate a patient-specific multivariable prediction model that uses variables readily available in the electronic medical record to predict 12-month mobility at the time of initial post-amputation prosthetic prescription. The prediction model is designed for patients who have undergone their initial transtibial (TT) or transfemoral (TF) amputation because of complications of diabetes and/or peripheral artery disease. DESIGN Multi-methodology cohort study that identified patients retrospectively through a large Veteran's Affairs (VA) dataset then prospectively collected their patient-reported mobility. SETTING The VA Corporate Data Warehouse, the National Prosthetics Patient Database, participant mailings, and phone calls. PARTICIPANTS Three-hundred fifty-seven veterans who underwent an incident dysvascular TT or TF amputation and received a qualifying lower limb prosthesis between March 1, 2018, and November 30, 2020 (N=357). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE The Amputee Single Item Mobility Measure (AMPSIMM) was divided into a 4-category outcome to predict wheelchair mobility (0-2), and household (3), basic community (4), or advanced community ambulation (5-6). RESULTS Multinomial logistic lasso regression, a machine learning methodology designed to select variables that most contribute to prediction while controlling for overfitting, led to a final model including 23 predictors of the 4-category AMPSIMM outcome that effectively discriminates household ambulation from basic community ambulation and from advanced community ambulation-levels of key clinical importance when estimating future prosthetic demands. The overall model performance was modest as it did not discriminate wheelchair from household mobility as effectively. CONCLUSIONS The AMPREDICT PROsthetics model can assist providers in estimating individual patients' future mobility at the time of prosthetic prescription, thereby aiding in the formulation of appropriate mobility goals, as well as facilitating the prescription of a prosthetic device that is most appropriate for anticipated functional goals.
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Affiliation(s)
- Daniel C Norvell
- VA Puget Sound Health Care System, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA; VA Center for Limb Loss and Mobility (CLiMB), Seattle, WA.
| | - Mary Lou Thompson
- Department of Biostatistics, University of Washington, Hans Rosling Center for Population Health, Seattle, WA
| | - Aaron Baraff
- VA Puget Sound Health Care System, Seattle, WA; Seattle Epidemiologic Research and Information Center (ERIC), Seattle, WA
| | | | - Alison W Henderson
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and Mobility (CLiMB), Seattle, WA
| | - Kathryn P Moore
- VA Puget Sound Health Care System, Seattle, WA; Seattle Epidemiologic Research and Information Center (ERIC), Seattle, WA
| | - Aaron P Turner
- VA Puget Sound Health Care System, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA; VA Center for Limb Loss and Mobility (CLiMB), Seattle, WA
| | - Rhonda Williams
- VA Puget Sound Health Care System, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA; VA Center for Limb Loss and Mobility (CLiMB), Seattle, WA
| | | | - Joseph M Czerniecki
- VA Puget Sound Health Care System, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA; VA Center for Limb Loss and Mobility (CLiMB), Seattle, WA
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Hong CC, Saha S, Pearce CJ. Does a shorter residual first metatarsal length after first ray amputation in diabetic patients leads to poorer outcomes - A risk factor study. Foot Ankle Surg 2023; 29:228-232. [PMID: 36746697 DOI: 10.1016/j.fas.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 01/08/2023] [Accepted: 01/24/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND The first ray plays a vital role in the normal function of the foot and the gait cycle where in its absence can lead to abnormal changes in weight distribution to the residual first metatarsal stump and lesser metatarsals with predisposition to developing lesser toe deformities reulcerations and reamputations particularly in diabetic patients. This study aims to characterise the outcomes after first ray amputation and its associated risk factors with focus on the impact of residual first metatarsal length. METHODS All diabetic patients with first ray amputations from January 2012 to December 2016 were reviewed. Residual first metatarsal length was measured using postoperative radiographs. Risk factors for outcomes such as readmission, reulceration and/or reamputation, transfer ulceration and/or amputation of lesser toes, proximal amputations, ulcer-free duration (UFD) and mortality were analysed using bivariate logistic/linear regression followed by multiple logistic/linear regression models adjusting for confounding factors. RESULTS Among 89 patients with first ray amputations, 65.3 % needed readmission for further treatment. Although only 10.1 % had reulceration at the first ray which all led to reamputation, there were 56.2 % with transfer ulceration and 40.4 % with transfer amputation of the lesser toes in this cohort. The prevalence of transmetatarsal amputation was 18 % and proximal amputations at 12.4 % while the average UFD was 27 months. Mortality rate was 31.5 % with an average of 3-year survival. Preservation of the first metatarsal length via metatarsophalangeal joint disarticulation independently reduced likelihood of readmissions and residual metatarsal length of > one third when compared to < one third after first ray amputations had lower likelihood of transfer amputation of lesser toes. CONCLUSION First ray amputation in diabetic patients leads to significant morbidities and mortality. Preservation of the residual first metatarsal length independently reduced the likelihood of readmissions and transfer amputation to the lesser toes.
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Affiliation(s)
- Choon Chiet Hong
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore, Singapore.
| | - Soura Saha
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore, Singapore.
| | - Christopher Jon Pearce
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore, Singapore.
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7
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Choi Y, Lee HS, Kim JW, Lee BS, Lee WJ, Jung HG. Analysis of repeated lesions after diabetic forefoot amputation. Diabetes Res Clin Pract 2022; 190:109992. [PMID: 35842029 DOI: 10.1016/j.diabres.2022.109992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 11/03/2022]
Abstract
AIM This study was performed to analyze the clinical characteristics, related factors, and prognosis of repeated lesions after diabetic forefoot amputation. METHODS The medical records of 998 patients who underwent forefoot amputation because of their diabetic feet from March 2002 to February 2021 were retrospectively analyzed. Of the 508 selected patients with a follow-up period of at least 6 months, 288 had repeated lesions in the forefoot, and 220 did not have repeated lesions. The related factors of repeated lesions were compared and analyzed. Of the patients with repeated lesions, 142 and 104 on the ipsilateral and contralateral sides, respectively were also compared and examined. RESULTS Repeated lesions were statistically significant in diabetic polyneuropathy, vascular calcification, and dialysis. However, the anatomical positions of diabetic foot lesions, causes of lesions, anatomical amputation levels, number of surgeries, and management duration had no significant differences. Contralateral lesions occurred 8 months later than ipsilateral lesions, but reamputation above the Lisfranc joint was more frequent and prognosis was poorer. CONCLUSIONS Repeated lesions were affected by general conditions, and the contralateral side must be carefully examined after diabetic forefoot amputation.
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Affiliation(s)
- Youngrak Choi
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Ho Seong Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea.
| | - Ji Wan Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Bum-Sik Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Woo Je Lee
- Asan Diabetes Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Hong-Geun Jung
- Department of Orthopedic Surgery, Konkuk University School of Medicine, Seoul 05030, Republic of Korea
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Speer CG, Rendos NK, Davis CE, Au B, Manway JM, Burns PR. Reoperation, reamputation, and new ulceration following complete or partial toe amputation among diabetic and non-diabetic patients. Diabetes Res Clin Pract 2021; 179:109008. [PMID: 34411621 DOI: 10.1016/j.diabres.2021.109008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 07/19/2021] [Accepted: 08/11/2021] [Indexed: 01/22/2023]
Abstract
AIMS To compare the number of reoperations, reamputations, and new ulcers following toe amputation in diabetic and non-diabetic patients with sub-group analysis on index amputation level. METHODS One-hundred sixteen patients with a complete (CTA) or partial (PTA) toe amputation and minimum of 12-month (12 M) follow-up were identified in electronic medical records. The number of reoperations and reamputations, number and location of new ulcers, and final amputation level of the ipsilateral extremity were compared between diabetic and non-diabetic patients and between those with CTA and PTA at 12 M and final follow-up (FFU). RESULTS Diabetic patients had significantly more reoperations, reamputations, and new ulcers than non-diabetic patients at 12 M and FFU. There were no differences in reoperations, reamputations, or new ulcer location between CTA and PTA; however, patients with PTA developed more new ulcers at 12 M and FFU and were more likely to have a distal final amputation level compared to those with CTA. CONCLUSIONS Diabetic patients required significantly more reoperations and reamputations following a toe amputation and developed more new ulcers than non-diabetic patients regardless of index amputation level. These high rates among diabetic patients highlight the complications encountered following toe amputation and emphasize the need for close, multi-disciplinary care.
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Affiliation(s)
- Carl G Speer
- Emerald Coast Foot and Ankle Center, 8333 N Davis Highway, Suite 6E, Pensacola, FL, 32514, United States; Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center, 1400 Locust Street, Pittsburgh, PA 15219, United States.
| | - Nicole K Rendos
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, 1441 Clifton Road NE, Atlanta, GA 30322, United States.
| | - Calvin E Davis
- Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center, 1400 Locust Street, Pittsburgh, PA 15219, United States.
| | - Brian Au
- Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center, 1400 Locust Street, Pittsburgh, PA 15219, United States.
| | - Jeffrey M Manway
- Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center, 1400 Locust Street, Pittsburgh, PA 15219, United States.
| | - Patrick R Burns
- Podiatric Medicine and Surgery Residency Program, University of Pittsburgh Medical Center, 1400 Locust Street, Pittsburgh, PA 15219, United States.
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9
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Collins PM, Joyce DP, O'Beirn ES, Elkady R, Boyle E, Egan B, Tierney S. Re-amputation and survival following toe amputation: outcome data from a tertiary referral centre. Ir J Med Sci 2021; 191:1193-1199. [PMID: 34156661 DOI: 10.1007/s11845-021-02682-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/09/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Toe amputation is a commonly performed procedure for irreversible foot sepsis. However, outcome and predictors of outcome are poorly understood. Our aim was to determine survival and rate of progression to further amputation following index toe amputation. METHODS Consecutive patients between 2010 and 2015 were included. Progression to further minor amputation, major amputation or death was recorded. Multivariable Cox regression analyses were undertaken to determine independent predictors of outcome and survival. RESULTS One hundred forty-six patients were included, with mean age of 65 years. Fifty-five (37.7%) patients underwent hallux amputation, while 91 (62.3%) underwent amputation of non-hallux digit(s). Following index toe amputation, 63 (43.2%) patients progressed to further minor or major ipsilateral amputation, median time to which was 36 months. Twenty-one patients (14.4%) progressed to major ipsilateral amputation. Patients undergoing index non-hallux amputation were significantly more likely to require further minor amputation (P = 0.050); however, the rate of major amputation between hallux (14.5%) and non-hallux (14.3%) groups was similar. Overall, 5-year ipsilateral amputation-free (iAFS) was 39.6 ± 4.1%, ipsilateral major amputation-free (iMAFS) was 55.9 ± 4.1% and overall survival (OS) was 64.3 ± 4.0% and did not differ between index amputation sites. CONCLUSION Almost half of patients undergoing toe amputation required further digital amputation. However, limb preservation rates are high, and a majority of patients are alive at 5-year follow-up. There was no significant difference in outcome between patients undergoing hallux and non-hallux primary procedures. Overall, increasing age remains the only independent predictor of iMAFS and OS.
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Affiliation(s)
- Patrick M Collins
- Department of Vascular Surgery, Tallaght University Hospital, Tallaght, Dublin 24, Ireland
| | - Doireann P Joyce
- Department of Vascular Surgery, Tallaght University Hospital, Tallaght, Dublin 24, Ireland
| | - Ellen S O'Beirn
- Department of Vascular Surgery, Tallaght University Hospital, Tallaght, Dublin 24, Ireland
| | - Ramy Elkady
- Department of Vascular Surgery, Tallaght University Hospital, Tallaght, Dublin 24, Ireland
| | - Emily Boyle
- Department of Vascular Surgery, Tallaght University Hospital, Tallaght, Dublin 24, Ireland
| | - Bridget Egan
- Department of Vascular Surgery, Tallaght University Hospital, Tallaght, Dublin 24, Ireland
| | - Sean Tierney
- Department of Vascular Surgery, Tallaght University Hospital, Tallaght, Dublin 24, Ireland. .,Royal College of Surgeons in Ireland, Dublin 2, Ireland.
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Liu R, Petersen BJ, Rothenberg GM, Armstrong DG. Lower extremity reamputation in people with diabetes: a systematic review and meta-analysis. BMJ Open Diabetes Res Care 2021; 9:9/1/e002325. [PMID: 34112651 PMCID: PMC8194332 DOI: 10.1136/bmjdrc-2021-002325] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 05/09/2021] [Indexed: 12/03/2022] Open
Abstract
In this study, we determined the reamputation-free survival to both limbs and to the contralateral limb only following an index amputation of any-level and assessed whether reamputation rates have changed over time. We completed a systematic search using PubMed and screened a total of 205 articles for data on reamputation rates. We reported qualitative characteristics of 56 studies that included data on reamputation rates and completed a meta-analysis on 22 of the studies which enrolled exclusively participants with diabetes. The random-effects meta-analysis fit a parametric survival distribution to the data for reamputations to both limbs and to the contralateral limb only. We assessed whether there was a temporal trend in the reamputation rate using the Mann-Kendall test. Incidence rates were high for reamputation to both limbs and to the contralateral limb only. At 1 year, the reamputation rate for all contralateral and ipsilateral reamputations was found to be 19% (IQR=5.1%-31.6%), and at 5 years, it was found to be 37.1% (IQR=27.0%-47.2%). The contralateral reamputation rate at 5 years was found to be 20.5% (IQR=13.3%-27.2%). We found no evidence of a trend in the reamputation rates over more than two decades of literature analyzed. The incidence of lower extremity reamputation is high among patients with diabetes who have undergone initial amputations secondary to diabetes, and rates of reamputation have not changed over at least two decades.
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Affiliation(s)
- Rongqi Liu
- Podimetrics Inc, Somerville, Massachusetts, USA
- Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Gary M Rothenberg
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - David G Armstrong
- Department of Surgery, USC Keck School of Medicine, Los Angeles, California, USA
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11
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Littman AJ, Young J, Moldestad M, Tseng CL, Czerniecki JR, Landry GJ, Robbins J, Boyko EJ, Dillon MP. How patients interpret early signs of foot problems and reasons for delays in care: Findings from interviews with patients who have undergone toe amputations. PLoS One 2021; 16:e0248310. [PMID: 33690723 PMCID: PMC7946282 DOI: 10.1371/journal.pone.0248310] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/23/2021] [Indexed: 11/18/2022] Open
Abstract
Aims To describe how patients respond to early signs of foot problems and the factors that result in delays in care. Methods Semi-structured interviews were conducted with a large sample of Veterans from across the United States with diabetes mellitus who had undergone a toe amputation. Data were analyzed using inductive content analysis. Results We interviewed 61 male patients. Mean age was 66 years, 41% were married, and 37% had a high school education or less. The patient-level factors related to delayed care included: 1) not knowing something was wrong, 2) misinterpreting symptoms, 3) “sudden” and “unexpected” illness progression, and 4) competing priorities getting in the way of care-seeking. The system-level factors included: 5) asking patients to watch it, 6) difficulty getting the right type of care when needed, and 7) distance to care and other transportation barriers. Conclusion A confluence of patient factors (e.g., not examining their feet regularly or thoroughly and/or not acting quickly when they noticed something was wrong) and system factors (e.g., absence of a mechanism to support patient’s appraisal of symptoms, lack of access to timely and convenient-located appointments) delayed care. Identifying patient- and system-level interventions that can shorten or eliminate care delays could help reduce rates of limb loss.
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Affiliation(s)
- Alyson J. Littman
- Department of Veterans Affairs Puget Sound Health Care System, Seattle Epidemiologic Research and Information Center, Seattle, WA, United States of America
- Department of Veterans Affairs Puget Sound Health Care System, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States of America
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, United States of America
- * E-mail:
| | - Jessica Young
- Department of Veterans Affairs Puget Sound Health Care System, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States of America
| | - Megan Moldestad
- Department of Veterans Affairs Puget Sound Health Care System, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, United States of America
| | - Chin-Lin Tseng
- Veterans Affairs New Jersey Healthcare System, East Orange, NJ, United States of America
| | - Joseph R. Czerniecki
- Department of Veterans Affairs Puget Sound Health Care System, Veterans Affairs Center for Limb Loss and Mobility (CLiMB), Seattle, WA, United States of America
- Department of Veterans Affairs Puget Sound Health Care System, Rehabilitation Care Services, Seattle, WA, United States of America
- Department of Rehabilitation, School of Medicine, University of Washington, Seattle, WA, United States of America
| | - Gregory J. Landry
- Oregon Health & Science University, Portland, OR, United States of America
| | | | - Edward J. Boyko
- Department of Veterans Affairs Puget Sound Health Care System, Seattle Epidemiologic Research and Information Center, Seattle, WA, United States of America
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, United States of America
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, United States of America
| | - Michael P. Dillon
- Department of Physiotherapy, Discipline of Prosthetics and Orthotics, Podiatry, and Prosthetics and Orthotics, School of Allied Health, Human Services and Sports, La Trobe University, Melbourne, Victoria, Australia
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12
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Littman AJ, Timmons AK, Moore KP, Tseng CL, Landry G, Robbins JM, Korpak A, Boyko EJ. Comparison of Diagnostic Accuracy for Lower-Extremity Amputation Codes During the ICD-9 and ICD-10 Eras in a High-Risk Population of Patients With Diabetes. Diabetes Care 2021; 44:e48-e49. [PMID: 33436400 DOI: 10.2337/dc20-2452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 11/28/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Alyson J Littman
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA .,Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA.,Department of Epidemiology, University of Washington School of Public Health, Seattle, WA
| | - Andrew K Timmons
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Kathryn P Moore
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Chin-Lin Tseng
- Veterans Affairs New Jersey Health Care System, East Orange, NJ
| | | | | | - Anna Korpak
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA.,Department of Epidemiology, University of Washington School of Public Health, Seattle, WA.,Department of Medicine, University of Washington School of Medicine, Seattle, WA
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