Reassessing Mortality After Lower Extremity Amputation With a Multidisciplinary Approach Focused on Function

Abstract

The recently published Global Vascular Guidelines on the management of chronic limb-threatening ischemia discuss the necessary role of lower extremity amputation (LEA). Five-year mortality rates after LEA in the chronic wound population have long been regarded as high and ineviTable with accepted 5-year mortality rates exceeding 50%. While acknowledging the high risk of mortality, the Global Vascular Guidelines emphasize that major LEA is an important option in a vascular surgeon’s armamentarium which can achieve good functional outcomes when a well-planned surgical approach is utilized. The aim of this study was to assess 5-year mortality after LEA performed with a multidisciplinary approach focused on function. We retrospectively enrolled all patients who underwent nontraumatic LEA at our institution from 2010 to 2013. Patients were stratified by LEA type: minor (toe, ray, transmetatarsal amputation, Lisfranc, Chopart, Symes) or major (below the knee amputation, above the knee amputation) to compare mortality. Key tenets of our major LEA surgical technique include myodesis of the peroneal muscle to the anterior tibialis and tibia, tenodesis of the Achilles tendon to the tibia, and utilization of the posterior myocutaneous flap (gastrocnemius-soleus complex) for closure. This optimizes joint motion and prevents atrophy of the gastrocnemius-soleus complex ensuring soft tissue bulk necessary for prosthesis use is maintained. Our multidisciplinary team, consisting of wound care, reconstructive, podiatric, vascular, and prosthetic specialists, ensures recovery and post-LEA function. Mortality was established via medical records and a commercial database. Kaplan-Meier estimates and log-rank tests were used to analyze 5-year mortality. Four hundred eighteen patients were identified: 223 minor and 195 major LEA. The Charlson Comorbidity Index was 5.0 ± 2.5. Seventy-five percent of patients were diabetic while 53% had a known diagnosis of peripheral vascular disease. Five-year mortality was 31% (Fig 1). Five-year mortality was not significantly different for minor (30%) versus major (33%) LEA (Fig 2; P = .5044). Within the major LEA cohort, peripheral vascular disease was not statistically significant for mortality at 5 years (P = .1620). We have demonstrated improved 5-year mortality after LEA with multidisciplinary care focused on functional outcomes. Major LEA can achieve comparable survival to minor podiatric amputations when performed with meticulous surgical technique that creates a stump optimal for future prosthesis wear and ambulation. These techniques are essential to achieving successful limb salvage, which is evaluated by preservation of function instead of limb length.Fig 2Comparison of mortality estimates for major versus minor amputation cohorts. Mortality at five years was comparable between cohorts (p=0.5044).View Large Image Figure ViewerDownload Hi-res image Download (PPT)