Below The Knee Amputation Research Articles

Postoperative Casting of Below-Knee Amputation Reduces StumpComplications

Against the technological advances in limb salvage, below-the-knee amputation (BKA) remains a common procedure. Although most elective BKA is classified as clean operation, the reported stump complication rate is much higher than predicted. Postoperative casting (PC) may reduce the number of these complications. The aim of this study was to compare the efficacy of elastic bandage with knee immobilizer (EBKI) and PC in BKA stump complications. Retrospective cohort comparison design identified patients who underwent BKA between 2000 and 2023 for non-correctable critical limb ischemia (CLI), or excessive tissue loss secondary to CLI, infection, severe neuropathy, or the combination of these and stratified them into 2 cohorts based on their postoperative stump dressing: EBKI and PC. BKAs that were done for trauma or neoplastic processes were excluded. The primary outcome measures: wound healing in 6weeks and length of stay (LOS). stump injury, infection, dehiscence, necrosis, number of higher-level amputations, knee contracture, and post-BKA mobility with Special Interest Group of Amputee Medicine score. One hundred sixteen patients with 122 limbs (52 EBKI and 70 PC) were found who met inclusion criteria and analyzed. The groups were comparable in demographics and comorbidities and preoperative variables, including mobility. The primary wound healing at 6weeks was higher (P=0.007); wound dehiscence (P=0.01) and LOS (P=0.006) was lower in the PC group compared to EBKI group. The PC group achieved higher Special Interest Group of Amputee Medicine mobility score and lower number of contractures developed compared to the EBKI group. Applying and maintaining PC to the BKA stump during the first month of healing reduced the incidence of stump complications, shortened the LOS, and improved postrehabilitation mobility results. We found no effect of PC on postoperative infections, stump necrosis, and higher-level amputations.

A Case-Based Discussion Supporting Ethics Education in Medical Schools

Background: Ethics education in medical schools lacks uniformity, yielding uncertainty when providers are faced with ethically complex patients. Without streamlined ethics training, providers are less confident in their ability to provide ethically appropriate care for all patients, particularly for those most ethically vulnerable. This case report seeks to elucidate ethical concerns when treating an ethically complex patient. Subsequently, the need for early ethics education is substantiated. The Case: A 58-year-old unhoused patient with no known medical history presented to the emergency department (ED) for evaluation of an infected foot wound. Imaging confirmed acute gas gangrene osteomyelitis. The patient refused the recommended below-the-knee amputation (BKA) but was amenable to intravenous antibiotic therapy. He was subsequently determined by psychiatry to lack decisional capacity and met the DSM-5 criteria for schizoaffective psychosis. Subsequently, the patient’s brother deferred decision-making to the patient, who he believed should make his own medical decisions. Following an ethics consultation, the brother’s decision, and by proxy the patient’s, was respected. Conclusion: In this case, the patient’s autonomy was prioritized, despite his high level of ethical vulnerability. Ethically conscious treatment was provided despite the implicit stigmatization of homelessness and psychiatric illness. However, an ethics consultation was necessary for this to occur. Ultimately, this paper should serve as a call to action for standardization and prioritization of ethics education during and beyond medical training.

To Cut or to Cast? An Evaluation of Demographics & Mortality in Operative, Conservative, and Failed- Conservative Management of Charcot Neuroarthropathy

Category: Midfoot/Forefoot; Diabetes Introduction/Purpose: Charcot neuroarthropathy (CN) is a chronic, destructive disease linked with diabetic neuropathy that affects the bone structure, joints, and soft tissues of the foot. Treatment can vary from a conservative shoe modification to a below-the-knee amputation (BKA). With no evidence based guidelines for CN management, treatment regimens are physician specific and dependent on stage of CN, comorbidities, and ulceration status. Further, no previous literature has compared the mortality rates of patients that are treated with casting versus common surgical procedures for CN. Here, we provide demographic and all-cause mortality data for patients who underwent casting, arthrodesis, exostectomy, and amputation, to evaluate the outcomes and characterize the populations treated for Charcot neuroarthropathy of the foot. Methods: Institutional review board approval was obtained. A database of all patients from 1/1/2000 to 1/31/2022 with CPT and ICD codes indicating a diagnosis of Charcot neuroarthropathy who underwent exostectomy, arthrodesis, minor amputation, major amputation, and/or casting was created from the electronic medical record. Demographic and mortality data was collected, including date-of-birth, sex, race, and all-cause mortality. Procedure data was collected, which included date, code, and description. Major amputations include transtibial and trans-metatarsal, whereas minor amputations include toe and metatarsal. In the casting group, patients were separated into two groups: casting as the sole intervention and failed casting that ultimately went on to have surgery. Patients who had postoperative casting or multiple instances of casting and surgery were excluded. Descriptive statistics were conducted and single-factor ANOVA and Chi squared tests were used for analysis. Results: A total of 2,130 patients were identified; 546 had arthrodesis, 488 had exostectomy, 677 had minor amputations, 332 had major amputations, 64 had casting only, and 23 failed casting. Of the 23 patients who failed casting and went on to have surgery, 11 had arthrodesis, 5 had exostectomy, 4 had minor amputation, and 3 had major amputation. The average overall was 57.7 ± 13.9. Mortality rates were 10.3%, 11.3%, 34.0%, 32.2%, 7.8%, 17.4% in the arthrodesis, exostectomy, minor amputation, major amputation, casting only, and failed casting groups, respectively (Figures 1A and 1B). Of those that failed casting and then had surgery, arthrodesis was the most common procedure. Conclusion: Treatment options for patients with CN range from simple casting to invasive amputation. Overall, patients who underwent casting as their sole intervention had a significantly lower all-cause mortality (7.8%) compared to those who had amputation (34% for minor amputations and 32.2% for major amputations). There was no significant difference in all-cause mortality between casting only and failed casting groups. These findings demonstrate a significant disparity in outcomes between conservative and operative management for CN. Understanding the mortality of the various treatment options for CN can help optimize standards of care to improve patient outcomes.

A Step in the Right Direction: Analyzing Differences in Demographics and Mortality in Operative Management of Charcot Neuroarthropathy

Category: Midfoot/Forefoot; Diabetes Introduction/Purpose: Charcot neuroarthropathy (CN) of the foot is a debilitating condition associated with diabetic neuropathy that involves progressive bone and joint destruction. Previous literature suggests the prevalence of CN is between 0.8%-8% in diabetic patients; however, CN diagnosis relies on skilled physician judgment, ultimately making management difficult. Physicians must account for the location, deformity, stage, and presence or absence of infection to appropriately treat CN. Correct diagnosis and treatment is essential to improving patients’ quality of life, but treatment varies with no definitive best-practice guidelines. Here, we provide demographic and all-cause mortality data for patients who underwent arthrodesis, exostectomy, minor amputations, and below-the-knee amputation (BKA), to evaluate the outcomes and characterize the populations managed with surgery for Charcot neuroarthropathy of the foot. Methods: Institutional review board approval was obtained. A database of all patients from 1/1/2000 to 1/31/2022 with CPT and ICD codes indicating a diagnosis of Charcot neuroarthropathy who underwent exostectomy, arthrodesis, and/or amputation was created from the electronic medical record. Demographic and mortality data was collected for the study sample, including date-of- birth, sex, race, and all-cause mortality. Procedure data was also collected, which included date, code, and description. Amputation patients were separated into major and minor; major include transtibial and trans-metatarsal, whereas minor include toe and metatarsal amputations. Descriptive statistics were conducted and single-factor ANOVA and Chi squared tests were used for analysis. Results: Of the 2,066 patients; 557 had arthrodesis, 493 had exostectomy, 681 had minor amputation, and 335 had major amputation. Average age was 58.17 ± 13.8 overall, and 54.8 ± 13.6, 55.0 ± 13.0, 61.6 ± 13.6, and 61.5 ± 13.4 years for arthrodesis, exostectomy, minor amputation, and major amputation, respectively. Females accounted for 56.6% of arthrodeses, 56.8% of exostectomies, 34.5% of minor amputations, and 28.4% of major amputations performed (p < 0.001). Patients were predominantly white in each group and overall, 2.1% were tobacco smokers. Mortality was 10.6%, 11.4%, 33.8%, and 31.9% in the arthrodesis, exostectomy, minor amputation, and major amputation groups, respectively (Figure 1). Conclusion: This is the first report of significant sample size (>2,000 patients) comparing both demographic and mortality between common surgical procedures for Charcot neuroarthropathy. Patients undergoing both minor and major amputations were more likely to be older and male compared to those undergoing less intensive operations. Most importantly, this data demonstrates that patients undergoing amputation have significantly worse mortality (33.8% and 31.9%) than those who undergo arthrodesis (10.6%) and exostectomy (11.4%). Future studies may include an analysis of cause-specific mortality for patients diagnosed with CN to evolve clinical and surgical management.

EPH96 Risk Factors for Below-the-Knee Amputation in Japanese Patients With Critical Limb Ischemia Who Underwent Plain Old Balloon Angioplasty Therapy: A Claims Database Analysis

Plain old balloon angioplasty (POBA) is a common endovascular therapy for below-the-knee lesions in patients with critical limb ischemia (CLI). However, restenosis often develops, resulting in amputation. This study examined the risk factors for below-the-knee amputation (BKA) in CLI patients that underwent POBA.

Serial Peripheral Nerve Blocks to Aid in Salvage of a Compromised Limb: A Case Report.

The management of postsurgical thrombosis in a medically complicated patient is often not straightforward. We describe a case of a congenital heart disease patient with multiple risk factors for thrombosis with a compromised limb immediately after heart transplant who received serial daily peripheral nerve blocks (PNBs) resulting in limb salvage. The analgesic effects of the blocks allowed for clinical progression and participation in rehabilitation therapy, and the vasodilatory effects of the blocks helped prevent a below the knee amputation (BKA) in this devitalized and congested extremity.

Utilizing of Removable Rigid Dressing to Decrease Below the Knee Amputations to Above the Knee Amputations Conversion Rates.

Below the knee amputations (BKAs) are preferred to above the knee amputations (AKAs) due to better rehabilitation and functional outcomes. Assessment of literature for best practice identified that utilization of a removable rigid dressing (RRD) improves post-operative BKA care by expediting wound healing and reduces the hospital length of stay compared to a soft dressing. We hypothesized that there would be a decrease of conversions from BKA to AKA following utilizing of RRD device. Retrospective chart review of all BKA performed by the vascular surgery service at a tertiary care hospital between January 2017 and December 2021. Demographic data obtained including age, body mass index (BMI), comorbid conditions, infection at time of BKA, anesthesia type, and operative blood loss. Data analyzed using Wilcoxon rank sum, Fisher's exact, and Student's t-tests. This study was approved by the institutional review board. From 2017 to 2019, conversion to AKA occurred in 18 out of the 42 patients who underwent BKA (42.86%) within the first 4-week post-operative period. After the standard used of a RRD, 53 patients underwent BKA surgery, with only 4 (7.55%) requiring conversion to AKA within the 4-week post-operative period. Utilizing a RRD after BKA can improve wound healing, protect the residual limb, and help prevent conversions to AKA. In this retrospective review at a single institution there was a decrease of conversion from BKA to AKA in a 2-year period. Ridged removal dressings should be considered first-line therapy in the post-operative care of BKA patients.

Opioid utilization after lower extremity amputation for peripheral vascular disease and discharge prescribing recommendations.

Opioids are commonly used for pain control after lower extremity amputations (LEA)-below the knee amputations (BKA) and above the knee amputations (AKA). Well-defined benchmarks for prescription requirements after amputation are deficient. This analysis evaluated opioid utilization after amputation to identify high-risk patients and provide recommendations for post-hospitalization opioid prescriptions at discharge. Patients undergoing LEA (2008-2016) with identified peripheral vascular disease were selected from Cerner's Health Facts® database using ICD-9 and 10 diagnosis and procedure codes. Patient demographics, disease severity, comorbidities, and hospital characteristics were evaluated. Post-operative opioid medications administered intravenously and orally during the hospital stay were identified from the data and converted to Morphine Milligram Equivalent per day (MME/d) for an evaluation and comparison during the index hospitalization. Descriptive statistics were used to report continuous and dichotomous variables. Dichotomous variables are reported as n (%) and continuous variables are reported as mean ± standard deviation (SD). Chi-square and T-tests were used as appropriate. 2399 patients who underwent AKA or BKA with peripheral vascular disease were evaluated. Sixty-three percent of the cohort was male, 67% Caucasian, and 42% married, and 58% had a Charlson index >3. The majority of patients had an average length of hospital stay of 5.7 days (M = 5.72, SD = 4.56). Patient groups that used significantly higher MME/d in the early postop period included: BKA (29.2 vs 20.7, p = 0.006), males (62.6 vs 54.0, p < 0.0001), Caucasians (64.3 vs 44.7, p < 0.0001), younger patients (69.6 vs 54.0, p < 0.0001), and those at non-training institutions (66.7 vs 56.7, p < 0.0001). Patients whose hospital stay was greater than 6 days were found to have increased opioid utilization likely secondary to index complications. For those discharged by post-operative day 7, the mean MME utilized on postop day 1 was 59.5 and decreased to a mean MME/d utilization prior to discharge of 17.6. This analysis demonstrates that younger patients, males, patients with BKAs, and those who receive amputations for vascular disease at non-training institutions have higher post-operative opioid utilization during the hospital stay. At the time of discharge, patients utilized an average of 17.6 MME/d which equates to approximately three hydrocodone/acetaminophen 5/325mg tablets per day. Based on these findings, vascular surgeons are likely over prescribing opioids at discharge and must be cognizant of appropriate dosing quantities. Prescriptions at discharge should reflect the daily utilization described from this analysis and tapered to avoid chronic utilization, overdose, and possible death.

Assessing Resident Impact on Surgical Outcomes in Below-the-Knee Amputations Based on Operative Autonomy

Gradual increases in resident autonomy with attending physician oversight is crucial to developing safe and competent surgeons1. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) follows surgical outcomes within the VA. We set forth to examine the VASQIP database to compare outcomes between resident independent cases and nonindependent cases during below-the-knee amputations (BKA). All VASQIP records for BKA from 2000 to 2020 were examined and categorized based on whether the attending was scrubbed during the case. Case matching was performed based on preoperative comorbidities; 30-day postoperative outcomes, including a return to the operating room, wound infection, and mortality, were assessed in addition to operative time, hospital length of stay, and transfusion requirements. Student's t-test and Fisher's Exact Test were utilized. A total of 13,208 BKA VASQIP records were obtained. After case control matching, 2,688 cases remained. Cases were identified with the attending surgeon noted as being scrubbed during the case (n=1,344), or not scrubbed (n=1,344). Patients were similar in comorbidities across both groups. No statistically significant difference in operative time (1.52hr±0.78 vs. 1.47hr±0.75, P=0.08), 30-day mortality (3.3% vs. 4.8%, P=0.05), or complication rate (19.5% vs. 21.3%, P=0.25). Resident independent cases were noted to have slightly longer postop length of stay (12.47days±12.69 vs. 15.33days±20.56, P<0.01) and operative bleeding requiring more than 4 units transfused (0.3% vs. 1.3%, P≤ 0.01). Resident independent operating during below-the-knee amputation at VA hospitals is associated with an increased length of stay and blood transfusion. There was no statistically significant increase in operative time, 30-day mortality, or total complication rate. Further research is required to assess the risks associated with surgical training, resident supervision, and resident preparedness for independent practice.

Prophylactic Regenerative Peripheral Nerve Interfaces in Elective Lower Limb Amputations.

Regenerative peripheral nerve interface (RPNI) is a relatively new surgical technique to manage neuromas and phantom pain after limb amputation. This study evaluates prophylactic RPNI efficacy in managing post-amputation pain and neuroma formation in amputees compared with patients in which lower limb amputation was performed without this procedure. We included 28 patients who underwent above the knee amputation (AKA) or below the knee amputation (BKA) for severe soft tissue infection from July 2019 till December 2020. All patients had insulin-dependent diabetes. The patients were divided into two groups, 14 patients with primary RPNI and 14 patients without. We analyzed the demographic data, level of amputation, number of RPNIs, operative time, postoperative complications and functional outcome on the defined follow up period. The mean patient age was 68.6 years (range 49-85), 19 (67.9 %) male and 9 (32.1 %) female patients. In this study 11 (39.3 %) AKA and 17 (60.7 %) BKA were performed. Overall, 37 RPNIs were made. The mean follow-up period was 49 weeks. PROMIS T-score decreased by 15.9 points in favor for the patients with RPNI. The VAS score showed that, in the RPNI group, all 14 patients were without pain compared to the group of patients without RPNI, where the 11 (78.6 %) patients described their pain as severe. Patients with RPNI used prosthesis significantly more (p < 0.005). Data showed significant reduction in pain and high patient satisfaction after amputation with RPNIs. This technique is oriented as to prevent neuroma formation with RPNI surgery, performed at the time of amputation. RPNI surgery did not provoke complications or significant lengthening of operative time and it should be furthermore exploited as a surgical technique.

Self-Identified Female Patients Experience Worse Outcomes After Carotid Endarterectomy, Endovascular Abdominal Aortic Aneurysm Repair, and Lower Extremity Amputation: Gender Disparities in Vascular Surgery

Carotid endarterectomy (CEA), endovascular abdominal aortic aneurysm repair (EVAR), and below-the-knee amputation (BKA) are frequently performed procedures in vascular surgery. Controlling for a naturally occurring higher prevalence of vascular disease in the biologically male population, we sought to determine whether gender disparities exist in the outcomes of these commonly performed procedures.

Operative Autonomy: Assessing Resident Impact on Surgical Outcomes In Below The Knee Amputations

INTRODUCTION AND OBJECTIVES Gradual increases in autonomy with attending physician oversight are consider crucial to successful training in surgery as well as safe patient care. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) follows patient outcomes and has yet to be examined for outcomes of specialty and includes information about attending surgeon oversight in the operation room (OR). We set forth to examine VASQIP database to determine the frequency of resident operative independence during below the knee amputations (BKA). METHODS All VASQIP records for BKA from 1990 to 2018 were examined and categorized based on if the attending was scrubbed during case. Case matching was performed based on gender, diabetes, preoperative renal failure, smoking status, steroid use, CHF, COPD, and open wound infections. Comorbidities, pre- and postoperative outcomes for each procedure within 30 days were tabulated. 30 day post-operative outcomes including return to the operating room, wound infections mortality were assessed in addition to operative time, hospital length of stay and transfusion requirements. Student t-test* and Fisher's Exact Test⁎⁎ were utilized. RESULTS A total of 28,768 BKA VASQIP records were obtained. After case control matching, 5,234 cases remained. Cases were identified with the attending surgeon noted as being scrubbed during the case (n=2617), or not scrubbed (n=2617). Patients were similar in comorbidities across both. CONCLUSIONS Increased resident independence during BKA at VA hospitals is associated with a statistically significant length of stay, return to OR, blood transfusion, and sepsis. There was no statistically significant increase in operative time, 30-day mortality, wound infection, or total complication. Further research is required in assessing the risks associated with surgical training, resident supervision, and resident preparedness for independent practice. Gradual increases in autonomy with attending physician oversight are consider crucial to successful training in surgery as well as safe patient care. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) follows patient outcomes and has yet to be examined for outcomes of specialty and includes information about attending surgeon oversight in the operation room (OR). We set forth to examine VASQIP database to determine the frequency of resident operative independence during below the knee amputations (BKA). All VASQIP records for BKA from 1990 to 2018 were examined and categorized based on if the attending was scrubbed during case. Case matching was performed based on gender, diabetes, preoperative renal failure, smoking status, steroid use, CHF, COPD, and open wound infections. Comorbidities, pre- and postoperative outcomes for each procedure within 30 days were tabulated. 30 day post-operative outcomes including return to the operating room, wound infections mortality were assessed in addition to operative time, hospital length of stay and transfusion requirements. Student t-test* and Fisher's Exact Test⁎⁎ were utilized. A total of 28,768 BKA VASQIP records were obtained. After case control matching, 5,234 cases remained. Cases were identified with the attending surgeon noted as being scrubbed during the case (n=2617), or not scrubbed (n=2617). Patients were similar in comorbidities across both. Increased resident independence during BKA at VA hospitals is associated with a statistically significant length of stay, return to OR, blood transfusion, and sepsis. There was no statistically significant increase in operative time, 30-day mortality, wound infection, or total complication. Further research is required in assessing the risks associated with surgical training, resident supervision, and resident preparedness for independent practice.

A Focus on Amputation Level: Factors Preventing Length Preservation in the National Inpatient Sample.

Diabetic lower-extremity disease is the primary driver of mortality in patients with diabetes. Amputations at the forefoot or ankle preserve limb length, increase function, and, ultimately, reduce deconditioning and mortality compared with higher-level amputations, such as below-the-knee amputations (BKAs). We sought to identify risk factors associated with amputation level to understand barriers to length-preserving amputations (LPAs). Diabetic lower-extremity admissions were extracted from the 2012-2014 National Inpatient Survey using ICD-9-CM diagnosis codes. The main outcome was a two-level variable consisting of LPAs (transmetatarsal, Syme, and Chopart) versus BKAs. Logistic regression analysis was used to determine contributions of patient- and hospital-level factors to likelihood of undergoing LPA versus BKA. The study cohort represented 110,355 admissions nationally: 42,375 LPAs and 67,980 BKAs. The population was predominantly white (56.85%), older than 50 years (82.55%), and male (70.38%). On multivariate analysis, living in an urban area (relative risk ratio [RRR] = 1.48; P < .0001) and having vascular intervention in the same hospital stay (RRR = 2.96; P < .0001) were predictive of LPA. Patients from rural locations but treated in urban centers were more likely to receive BKA. Minorities were more likely to present with severe disease, limiting delivery of LPAs. A high Elixhauser comorbidity score was related to BKA receipt. This study identifies delivery biases in amputation level for patients without access to large, urban hospitals. Rural patients seeking care in these centers are more likely to receive higher-level amputations. Further examination is required to determine whether earlier referral to multidisciplinary centers is more effective at reducing BKA rates versus satellite centers in rural localities.

Loss of independence as a metric for racial disparities in lower extremity amputation for diabetes: A National Surgery Quality Improvement Program (NSQIP) analysis

IntroductionThis study assessed the association between race/ethnicity and amputation with mortality and loss of independence (LOI) for diabetic gangrene. MethodsWe analyzed the American College of Surgeons National Surgery Quality Improvement Program database from 2016 to 2019. Chi-squared tests were performed to evaluate differences in baseline characteristics and complications. Multivariable logistic regression was performed to model LOI and 30-day mortality. Results5250 patients with diabetes underwent lower extremity amputation as treatment for gangrene. Hispanic patients were more likely to undergo below the knee amputation (BKA) (P = 0.006). Guillotine amputation (GA) was associated with age > 65 (P < 0.0001), independent functional status prior to admission (P < 0.0001), and mortality (OR 1.989, 95%CI 1.29–3.065), but was not associated with LOI. Mortality was less frequent in Black patients (OR 0.432, 95%CI 0.207–0.902), but loss of independence (LOI) was more frequent in Black patients (OR 1.373, 95%CI 1.017–1.853). Hispanic patients were less likely to experience LOI (OR 0.575, 95%CI 0.477–0.693). ConclusionsLOI and mortality provide contrasting perspectives on outcomes following lower extremity amputation. Further assessment of risk factors may illuminate healthcare disparities.

Safety and Feasibility of Autologous and Allogeneic Cell Therapy in Preventing Wound Complications After Below-the-knee Amputation

Ischemic wound complications of below-the-knee amputation (BKA) will necessitate conversion to above-the-knee amputation (AKA) in ≤36% of cases. Loss of the knee joint has deleterious effects on patient rehabilitation. Cell therapy has demonstrated proangiogenic benefits in patients with peripheral arterial disease, which might allow for improved wound healing after BKA. We assessed the use of cell therapy in BKA wound healing through a safety and feasibility study.

Opioid Usage After Lower Extremity Amputation and Discharge Prescribing Recommendations

Opioids are commonly used for pain control after lower extremity amputations, including below-the-knee amputations (BKAs) and above-the-knee amputations (AKAs). Well-defined benchmarks for discharge prescription requirements after amputation are deficient. We evaluated opioid usage after amputation to identify high-risk patients and provide recommendations for posthospitalization opioid prescriptions at discharge.

A predictive score for 30-day survival for patients undergoing major lower limb amputation for peripheral arterial obstructive disease

To analyze outcomes following major lower extremity amputations (mLEAs) for peripheral arterial obstructive disease, gangrene, infected non-healing wound and to create a risk prediction scoring system for 30-day mortality. In this single-center, retrospective, observational cohort study. All patients treated with above-the-knee amputation (AKA) or below-the-knee amputation (BKA) between January 1st, 2010 and June 30th, 2018 were identified. The primary outcome of interest was early (≤ 30 days) mortality. Secondary outcomes were postoperative complications and freedom from amputation stump revision/failure. We identified 310 (77.7%) mLEAs performed on 286 patients. There were 188 (65.7%) men and 98 (34.3%) women with a median age of 79 years (IQR, 69–83 years). We performed 257 (82.9%) AKA and 53 (17.1%) BKA. There were 49 (15.8%) early deaths, which did not differ among the age quartiles of this cohort (15.4% vs. 14.3% vs. 15.4% vs. 19.5%, P = 0.826). Binary logistic regression analysis identified age > 80 years (OR 2.24, 95% CI 1.17–4.31; P = 0.015), chronic obstructive pulmonary disease (OR 2.12, 95% CI 1.11–4.06; P = 0.023), and hemodialysis (OR 2.52, 95% CI 1.15–5.52; P = 0.021) to be associated with early mortality. The final score (range 0–10) identified two subgroups with different mortality at 30 days: lower-risk (score < 4, 10.8%), and higher-risk (score ≥ 4: 28.7%; OR 3.2, 95% CI 1.63–6.32; P < 0.001). In our experience, mLEAs still have a 14% mortality rate over the years. Our lower-risk group (score < 4) is characterized by a lower rate of perioperative death and longer survival.Graphic abstract

444-P: Rates and Reasons for 30-Day Readmissions in Hospitalizations among Patients with Diabetes Mellitus Who Underwent Below-Knee Amputation: Analysis of the Nationwide Readmissions Database

Introduction: Diabetes mellitus (DM) is the commonest cause of nontraumatic amputation worldwide. With increasing prevalence of DM, there has been an increase in the rate of below the knee amputations (BKA), usually in the setting of severe soft tissue infections and osteomyelitis. Readmissions are often related to prior admissions and account for significant and usually preventable healthcare cost burden. This study assessed the rate and reasons for 30-day readmissions (30DR) in DM patients with BKA with the aim of identifying preventable factors for readmissions. Methods: The National Readmission Database for 2018 was queried for hospitalizations involving adult patients with DM who had BKA from January 1 to November 30, 2018. Elective and traumatic admissions were excluded. Outcomes assessed were 30DR rates, mortality, length of stay (LOS), hospitalization costs (THC) and top principal diagnosis for readmitted patients following BKA. Results: A total of 15,090 hospitalizations involved adults with DM who had DKA as index admissions. The 30DR rate was 13.79%. The most common reasons for readmission were sepsis unspecified (18.4%), hypertension with CKD and heart failure (7.0%), DM angiopathy with gangrene (4.2%), acute renal failure (3.0%), and hypertension with heart failure (2.1%). Readmission was associated with higher odds of mortality (6.1% vs. 4.3%, OR: 1.45, 95% CI: 1.11 - 1.89, p=0.007) compared to the index admission. In patients with DM with BKA, readmissions accounted for a cumulative 18,078 days of hospitalization, which cost patients over $40 million within the period. Conclusion: A significant proportion of patients with DM with BKA are readmitted for various complications. 30DR is associated with higher mortality and result in a significant cost burden to the patient and healthcare system. Mitigating the rate or readmissions would significantly improve patient outcomes. Disclosure C. D. Corpuz: None. H. Shaka: None. M. Ramirez: None. M. C. Aguilera: None. S. T. Yap: None. A. Kichloo: None. M. Murthi: None. R. Atluri: None. S. Gonakoti: None.

Sex, age, and other barriers for prosthetic referral following amputation and the impact on survival

BackgroundDespite advances in peripheral vascular disease treatment, lower extremity amputation continues to be necessary in a significant number of patients. Up to 80% of amputees are not referred for prosthetic fitting. The factors contributing to referral decisions have not been adequately investigated, nor has the impact of prosthetic referral on survival. We characterized differences between patients who were successfully referred to our in-house prosthetists and those who were not, and identified factors associated with prosthetic referral and predictive of survival. MethodsThis was a retrospective analysis of all patients who underwent lower extremity amputation by surgeons in our practice from January 1, 2010, to June 30, 2017. Data regarding age, sex, race, body mass index (BMI), diabetes, hypertension, hyperlipidemia, end-stage renal disease, prior coronary artery bypass graft surgery, congestive heart failure, tobacco use, American Society of Anesthesiologists (ASA) score, previous arterial procedure, chronic obstructive pulmonary disease, statin use, postoperative ambulatory status, level of amputation, stump revision, and referral for prosthesis were collected. Survival was determined from a combination of sources, including the Social Security Death Master Index, multiple genealogic registries, and internet searches. Multivariable logistic regression was used to determine risk factors associated with prosthesis referral. Multivariable Cox proportional hazard regression with time-dependent covariates was performed to assess risk factors associated with 5-year mortality. ResultsThere were 293 patients included in this study. Mean age was 66 years, and mean BMI 27 kg/m2. The majority of patients were male (69%), white (53%), with diabetes (65.4%) and hypertension (77.5%), and underwent below-the-knee amputation (BKA) (73%). Prosthetic referral occurred in 123 (42.0%). Overall 5-year survival was 61.7% (95% confidence interval [CI], 55.9%-68.1%) (BKA 64.7% [95% CI, 57.9%-72.3%]; above-the-knee amputation 53.8% [95% CI, 43.4%-66.6%]). On multivariate analysis, age >70 years, female sex, diabetes, ASA score 4 or 5, and current tobacco use were associated with no referral for prosthetic fitting. Patients with BMI 25 to 30, a previous arterial procedure, BKA, and history of stump revision were more likely to be referred. Factors associated with decreased survival were increasing age, higher ASA class, black race, and BMI; prosthetic referral was seen to be protective. ConclusionsWe identified multiple patient factors associated with prosthetic referral, as well as several characteristics predictive of reduced survival after amputation. Being referred for prosthetic fitting was associated with improved survival not explained by patient characteristics and comorbidities. Further research is needed to determine whether the factors identified as associated with nonreferral are markers for patient characteristics that make them clinically unsuitable for prosthetic fitting or if they are symptoms of unconscious bias or of the patient's access to care.

Below-the-Knee Amputation With Targeted Muscle Reinnervation: Operative Technique and Technical Pearls of an Interfascicular Superficial Peroneal Nerve Targeted Muscle Reinnervation

INTRODUCTION: Targeted muscle reinnervation (TMR) is a nerve transfer technique by which the severed ends of sensory nerves are transferred to expendable donor motor nerves to minimize pain. TMR has successfully been used to reduce residual limb and phantom limb pain in patients with upper and lower extremity amputations. For patients with below-the-knee amputations (BKAs), the tibial nerve and superficial peroneal nerve (SPN) are the most common sensory nerves addressed with TMR. Although the tibial nerve coaptation is well-protected by the deep posterior musculature, the SPN coaptation is commonly positioned at the weight-bearing portion of the stump without significant soft tissue padding. This study details a novel interfascicular SPN TMR technique performed through a proximal incision at the fibular head. TECHNIQUE: TMR performed primarily at time of BKA is offered to all patients preoperatively to prophylactically reduce pain. TMR is also offered secondarily to patients who develop severe neuroma or phantom limb pain after their amputation. When performed primarily, TMR is performed on the SPN and tibial nerve. When performed secondarily, TMR is performed on the involved nerves based on clinical exam. The SPN TMR is performed through an approach to the common peroneal nerve (CPN) at the fibular head. Accessing the CPN at this level allows for complete decompression of the CPN through the peroneal tunnel. An internal neurolysis is performed, and a nerve stimulator is used to map the motor fascicles to identify an expendable target. The extensor digitorum longus is preferentially selected since it is not critical to tibial padding. The SPN is then translocated from the distal wound into the peroneal tunnel incision and an antegrade nerve transfer is performed to the motor target, typically with a close size match (Video). RESULTS: This technique for primary TMR for BKAs was performed in 109 patients over a 2-year period from January 1, 2018 to December 31, 2019. The SPN was transferred to the extensor digitorum longus 78.5% of the time, peroneus brevis 9.3%, redundant branch of tibialis anterior 6.5%, and peroneus longus 5.6%. The tibial nerve was transferred to the tibialis posterior 66.7% of the time, soleus 10.0%, flexor digitorum longus 8.3%, flexor hallucis longus 8.3%, and unspecified muscle of the deep flexor compartment 6.7%. No primary DPN, sural, or saphenous TMRs were performed. There were no added surgical complications attributable to the TMR portion of the case: no surgical site infections at the fibular head incision or reoperation for seromas or hematomas. If patients developed pain in the saphenous or sural distributions a secondary TMR was performed, but this was only required in 2 patients. CONCLUSIONS: TMR has been demonstrated to greatly improve amputees’ pain and ambulation following a major lower extremity amputation. This article provides insight into the technical pearls of the unique interfascicular SPN TMR, which places the coaptation away from the weight-bearing stump and allows for a close size match. This technique has been used with excellent clinical outcomes and no procedure-specific complications in over 100 patients.