Lower-extremity Amputation Level Research Articles

Shared decision-making when deciding on lower extremity amputation level – perceived facilitators and barriers among surgeons

Shared decision-making when deciding on lower extremity amputation level – perceived facilitators and barriers among surgeons

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

ObjectiveDecision-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. MethodsPatients 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. ResultsWe 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). ConclusionsReoperation 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.

Indirect impact of the COVID-19 pandemic on diabetes-related lower extremity amputations: A regional study.

Objectives This study aims to evaluate the indirect impact of the novel coronavirus disease 2019 (COVID-19) pandemic on diabetes-related lower extremity amputations.Patients and methods Patients who underwent lower limb amputation due to complications of diabetes between August 2019 and February 2020 (control group) and August 2020 and February 2021 (pandemic group) were retrospectively reviewed. None of the patients had a previous COVID-19 infection. Patients’ amputation level and latest diabetes follow-up date until amputation were recorded.Results A total of 19 feet of 19 patients (14 males, 5 females; mean age: 70.0±10.5 years; range, 53 to 91 years) in the control group and 18 feet of 18 patients (12 males, 6 females; mean age: 70.4±11.3 years; range, 54 to 91 years) were included. There was no statistically significant difference in amputation levels between the two groups (p=0.959). The mean time elapsed from the last diabetes control in the control and the pandemic group was 5.9±12.8 months and 8.2±9.8 months, respectively (p=0.038). A total of eight (42.1%) patients in the control group and seven (38.9%) patients in the pandemic group did not have a follow-up for diabetes in the last year prior to amputation (p=0.842).Conclusion Although the COVID-19 pandemic seems to cause a delay in the routine medical care of patients with diabetes, it appears not to have an indirect effect on the lower extremity amputation level and incidence. Patients’ adherence may be the major determinant in amputation surgery.

Duplex Ultrasound May Predict the Best Level of Lower Limb Amputation in Patients with Chronic Limb-Threatening Ischemia: A Retrospective Observational Cohort Study

Despite improved revascularization options, many patients with chronic limb-threatening ischemia (CLI) require lower limb amputation. Duplex ultrasound (DUS) is recommended as first-choice imaging technique in CLI. However, the prognostic utility of DUS for planning lower limb amputations has never been described before. This study aims to evaluate if DUS and findings from physical examination could be used to help predict the best level of lower limb amputation in patients with CLI. A retrospective cohort of 124 patients with CLI and a lower limb amputation was analyzed. Outcome measurements were reoperation, revision, and conversion rates, which were related to findings from physical examination and DUS examinations. Thirty-nine reoperations were performed, of which 17 stump revisions and 22 conversions were from below- to above-knee amputation. There was a discrepancy in findings of physical examination and DUS of 25% and 64% of femoral and popliteal pulsations respectively. Conversion rates increased with a more proximal occlusion on DUS. All patients with a vascular occlusion in the aortoiliac trajectory or deep femoral artery required a higher amputation level. Physical examination seems to be unreliable, and therefore should not be used to assess the optimal level of lower extremity amputation. Performing a primary above-knee amputation in patients with vascular occlusion in the aortoiliac trajectory or deep femoral artery could significantly reduce reoperation rates.

Influence of Macrovascular and Microvascular Disease on the Level of Lower-Extremity Amputation in Patients with Type 2 Diabetes

Introduction - Peripheral Arterial Disease (PAD) is associated with a high amputation rate in patients with type 2 diabetes (T2DM). However, the relationship between vascular disorders and the level of amputation has been poorly investigated. We examined the impact of microvascular and macrovascular disease on the risk and site of amputation. Our hypothesis was that distal amputations were related to microvascular and proximal amputations to macrovascular disease. Methods - A prospective, monocentric cohort of consecutive T2DM patients (the SURDIAGENE cohort: 1468 patients; 58% men, mean +/- SD age 65+/- 11 years) was followed for a median of 7 years for primary endpoint, global amputation, and secondary endpoints minor amputations (toes and mediotarse leve)l and major amputations (leg and thigh amputation). Microvascular disease was defined as a history of albuminuria or proliferative retinopathy and macrovascular disease as a history of previous coronary revascularization or myocardial infarction or previous carotid revascularization or stroke. History of PAD included previous lower limb revascularization (endovascular or open repair) and previous major amputation. Results - During follow up, 79 patients (5.5%) were amputed: 50 major and 29 minor amputations. History of PAD (HR 5.43 [3.33-8.84]; p<0.0001), Systolic Blood Pressure (SBP) (HR 1.01 [1.00-1.03]; p=0.003) and male sex (HR 4.48 [2.28-8.79]; p<0.0001) were significantly associated with global amputations after multiple stepwise regression model. History of PAD (HR 6.60 [3.61-12.05]; p<0.0001), SBP (HR 1.02 [1.00-1.03]; p=0.006), male sex (HR 3.63 [1.60-8.22]; p=0.002), beta blocker therapy (HR 2.09 [1.16-3.77]; p=0.013), smoking status (HR 2.24 [1.07-4.68]; p=0.031) were associated with major amputations after multiple stepwise regression model. History of PAD (HR 4.04 [1.76-9.26] ; p=0.0009), male sex (HR 5.13 [1.52-12.27] ; p=0.008), proliferative retinopathy (HR 2.60 [1.18-5.72] ; p= 0 .017) and Diastolic Blood Pressure (HR 1.03 [1.00-1.07] were associated with minor amputations after multiple stepwise regression model. History of urinary albumin excretion did not impact global, minor and major amputation. Other atherosclerotic localisations (carotid and coronary artery lesions) had no impact on amputation occurrence regardless of the level of amputation in our model. Minor or major amputation were neither influenced by a surgeon specialty (vascular surgeon vs. orthopedic surgeon; p=0.774) nor surgeon’s experience (senior vs. junior surgeon; p= 0.713). Conclusion - History of PAD was a robust risk factor for amputation regardless the level of amputation in patients with T2DM. Microvascular disease, particularly proliferative retinopathy, predicted minor amputation only. Carotid and/or coronary macrovascular disease did not predict amputation. This study suggests that the risk factors associated with the level amputation (proximal vs distal) should be considered differently in patients with T2DM.

Review of Socioeconomic Disparities in Lower Extremity Amputations: A Continuing Healthcare Problem in the United States.

Lower extremity amputation is one of the most unfortunate, yet preventable, consequences of uncontrolled lower limb ischemia occurring secondary to diabetes mellitus or peripheral arterial disease. In the United States, racial and socioeconomic disparities are associated with significant differences seen in the incidence and type or level of lower extremity amputation among patients. Due to shifting demographics and the uncertain state of healthcare coverage, lower extremity amputation rates are only projected to increase in the future. Given the potential societal and individual costs associated with the loss of a limb, this review seeks to summarize the recent findings on disparities in the identification, treatments offered, and outcomes of lower limb ischemia in order to elucidate potential interventions at the practitioner and policy levels.

Influence of micro- and macro-vascular disease and Tumor Necrosis Factor Receptor 1 on the level of lower-extremity amputation in patients with type 2 diabetes

BackgroundPatients with type 2 diabetes (T2D) face a high amputation rate. We investigated the relationship between the level of amputation and the presence of micro or macro-vascular disease and related circulating biomarkers, Tumor Necrosis Factor Receptor 1 (TNFR1) and Angiopoietin like-2 protein (ANGPTL2).MethodsWe have analyzed data from 1468 T2D participants in a single center prospective cohort (the SURDIAGENE cohort). Our outcome was the occurrence of lower limb amputation categorized in minor (below-ankle) or major (above ankle) amputation. Microvascular disease was defined as a history of albuminuria [microalbuminuria: uACR (urinary albumine-to-creatinine ratio) 30–299 mg/g or macroalbuminuria: uACR ≥ 300 mg/g] and/or severe diabetic retinopathy or macular edema. Macrovascular disease at baseline was divided into peripheral arterial disease (PAD): peripheral artery revascularization and/or major amputation and in non-peripheral macrovascular disease: coronary artery revascularization, myocardial infarction, carotid artery revascularization, stroke. We used a proportional hazard model considering survival without minor or major amputation.ResultsDuring a median follow-up period of 7 (0.5) years, 79 patients (5.5%) underwent amputation including 29 minor and 50 major amputations. History of PAD (HR 4.37 95% CI [2.11–9.07]; p < 0.001), severe diabetic retinopathy (2.69 [1.31–5.57]; p = 0.0073), male gender (10.12 [2.41–42.56]; p = 0.0016) and serum ANGPTL2 concentrations (1.25 [1.08–1.45]; p = 0.0025) were associated with minor amputation outcome. History of PAD (6.91 [3.75–12.72]; p < 0.0001), systolic blood pressure (1.02 [1.00–1.03]; p = 0.004), male gender (3.81 [1.67–8.71]; p = 0.002), and serum TNFR1 concentrations (HR 13.68 [5.57–33.59]; p < 0.0001) were associated with major amputation outcome. Urinary albumin excretion was not significantly associated with the risk of minor and major amputation.ConclusionsThis study suggests that the risk factors associated with the minor vs. major amputation including biomarkers such as TNFR1 should be considered differently in patients with T2D.

Changes in Level of Lower Extremity Amputation and Re-amputation Rate in Diabetic Patients

Changes in Level of Lower Extremity Amputation and Re-amputation Rate in Diabetic Patients

Effectiveness of the combat pelvic protection system in the prevention of genital and urinary tract injuries: An observational study.

Historically, the incidence of genital and urinary tract (GU) injuries in major conflicts has been approximately 5%. To mitigate the risk of blast injury to the external genitalia, the United States and United Kingdom issued protective overgarments and undergarments to troops deployed in support of Operation Enduring Freedom. These two systems combined constitute the pelvic protection system (PPS). Our hypothesis was that PPS use is associated with a reduction of GU injuries in subjects exposed to dismounted improvised explosive device blast injuries. We identified two groups for comparison: those who were confirmed to have worn the PPS at time of injury (n = 58) and a historical control group who were confirmed as not wearing the PPS (non-PPS) (n = 61). Patients with any level of lower extremity amputation from dismounted improvised explosive device blast mechanism were included. The primary outcome measure was presence of a GU injury on admission. A univariate analysis assessing the strength of association with odds ratios and 95% confidence intervals was performed between the PPS and non-PPS groups. Mean Injury Severity Score (ISS) was higher in the PPS versus the non-PPS group (26.1 vs. 19.3, p = 0.0012). Overall, 31% of the patients in the PPS group sustained at least one GU injury versus 62.3% in the non-PPS group. The odds ratio of sustaining a GU injury in the PPS group as compared with the PPS group is 0.28 (31% vs. 62.3%; 95 % confidence interval, 0.62-0.12; p < 0.001). The most frequent injures were open scrotal/testes wounds, followed by open penis, and open bladder/urethra injuries. The use of the PPS is associated with a decreased odds ratio of GU injury. Despite a 31% absolute reduction, future work should focus on improved efficiency. Prognostic/epidemiologic study, level IV; therapeutic study, level V.

Incidence of lower extremity amputation in the diabetic compared to the non-diabetic population: a systematic review protocol.

BackgroundDiabetic individuals have a largely increased risk of lower extremity amputation (LEA) compared with non-diabetic patients. Prior systematic reviews of incidence of LEA have some limitations with respect to lack of consensus in the definition of LEA, level of LEA (all, major, minor), and definition of source population (general population or population with diabetes at risk). The purpose of our review is to evaluate the incidence of LEA in the diabetic population and its differences with regard to sex, ethnicity, age, and regions; to compare the incidence rate (IR) in the diabetic and non-diabetic population; and to investigate time trends.Methods/designWe will perform a systematic literature search in MEDLINE, Embase, Web of Knowledge, and publisher databases such as Journals@OVID and ScienceDirect. We will develop comprehensive systematic search strategies according to established guidelines for meta-analyses of observational studies in epidemiology (the MOOSE group). Two authors will independently screen abstracts and full text of all references on the basis of inclusion criteria with respect to types of study, types of population, and the main outcome. We will exclude studies if they report solely incidences of LEA among persons with diabetes mellitus when referring to the total population (diabetic and non-diabetic) and not exclusively to the diabetic population. Data extraction and assessment of risk of bias will be undertaken by two review authors working independently. We will assess incidence rate (IR) or cumulative incidence (CumI), relative risk of amputations comparing the diabetic to non-diabetic populations, cause of LEA, and type of diabetes. If we find subsets of studies to be homogeneous enough, we will perform meta-analyses for incidence rates by Poisson generalized linear mixed models (GLMM).Systematic review registrationPROSPERO CRD42015017809Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-015-0064-9) contains supplementary material, which is available to authorized users.

Mortality, causes of death and associated risk factors in a cohort of diabetic patients after lower-extremity amputation: A 6.5-year follow-up study in Taiwan

Background To determine the mortality, causes of death and associated risk factors in Taiwanese diabetic patients after lower-extremity amputation (LEA). Methods A total of 358 diabetic patients (191 men and 167 women, aged 66.6 ± 10.3 years) after LEA from the Taiwanese cohort of 778 cases previously recruited in the multinational Global Lower Extremity Amputation Study were followed. Risk factors included age, sex, smoking, body mass index (BMI), hypertension, systolic (SBP) and diastolic blood pressure (DBP), and LEA level. Mortality was ascertained from the National Death Registry. Results With a follow-up period of up to 6.5 (median: 4.0) years and 1239.17 patient-years, 214 patients died. Crude mortality rate was 172.7 per 1000 patient-years and median survival time 4.1 years. The underlying cause of death was recorded as diabetes mellitus in 57.9% of those who died and none to disease of arteries, arterioles and capillaries. After adjustment for age and sex, smoking, SBP as a continuous variable, SBP ≥140 mmHg and BMI <18.5 kg/m 2 (underweight) were predictors for mortality with respective odds ratios (95% confidence intervals) of 1.580 (1.030–2.425), 1.011 (1.000–1.022), 1.363 (1.007–1.845) and 1.889 (1.203–2.968); but hypertension, DBP as a continuous variable and DBP ≥90 mmHg, BMI as a continuous variable and LEA level were not. Conclusions Mortality after LEA in Taiwanese diabetic patients is high. The most common cause of death was recorded as diabetes mellitus. After adjustment for age and sex, smoking, SBP and underweight are predictive for mortality; while LEA level is not.