Non-traumatic Lower Extremity Amputations Research Articles

English

BACKGROUND Foot problems are a leading cause of hospitalization for patients having diabetes mellitus all over the world. Foot ulcers in diabetes precede 85 % of nontraumatic lower-extremity amputations. Fifteen percent develop foot ulcers during their lifetime. Individuals who develop foot ulcers have a decreased health-related quality of life and consume a lot of healthcare resources. Foot abnormalities is a frequently missed diagnosis and a focus in this area of medical education has never been optimal despite its frequency of presentation. In this study, we wanted to determine clinical and radiographic foot abnormalities in diabetic patients. METHODS A cross-sectional study was carried out on 180 type 2 diabetic patients diagnosed as per ADA definition of diabetes, they were categorized into three groups, the first consisted of 60 diabetic patients without neuropathy or foot ulcers, the second had 60 diabetic patients with neuropathy and the third had 60 diabetic patients with both neuropathy and foot ulcer. Based on the clinical examination of the foot and foot X-ray oblique and lateral view of the affected feet along with other relevant investigations were obtained and analysed using descriptive and inferential statistical analysis. RESULTS We observed that poor glycaemic control and duration of diabetes were important risk factors for foot complications in diabetic patients which were statistically significant. Among patients with only diabetes, 3.3 % had HbA1c less than 6, 35 % had HbA1c between 6 - 9 and 61.7 % with HbA1c of more than 9. Among the patients with diabetes and neuropathy, 1.7 % of people had Hba1c of less than 6, 20 % with Hba1c between 6 - 9 and 78.3 % with Hba1c of more than 9. In patients who had diabetes and neuropathy with foot ulcers, 6.7 % had HbA1c of less than 6, among the same cohort 8.3 % had HbA1c between 6 - 9 and 85 % had HbA1c above 9. The prevalence of various radiological abnormalities of the foot was more common in diabetic patients with both neuropathy and foot ulceration (group lll) (83.3 %). The most common abnormality as observed from our study was Osteopenia with osteoporotic changes seen in 36.7 % of Group III patients VS 16.7 % of Group II (patients with diabetes and neuropathy ) and only in 10 % of Group I patients (patients with diabetes without any complications). Vascular calcifications were observed in 26.7 % VS 16.7 % VS 6.7 % in Group III, Group II, Group I respectively. Periosteal reactions were also more common in Group III patients (6.7 %). Subluxation of 2nd, 3rd, 4th, and 5th metatarsals was observed only in 3.3 % of Group III patients. CONCLUSIONS Diabetic foot is one of the most devastating complications of diabetes. Preventing the diabetic foot should be the first priority. This can be achieved by identifying the high-risk individuals with the above said risk factors by proper clinical examination and use of foot X-ray. KEY WORDS Diabetic Foot, Foot Problems, Foot Infections.

A Study of the Risk Factors Predicting Amputation in Diabetic Foot

Background: Diabetic foot ulcers are the main cause of non-traumatic lower extremity amputation. The objective of this study was to evaluate the risk factors for major amputation in diabetic foot patients. Materials & Methods: This open, single center, prospective and observational study conducted in Chalmeda Anand Rao Institute of Medical Science, Karimnagar for a period from Nov. 2018 to Dec. 2020 The patients admitted in General Surgery with diabetic foot problems were selected for the study with proper consent of patients and his/her attendants. Results: In this study Fifty patients were admitted to the diabetic wound in Department of Surgery for foot ulcers between Nov 2018 to Dec 2020. Among the 50 patients, Male: Female ratio was 4.6:1. out of which 41 (82.0%) were male, 18 (36.0%) belonged to the 50 to 59 years age group, 15 (30.0%) were having complaints for Ulcer, 15 (30.0%) were smoker. The Amputation rate was 42.0%. Conclusion: In the results of analysis, poor glycemic control, peripheral arterial disease, peripheral neuropathy and higher Wagner grade are significant risk factors for amputation in diabetic foot infection. Keywords: Diabetic foot, Wagner grading, HbA1c, TLC, Albumin.

Formulation and characterisation of deferoxamine nanofiber as potential wound dressing for the treatment of diabetic foot ulcer

Diabetic foot ulcer (DFU) is often associated with the risk of non-traumatic lower extremity amputations in diabetic patients. Wound dressing with the active therapeutic agent(s) would be necessary to effectively manage the chronic condition of DFU. Deferoxamine (DFO) has been reported as a potential therapeutic agent in improving the wound healing process by regulating the expression and increasing the stability of hypoxia-inducible factor-1α (HIF-1α). Concurrently, polymeric nanofiber mats offer great potential for delivering therapeutic agents to wound owing to their high surface area to volume ratio and high porosity. Therefore, this study was aimed to develop a biomaterial-based nanofibrous wound dressing containing DFO as a novel platform to increase angiogenesis at the wound environment for rapid healing. A DFO-loaded bilayer nanofiber mat was formulated using chitosan, sodium alginate, and polyvinyl alcohol using electrospinning method. The effects of three independent parameters on nanofibers morphology were investigated using Box-Behnken statistical design. The fabricated bilayer electrospun fiber matrices had displayed the criteria of an ideal wound dressing with a high swelling degree of 594%, sufficient water vapour transmission rate (427.49 g/m2∙day), high entrapment efficiency (98%), sustained drug release up to 48h, and zone of inhibition against Gram + ve (0.79 ± 0.07 cm2) and Gram –ve (0.95 ± 0.04 cm2) organisms. The bilayer nanofiber mat was also found to be non-cytotoxic and the in vitro scratch test revealed wound healing potential, which implied its promising role as wound dressing tool to provide efficient treatment against DFU.

Comprehensive Assessment of Current Management Strategies for Patients With Diabetes and Chronic Limb-Threatening Ischemia.

Chronic limb-threatening ischemia (CLTI) is the most severe form of peripheral artery disease. It is estimated that 60% of all nontraumatic lower-extremity amputations performed annually in the United States are in patients with diabetes and CLTI. The consequences of this condition are extraordinary, with substantial patient morbidity and mortality and high socioeconomic costs. Strategies that optimize the success of arterial revascularization in this unique patient population can have a substantial public health impact and improve patient outcomes. This article provides an up-to-date comprehensive assessment of management strategies for patients afflicted by both diabetes and CLTI.

1053-P: Predictors of Nontraumatic Lower Extremity Amputations in Patients with Diabetes Mellitus and Peripheral Artery Disease

Introduction: Nearly 50% of patients with diabetes and foot ulcers have concurrent peripheral artery disease (PAD), which increases risk of amputation events. These patients have a 5-year mortality rate of over 50% after lower extremity amputation. We sought to identify patients with diabetes and PAD in a national patient database to identify predictors of amputation. Methods: We queried the national Cerner Health Facts EMR database for patients with diabetes and PAD diagnoses between 2010 and 2018. We used Poisson regression to generate risk ratios for variables predictive of lower extremity amputation. Results: We identified 203,730 patients from 512 sites. The average age of a patient was 68.9 (± 12.02 SD), 57.2% were male, and 77.5% of patients were white; 8.8% (N=17,991) of patients had a documented amputation. History of osteomyelitis (risk ratio [RR] 7.92, 95% confidence interval [CI] 7.66-8.19), history of hypertension (RR 1.54, 95% CI 1.48-1.62), previous limb amputation (RR 1.46, 95% CI 1.41-1.52), were predictive of lower extremity amputation (Figure). Conclusions: In patients with diabetes and PAD, history of osteomyelitis, history of hypertension, and previous limb amputation were most predictive of a future lower extremity amputation. Patients with the above risk factors should be monitored more closely for clinical indicators that could lead to amputation. Disclosure G. Rajagopal: None. J. B. Provance: None. B. Drees: None. M. Abu kishk: None.

1042-P: Major Amputation Rates in the Diabetes Belt and Surrounding Counties among Medicare Beneficiaries in 2006-2015

Objective: Rates for non-traumatic lower-extremity amputations (LEA) have been declining, but concerns exist over disparities in rates between races/ethnicities. Our objective is to track changes in major LEA (MLEA) rates before and after the Affordable Care Act (ACA) among Medicare beneficiaries residing in the Diabetes Belt compared to those in the surrounding areas. Methods: We used Medicare claims files for a sample of ~1 million Fee-for-Service beneficiaries in 2006 - 2015 to compute rates per 1000 patients with diabetes. The Diabetes Belt was identified by the CDC as 644 counties across Appalachian and southeastern counties in the US that had diabetes prevalence ≥ 11% in 2008. Results: MLEA rates for the Diabetes Belt and surrounding counties as well as rates for Non-Hispanic (NH) Black and NH White are in Figure. Patients in the Belt experienced one full MLEA more per 1000 patients than those in the surrounding area. Although amputation rates declined rapidly in both areas, NH blacks consistently had > 3 times higher rates than NH whites in the Belt. Trends did not show noticeable changes in MLEAs before and after the ACA. Discussion: Our data show persistent disparities in MLEA rates between the Diabetes Belt and surrounding counties. Racial disparities were much larger in the Belt. Targeted policies to prevent MLEAs among NH black patients are needed to reduce the disparities in this region. Disclosure J. M. Lobo: None. S. Kim: None. H. Kang: None. T. L. Mcmurry: None. M. Sohn: None. Funding National Institutes of Health (R01DK113295)

Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association.

Nontraumatic lower-extremity amputation is a devastating complication of peripheral artery disease (PAD) with a high mortality and medical expenditure. There are ≈150 000 nontraumatic leg amputations every year in the United States, and most cases occur in patients with diabetes. Among patients with diabetes, after an ≈40% decline between 2000 and 2009, the amputation rate increased by 50% from 2009 to 2015. A number of evidence-based diagnostic and therapeutic approaches for PAD can reduce amputation risk. However, their implementation and adherence are suboptimal. Some racial/ethnic groups have an elevated risk of PAD but less access to high-quality vascular care, leading to increased rates of amputation. To stop, and indeed reverse, the increasing trends of amputation, actionable policies that will reduce the incidence of critical limb ischemia and enhance delivery of optimal care are needed. This statement describes the impact of amputation on patients and society, summarizes medical approaches to identify PAD and prevent its progression, and proposes policy solutions to prevent limb amputation. Among the actions recommended are improving public awareness of PAD and greater use of effective PAD management strategies (eg, smoking cessation, use of statins, and foot monitoring/care in patients with diabetes). To facilitate the implementation of these recommendations, we propose several regulatory/legislative and organizational/institutional policies such as adoption of quality measures for PAD care; affordable prevention, diagnosis, and management; regulation of tobacco products; clinical decision support for PAD care; professional education; and dedicated funding opportunities to support PAD research. If these recommendations and proposed policies are implemented, we should be able to achieve the goal of reducing the rate of nontraumatic lower-extremity amputations by 20% by 2030.

Frailty Index associated with postoperative complications and mortality after lower extremity amputation in a national veteran cohort

ObjectiveSurgical frailty and its assessment have become essential considerations in perioperative management for the modern aging surgical population. The risk analysis index is a validated frailty score that has been proven to predict short-term outcomes and long-term mortality in several surgical subspecialties and high-risk procedures. We examined the association of risk analysis index scores with postoperative outcomes in a retrospective nationwide database of patients who underwent lower extremity amputation in the Veterans Health Administration Health Care System. MethodsThe Veteran Affairs Surgical Quality Improvement Program data was queried across the Veteran Affairs Health Care System with institutional review board approval for lower extremity amputations. Records of above and below knee amputation, Current Procedural Terminology codes 27590, 27591, 27592, 27594, 27596 and 27880, 27881, 27882, 27884, and 27886, respectively, from 1999 to 2018 were obtained. Incomplete and traumatic entries were removed. Risk Analysis Index score was calculated from preoperative variables and patients were separated into five score cohorts (≤15, 16-25, 26-35, 36-45, ≥46). The χ2 test and analysis of variance were used to compare the cohorts. Forward binary logistic regression modeling was used to determine covariate-adjusted odds ratios for outcomes in each cohort (SPSS software; version 25, IBM Corp). ResultsA total of 47,197 patients (98.9% male) with an average age of 66.4 ± 10.6 years underwent nontraumatic lower extremity amputation, including 27,098 below knee and 20,099 above knee amputations, during the study period. Frailty was associated with increased rates of deep vein thrombosis, sepsis, cardiac arrest, myocardial infarction, pneumonia, intubation for more than 48 hours, pulmonary embolism, reintubation, acute kidney injury, renal failure, increased length of stay, overall complications, and death. Increases in the frailty score were associated with up to three times the likelihood for the occurrence of a postoperative complication and up to 32 times likelihood to perish within 30 days than those with low frailty scores. ConclusionsRisk analysis index assessment of frailty was found to be associated with several postoperative outcomes in a dose-dependent manner in patients undergoing lower extremity amputation in the Veterans Health Care System, with higher scores associated with higher rates of death and major cardiac (myocardial infarction, cardiac arrest), pulmonary (pneumonia, failure to wean vent, reintubation), and renal (renal insufficiency, renal failure) complications. We recommend the use of risk analysis index score as a frailty screening tool for patients undergoing lower extremity amputation to enable providers to adequately inform and counsel patients regarding potential significant risks.

Classifier Algorithms and Ensemble Models for Diabetes Mellitus Prediction: A Review

Timely disease prediction means a lot to the improvement of the health care services and this will go a long way to assist populaces to avoid unsafe health circumstances before resulting in complex medical situations. Diabetes Mellitus as one of the deadly diseases that is described by hyperglycemia taking place due to defects in insulin secretion which allow an irregular increase in glucose level. Diabetes Mellitus can lead to loss of sight, non-traumatic lower extremity amputation, chronic kidney disease, coronary heart disease, stroke, etc. Hence, prompt diagnosis of the Diabetes Mellitus disease has to pay more attention to in the recent area of research. Presently, there is a great and wide work carried out on Machine Learning with a focus on medical and its application. This paper reviewed recent journalsthat made use of Artificial Intelligencetechniques, different classifiers and ensemble methods to assist in the management of diabetes. Classifiers algorithms such as Naive Bayes, Decision Tree, Artificial Neural Network, Support Vector Machine, K-Nearest Neighbour and Multi-Layer Perceptron. The results from over 1,137most related reviewed journalsreveled that Ensemble Models have the highest average accuracy of 87.09 % in respect to prediction of diabetes mellitus

Prevalence of postamputation pain and its subtypes: a meta-analysis with meta-regression.

The inconsistent use of standardized approaches for classifying postamputation pain (PAP) has been a barrier to establishing its prevalence. The primary objective of this systematic review and meta-analysis is to determine the prevalence of nontraumatic lower-extremity PAP using an established taxonomy. The secondary objective is to determine the prevalence of PAP subtypes, including phantom limb pain and residual limb pain (RLP). An a priori protocol was registered, and a database search was conducted by a reference librarian. Randomized trials and uncontrolled studies were eligible for inclusion. The risk of bias was assessed using a tool developed for uncontrolled studies. A total of 2679 studies were screened, and 13 studies met inclusion criteria (n = 1063). The sources of risk of bias included selection bias and, to a lesser extent, whether the outcome was adequately ascertained. Two studies reported the prevalence of PAP and the pooled prevalence was 61% (95% confidence interval [CI], 33%-86%) with high heterogeneity (I2 = 93%). Thirteen studies reported the prevalence of phantom limb pain and the pooled prevalence was 53% (95% CI, 40%-66%) with high heterogeneity (I2 = 93%). Eight studies reported the prevalence of RLP and the pooled prevalence was 32% (95% CI 24%-41%) with high heterogeneity (I2 = 76%). Clinical subtypes of RLP were not reported. The prevalence of PAP is high in patients with nontraumatic lower-extremity amputations. Ongoing research that uses a taxonomy for PAP is needed to fully delineate the prevalence of PAP subtypes.

Analysis of Doppler ultrasonography and computer tomography angiography for predicting amputation level and re-amputation rate.

OBJECTIVEPeripheral arterial disease of the lower extremities is one of the most common causes of non-traumatic lower extremity amputation. Computed tomography (CT) angiography and Doppler ultrasonography are mainly used to evaluate distal vascular structures. Our objective was to evaluate the predictive efficacy of Doppler ultrasound and CT angiographic radiographic examinations in determining amputation levels and reamputation rates in patients undergoing lower extremity amputation.METHODSPatients with major or minor amputation at various levels due to lower extremity lesions were included in the study. Standard demographic information, clinical accompanying diseases, reamputation datas, Doppler ultrasound, and CT angiography radiological evaluation reports were obtained retrospectively from the hospital system records of the patients.RESULTSA total of 166 cases including 119 (71.7%) males and 47 (28.3%) females were included in the study. About 36.7% (n=61) cases had amputation at the level of surgery above the knee, 38.6% (n=64) below the knee and 24.7% (n=41) at the level of foot/finger. In patients who underwent amputation above the knee, occlusion was seen at the level of the iliac artery (88.9%), femoral artery (47.8%), and popliteal artery (37%). The rate of occlusion at the level of the popliteral artery in patients with below-knee amputation (59.3%) was found in patients with foot/finger amputation (51.5%) at the levels arteria dorsalis pedis and posterior tibial artery. According to the level of occlusion at all blood flow levels, it was observed that the rate of reamputation was most common in occlusions at the level of popliteal artery.CONCLUSIONIt was found that radiological data are effective in planning amputation according to blood flow level and does not make any difference per se. It was found that the reamputation rates were related to the determination of the level of blood flow in the primary surgical phase.

Sepsis and anticoagulant, is amputation a lifesaving surgery?

Patients with severe sepsis are associated with coagulation abnormalities ranging from minimal to major activation of coagulation system, which may lead to fulminant disseminated intravascular coagulation (DIC) and multiorgan failure. Lower extremity amputation is indicated to remove ischemic, infected, or necrotic tissue or locally unresectable tumor and, at times, may be lifesaving. Peripheral artery disease and diabetes are the leading causes of non-traumatic lower extremity amputation. Amputation of lower limb in patient of severe sepsis associated with coagulation abnormalities may be limb saving surgery but may not be lifesaving surgery as in our case patient died due to multiorgan failure.

Machine Learning Analysis of Multispectral Imaging and Clinical Risk Factors to Predict Amputation Wound Healing

Machine Learning Analysis of Multispectral Imaging and Clinical Risk Factors to Predict Amputation Wound Healing

Abstract 15232: Lifetime Risk of Nontraumatic Lower-extremity Amputation: The Atherosclerosis Risk in Communities Study

Introduction: Nontraumatic lower-extremity amputation is a serious clinical outcome. Major risk factors include peripheral artery disease and diabetic neuropathy. Although incidence rates of amputation have been reported, no lifetime risk estimates are available. Hypothesis: The lifetime risk of amputation is higher in men, blacks, and those of low socioeconomic status (SES). Methods: In 15,744 ARIC participants aged 45-64 at baseline (1987-89), we estimated the lifetime risk of amputation through age 80 by race-sex and race-SES using Fine and Gray’s proportional subhazards model accounting for the competing risk of death. This method is optimal for time-fixed exposures and thus our primary exposures are sex and race. SES included education, annual family income, and the Area Deprivation Index linked to census tract geocoding. Non-traumatic amputation was identified from hospitalization ICD codes (e.g., 84.1, Z89.4) and related operation codes. Results: There were 253 non-traumatic amputations during a median follow up of 29 years. Lifetime risk of amputation at age 80 was highest in black men (4.6%), followed by black women (2.8%), white men (1.1%) and white women (0.7%) ( Figure ). Blacks of low SES showed the highest lifetime risk (4.5%). Blacks with high SES had a higher lifetime risk of amputation than whites with low SES. The pattern was consistent when we investigated each of education (≤ vs. > high school), income (< vs. ≥$25,000) and Area Deprivation Index (< vs. ≥ race-specific median), separately. Conclusions: In this population-based cohort 5% of black men and 3% of black women experienced a non-traumatic amputation during their lifetime, while only 1% of white men and women had a hospitalization for amputation. The lifetime risk was higher among those with lower SES in both race groups. Future public health and primary care efforts should emphasize risk factor management (e.g., diabetes and smoking) among racial minority groups and those with low SES.

Mortality and Conversion Rate to Below Knee or Above Knee Amputation Following Transmetatarsal Amputation

Category:Midfoot/Forefoot; Diabetes; OtherIntroduction/Purpose:Non-traumatic lower extremity amputations (LEA), especially those performed in dysvascular and diabetic patients, are known to have poor long-term prognosis. Perioperative mortality has been reported at between 4 and 10%, and the 1 and 5 year mortality rates range between 22-33% and 39-69%, respectively. While poor outcomes in these patients have been described, there is no consensus as to the predictors of mortality. The purpose of the study is to determine the percentage of patients who had a complication following transmetatarsal amputation (TMA) and identify associated risk factors for complications and mortality.Methods:We queried our institution’s administrative database to identify 247 TMA procedures performed in 229 patients between January, 2002 and December, 2016. Electronic health records were reviewed to document complications defined as reoperation, amputation and mortality. Mortality was also verified using the National Death Index. Additionally, we recorded risk factors including diabetes, A1c level, end stage renal disease (ESRD), cardiovascular disease (CVD), peripheral vascular disease (PVD), history of revascularization, contralateral amputation, and neuropathy. The majority of the study patients were males (157, 69%) and the average age was 57 years (range 24-91). The median BMI was 28 (range 16-58) and 29% of the study patients were obese with a BMI ≥ 30. Fishers Exact tests were used to compare categorical variables. Kruskal-Wallis and Independent T-tests were used to compare numeric data. All data were analyzed using SAS/STAT software version 9.4 (Carey, NC) and a 0.05 level of significance was defined apriori.Results:The conversion rate to below (BKA) or above knee amputation (AKA) was 26% (64 of 247). Males (p=.0274), diabetics (p=.0139), patients in ESRD (p=.019), and patients with a history of CVD (p=.0247) or perioperative revascularization (p=.022) were more likely to undergo further amputation following an index TMA. BMI was significantly higher in patients requiring BKA/AKA (p=.0305). There were no significant differences in age (p=.2723) or A1c levels (p=.4219). The overall mortality rate was 35% (84 of 229). Diabetes (p=.0272), ESRD (p=.0031), history of CVD (p<.0001) or PVD (p=.0179) were all significantly associated with mortality. Patients who died were significantly older (p=.0006) and had significantly higher A1c levels (p=.0373). BMI was not significantly associated with mortality. Twenty-two patients who had 23 further amputations subsequently died.Conclusion:In our series of patients undergoing TMA, 26% underwent further amputation and 35% of patients died. Conversion rate to BKA or AKA occurred at a high rate regardless of preoperative revascularization or the use of tendo-achilles or gastrocnemius lengthening procedures. Male sex, diabetes, ESRD, history of CVD or revascularization are significant risk factors for further amputation. ESRD, diabetes, history of CVD or PVD, older age and higher A1c levels are significant risk factors for mortality. These data provide useful insight into risk factors to be emphasized when counseling patients and their families to establish realistic postoperative expectations.

National and State-Level Trends in Nontraumatic Lower-Extremity Amputation Among U.S. Medicare Beneficiaries With Diabetes, 2000-2017.

Diabetes is a leading cause of nontraumatic lower-extremity amputation (NLEA) in the U.S. After a period of decline, some national U.S. data have shown that diabetes-related NLEAs have recently increased, particularly among young and middle-aged adults. However, the trend for older adults is less clear. To examine NLEA trends among older adults with diabetes (≥67 years), we used 100% Medicare claims for beneficiaries enrolled in Parts A and B, also known as fee for service (FFS). NLEA was defined as the highest-level amputation per patient per calendar year. Annual NLEA rates were estimated from 2000 to 2017 and stratified by age-group, sex, race/ethnicity, NLEA level (toe, foot, below-the-knee amputation [BKA], or above-the-knee amputation [AKA]), and state. All rates were age and sex standardized to the 2000 Medicare population. Trends over time were assessed using Joinpoint regression and annual percent change (APC) reported. NLEA rates (per 1,000 people with diabetes) decreased by half from 8.5 in 2000 to 4.4 in 2009 (APC -7.9, P < 0.001). However, from 2009 onward, NLEA rates increased to 4.8 (APC 1.2, P < 0.01). Trends were similar across most age, sex, and race/ethnic groups, but absolute rates were highest in the oldest age-groups, Blacks, and men. By NLEA type, overall increases were driven by increases in rates of toe and foot NLEAs, while BKA and AKA continued to decline. The majority of U.S. states showed recent increases in NLEA, similar to national estimates. This study of the U.S. Medicare FFS population shows that recent increases in diabetes-related NLEAs are also occurring in older populations but at a less severe rate than among younger adults (<65 years) in the general population. Preventive foot care has been shown to reduce rates of NLEA among adults with diabetes, and the findings of the study suggest that those with diabetes-across the age spectrum-could benefit from increased attention to this strategy.

Survival and factors predicting mortality after major and minor lower-extremity amputations among patients with diabetes: a population-based study using health information systems

IntroductionThe aim of the study was to identify the sociodemographic and clinical factors associated with death after the first lower-extremity amputation (LEA), minor and major separately, using data from regional...

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

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)

1505-P: Lower Extremity Amputation Trends among People with Diabetes in a Large Urban Environment

Non-traumatic lower extremity amputations (NLEAs) are a major complication for individuals with poorly controlled diabetes. We sought to identify trends for diabetic NLEAs in Dallas County between 2015 (4th quarter) to 2019 (3rdquarter) by using hospitalization data available from Dallas-Fort Worth Hospital Council Educational and Research Foundation and the CDC’s Behavioral Risk Factor Surveillance System (BRFSS). Per BRFSS, the prevalence of diabetes in Dallas County is 11.7% with a mean (±SD) age of 53±19.1 years, and 56% male, 27% Hispanic, 35% black and 30% non-Hispanic white. The age-adjusted NLEA rates per 1,000 in this population of adults with diabetes increased 18.1% between 2015 and 2019 (incomplete years annualized), with men experiencing higher NLEA rates than women. There was a significant decrease in age-adjusted rates of all NLEAs in women from 2017 and 2018, reflecting prior reports at the national level. The age-adjusted rates for major NLEAs decreased in all age groups except ages 75+ between 2018 and 2019 with a concomitant increase in minor NLEAs; this had been preceded by a steady increase in rates of all NLEAs up to 2018. Of relevance is that starting in 2018 the proportion of major to minor NLEAs has been decreasing steadily. In conclusion, we note a fall in NLEA rates in the last year of observation with the added benefit of a relative fall in major compared to minor NLEAs in patients with diabetes. Disclosure K.K. Chatha: None. B. Walsh: None. J. La Fontaine: None. M.E. Bowen: None. L. Meneghini: Advisory Panel; Self; Novo Nordisk Inc., Sanofi US. Consultant; Self; Applied Therapeutics, Sanofi US.

106-OR: National Trends in Lower Extremity Amputation among U.S. Medicare Beneficiaries with Diabetes, 2000-2017

Diabetes is the leading cause of non-traumatic lower extremity amputation (NLEA) in the United States. After a period of decline, some U.S. data show that diabetes-related NLEA has recently increased, particularly among young and middle-aged adults. However, the trend for older adults is less clear. To examine NLEA trends among older adults with diabetes (≥67 years), we used 100% Medicare claims for beneficiaries enrolled in Parts A and B during 2000-2017. NLEA was defined as the highest-level amputation per patient per calendar year. NLEA rates were stratified by sex, race and ethnicity, and NLEA level. All rates were age-sex standardized to the 2000 Medicare population. Trends over time were assessed using Joinpoint regression and annual percent change (APC) reported. NLEA rates (per 1,000 persons) halved from 8.5 in 2000 to 4.4 in 2009 (APC -7.9, p value<0.001). However, from 2009 to 2017 NLEA rates increased slightly to 4.8 (APC 1.2, p-value<0.001). Trends were similar across most sex and race/ethnic groups, however absolute rates were highest in blacks and men (Figure A). By NLEA level, overall increases were driven by increases in rates of toe and foot NLEAs. This study of the U.S. Medicare population shows that recent increases in diabetes-related NLEA are also occurring in the older population but at a less severe rate.